What the Blues are Doing
Rewarding quality care
Blue Cross and Blue Shield of Massachusetts’ Alternative Quality Contract (AQC), launched in January 2009, replaces the typical fee-for-service model with a modified global payment model, designed to encourage cost-effective, patient-centered care by paying participating physicians and hospitals for the quality, not the quantity, of the care they deliver. The new model combines a per-patient global budget with performance incentives based on nationally endorsed measures tied to quality, health outcomes and patient experience. Physicians and hospitals provide the care they believe is needed to improve the health of their patients, giving them the flexibility to directly contact patients (e-visits), offer group visits for patients who share a common chronic illness, or provide follow-up home visits for patients after hospitalizations. This program already has positively affected major healthcare cost drivers. For example, while AQC groups reduced their readmission rates, avoiding $1.8 million in related costs, the rates for the rest (non-AQC) of the network increased.
Blue Cross and Blue Shield of Minnesota is partnering with the largest healthcare systems in the state on an Aligned Incentive Contracting model that is designed to achieve accountable care. This multi-year contract between the provider and insurer, ties provider payment increases to their ability to improve quality and lower costs during a three-year term. While the program is still in its infancy, these efforts are already showing promise. Findings indicate that the cost trend is below the national average while quality has remained high. Through collaboration, Blue Cross and Blue Shield of Minnesota and providers in the state were able to re-engineer the payment structure to make it possible for patients to get high-quality healthcare at a lower cost.
Blue Cross Blue Shield of North Dakota has collaborated with the state’s healthcare providers to launch the Sustainable Health Initiative, an action plan designed to reduce the medical inflation trend by 1.5 percent, a potential savings of $30 million, during the next three years. Designed to ensure a sustainable and affordable healthcare system in the state, the initiative is focused on developing local solutions to the issues of cost, quality and access to care. Though in its first year of implementation, many of the innovative programs included will impact quality and efficiency of care.
Since 2006, Wellmark Blue Cross and Blue Shield partnered with an industry leading radiology benefit management company to ensure appropriate outpatient diagnostic imaging utilization, the use of evidence-based clinical criteria and appropriate exchange of member information. Appropriate management of diagnostic imaging services helps patients receive appropriate, quality radiology services while minimizing unnecessary costs and exposure to radiation. Diagnostic imaging is one of the fastest-growing medical expenditures in the U.S. for public and private payers. While much of this growth can be attributed to the improved diagnostic capabilities of new technologies and to the rapidly aging population, it is estimated that as much as one-third of all outpatient imaging is clinically unnecessary. The program has consistently demonstrated an annual return of at least 3-to-1 and realized a gross return on investment of over 10-to-1 in its first two years.
Building high-quality networks
Blue Cross and Blue Shield companies and the Blue Cross and Blue Shield Association developed Blue Distinction®, a national quality and value-based designation program designed in close collaboration with the medical community, to recognize medical facilities demonstrating expertise in delivering high-quality specialty care efficiently. Consumers and employers expect their health insurers to continuously identify solutions that improve the quality and value of care. While the Blue Distinction program began as a designation based purely on quality (e.g., 21-percent lower readmission rate for cardiac bypass procedures for Blue Distinction Center (BDC) vs. non-BDC), it is evolving to become a designation awarded to facilities that not only meet stringent quality measures focused on patient safety and outcomes but also meet clear cost measures. BDCs today help identify programs with better overall patient results and value in the areas of bariatric surgery, cardiac care, complex and rare cancers, knee and hip replacement, spine surgery and transplants. These categories address medical services that comprise more than 30 percent of today’s total inpatient hospital expenditures.
Anthem Blue Cross and Blue Shield developed the Care Comparison tool that serves as the foundation for a nationwide cost-based shopping tool designed to help Blue members make informed healthcare decisions when choosing a healthcare provider. By year-end 2011, the tool will contain nationwide cost data for more than 100 of the most commonly billed elective inpatient, outpatient, diagnostic and office-visit procedures. It is designed to help members understand the typical costs associated with all aspects of a medical procedure and is made available to members in the majority of markets nationwide. Blue members can compare the differences in costs among hospitals as well as get information about how frequently facilities perform each procedure, which can assist members in making more informed decisions.
BlueCross BlueShield of Tennessee’s Quality and Cost Transparency Program provides members access to clinical quality and cost-of-care information for physicians and hospital facilities via a secure, Web-based provider directory. Using nationally recognized quality indicators, a statewide physician advisory panel helped select a set of measures used to evaluate the performance of physicians. Included with the quality measures are cost ratings based on claims data. The performance results for physicians and hospitals are available online to showcase high-quality healthcare providers. This online directory along with telephonic support from care coordinators allows members to research their best options for chronic care services.
Putting research and analytics into practice
Excellus BlueCross BlueShield worked with local cardiologists to understand, measure and address gaps between clinical practice and evidence-based guidelines regarding variation in practice patterns for non-invasive and invasive cardiac diagnostic testing. As a result of this collaborative approach, trends in testing from 2007 to 2010 revealed a 35-percent decrease in nuclear stress tests and a 6.3-percent decrease in cardiac angiography. This effort with the cardiology community clearly reduced Excellus members’ unnecessary exposure to radiation and related risks.
Founded in 1985, the Blue Cross and Blue Shield Association’s Technology Evaluation Center pioneered the development of scientific criteria for assessing the effectiveness of medical devices, procedures and biological products through comprehensive reviews of clinical evidence. As one of 14 Evidence-based Practice Centers (EPCs) for the U.S. Agency for Healthcare Research and Quality, TEC assessments are based on objective clinical and scientific evidence used to evaluate whether a technology improves key health outcomes. TEC most recently has taken a national leadership role in the evaluation and analysis of evidence in the rapidly proliferating area of genetic testing and pharmacogenomics (i.e., how a person’s genetic make-up interacts with a drug’s effectiveness). TEC produces evidence-based healthcare technology assessments that are publicly available at http://www.bcbs.com.
Blue Health Intelligence (BHI®) leverages Blue data representing the healthcare experience of more than 110 million individuals nationwide to improve the delivery of care. BHI’s advanced analytics and applied research studies produce findings that improve medical cost and network management, increase operational efficiency and support consumer engagement. BHI analytics quantify variation in quality, utilization and cost, for example, by measuring the impact of specific co-morbidities in knee replacement patients. Blue companies have identified leading providers and instituted pre-surgical programs that minimize complications.
BHI’s sophisticated predictive models include the identification of individuals at greatest risk of hospitalization due to diabetes-related complications. By focusing on modifiable risk factors, health plans design patient and provider programs targeted to meet unique patient needs. BHI is a leader in delivering the next generation of data-driven information about healthcare trends and best practices resulting in healthier lives and affordable access to safe and effective care.
Reducing medication costs while ensuring safety and efficacy
Premera Blue Cross of Washington’s Polypharmacy Program has been touted by Harvard Medical School researchers as “... a simple yet effective example of what we can do to improve safety and reduce medical errors and healthcare costs.” The program helps engage members in understanding how medications work by identifying members older than 19 years of age who are taking five or more medications. These members, more than 166,000 to date, are sent proactive communications educating them about the increased risks for medication-related problems and the importance of reviewing all medications with their healthcare providers. An observational study showed decreased emergency room and hospital utilization rates in members the year after they were sent the educational materials, as compared with the year before. Member research also showed that since the program’s inception in June 2001, there has been a measurable decrease in inappropriate treatment or dosage: 29 percent reported medication changes, 64 percent reported dosage changes and 57 percent reported that a medication was stopped.
Blue Cross of Idaho Health Service implemented a pharmacy program that used coupons as an incentive to move members from prescription drugs to appropriate over-the-counter (OTC) alternatives that offered similar quality and greater value for members using non-sedating antihistamines. The program decreased the company’s drug and prescription processing costs overall and achieved $1.9 million in savings, nearly double the initial target.
Preventing and fighting healthcare fraud
Blue Cross and Blue Shield companies actively work to combat healthcare fraud and abuse. Anti-fraud efforts protect consumers’ health and lives, and help save consumers’ healthcare dollars. Blue companies’ investigators work alongside federal, state and local enforcement authorities and other anti-fraud organizations to investigate and prosecute healthcare fraud. Blue companies’ anti-fraud investigations have resulted in an annual average of $326 million in savings and recoveries for the past five years, totaling more than $1.6 billion.
Anthem Blue Cross and Blue Shield (Georgia) detected suspicious billing practices by a provider. In-depth data analysis revealed excessive provider billing, namely surrounding protracted treatment times. Undercover activities by the company’s internal Fraud and Abuse team revealed evidence, including intent to defraud and kickback arrangements. The investigation was referred to the Federal Bureau of Investigation and the U.S. Office of Personnel Management. This investigation resulted in the indictment and conviction of three providers, with restitution of $6.6 million ordered by the court and the closing of clinics offering fraudulent services.
