What the Blues are Doing
Coordinating care to better manage chronic illness
Regence Blue Shield developed a Patient-Centered Medical Home (PCMH) pilot, the Intensive Outpatient Care Program (IOCP), in partnership with a major account, for “highest-risk” employees - those representing 65 percent of the company’s healthcare costs. By delivering highly personalized, coordinated care, the program aimed to improve health and employee productivity, increase patient and provider satisfaction and reduce overall costs. Employees in the program received 24/7 access to a care team and a personal registered nurse that worked with the member to develop an integrated care plan. Regence provided patient claims history back to providers to help identify gaps in care and target interventions. In addition to high reported patient and provider satisfaction scores, the pilot resulted in a 14.8-percent increase in patient-reported physical function and a 16.1-percent increase in mental function. The average number of patient-reported workdays missed in the last six months of the pilot decreased by 65.5 percent. Healthcare costs of pilot participants were 20 percent less than the control group, primarily due to reduced emergency room use, hospital admissions and inpatient days.
Horizon Blue Cross and Blue Shield of New Jersey, Inc. pays for what are traditionally non-covered care coordination activities such as telephonic consultations and reaching out to patients who may need additional assistance with taking their medications or keeping doctor’s appointments. The company uses claims’ data to identify and alert providers when patients need routine tests and screenings. In one program covering 7,000 State Health Benefit members with diabetes, patients’ compliance with tests rose substantially, and overall healthcare costs decreased by nearly 10 percent in one year.
Blue Cross of Idaho Health Service provides one-on-one nurse health coaching and outreach to members who visit the ER or receive inpatient services due to congestive heart failure. By using a team-based and patient-centered approach, the program helps ensure that members take the correct medications and receive the necessary screenings and follow-up care. Biometric monitoring equipment is shared with high-risk members with congestive heart failure, enabling them to report their conditions from home. The program collectively achieved more than $1 million in medical claims cost savings in a single year, and a recent in-depth medical cost savings analysis revealed an average return on investment of 4-to-1 for members who participate in disease management programs. Blue Cross of Idaho offers disease management programs for members with diabetes, chronic obstructive pulmonary disease, coronary artery disease, asthma and depression.
Enhancing the practice and delivery of primary care
The Blues are working in collaboration with national and local healthcare industry stakeholders to enhance the practice and delivery of primary care. The Patient-Centered Medical Home (PCMH) places the patient and primary care practice at the center of care, creating a partnership between the patient and their personal physician. The goal of the PCMH is to provide comprehensive and coordinated care delivery by a primary care team focused on continuous care across all aspects of the healthcare system. Blue Cross and Blue Shield companies have launched PCMH programs across 38 states, the District of Columbia and Puerto Rico, encouraging increased use of health information technology and greater patient involvement and interaction with primary care providers.
Since 2007, Independence Blue Cross has demonstrated a commitment to better primary care through its participation in Pennsylvania’s Chronic Care Initiative, a groundbreaking patient-centered medical home model. Pennsylvania is one of only eight states to be part of a new federal medical home demonstration pilot that will explore better ways of raising quality of care while lowering costs. The early results of Pennsylvania’s Chronic Care Initiative demonstrate that chronically ill participants took more responsibility for their care and showed marked improvement in health outcomes. Diabetic patients showed positive results in key factors important to preventing complications: significant increases in controlling blood sugar, blood pressure and cholesterol; getting preventive eye and foot exams; and taking medications proven to delay and prevent kidney disease. Of the participants in the program, 50 percent more had well-controlled diabetes, 70 percent more had well-controlled cholesterol, and 38 percent more had well-controlled blood pressure.
Blue Shield of California created an Accountable Care Organization (ACO) pilot to improve quality of care for the 41,500 CalPERS members it serves in Sacramento. Launched in January 2010, the CalPERs ACO brought together leaders from physician groups, hospitals and Blue Shield of California to develop strategies to improve quality and lower costs. Care delivery improvements, including shared systems that allow the ACO to communicate seamlessly with members, have led to a 15-percent decrease in hospital readmissions; a 15-percent decrease in inpatient hospital stays; a 50-percent decrease in inpatient stays of 20 days or more; a half-day reduction in the average patient length of stay; and an estimated $15.5 million in overall healthcare cost savings. Leveraging the lessons learned and success of the Sacramento pilot, the company has replicated the ACO model in San Francisco, Modesto and Orange County.
Blue Cross Blue Shield of Arizona, in partnership with Arizona hospitals, launched a pilot program in January 2011 to lower readmission rates for its members. The program aims to lower hospital readmission rates by ensuring members have their prescriptions filled and keep follow-up appointments with their physicians after discharge. Compliance with these two key measures can decrease readmission rates and avoid an estimated $1 million in costs. Of the 456 members in the program, 66.2 percent had their prescriptions filled within five days of discharge; 63 percent saw their doctor within 14 days of discharge; and fewer than 20 percent were readmitted within 30 days of discharge. In contrast, members who did not participate in the program had lower medication refill rates and fewer follow-up physician visits, resulting in a 10 percent higher hospital readmission rate than program participants. By simply focusing interventions on these two important evidence-based measures, the company and state hospitals can collectively improve patient outcomes and reduce healthcare costs.
Investing in the primary care workforce
Blue Cross Blue Shield of Michigan’s Physician Group Incentive Program (PGIP) connects physician organizations from across the state to encourage information sharing and collaboration among primary care physicians and specialists, with the goal of improving the state’s healthcare system. Each initiative offers incentives based on clearly defined metrics to measure performance improvement and program participation. PGIP includes more than 30 initiatives that reward physician organizations for their efforts to improve quality of care and affordability by implementing capabilities such as e-prescribing, registries and care coordination. By end of 2011, PGIP will include 40 contracted physician organizations with membership totaling more than 11,000 primary care physicians and specialists who provide care for approximately 1.7 million members. Sixty percent of members in participating practices have 24/7 access to care, as compared to 25 percent in non-participating practices. Practice units that have met program criteria have 17 percent fewer inpatient admissions for ambulatory-care sensitive conditions, a 6-percent lower 30-day readmission rate and a 4.5-percent lower emergency room visit rate.
Blue Cross and Blue Shield of North Carolina Foundation awarded a grant to the North Carolina Academy of Family Physicians (NCAFP) Foundation to develop a mentoring program to help address the state’s shortage of family physicians. The $1.18 million grant supports the establishment of the Family Medicine Interest and Scholars Program, an effort to help increase the number of North Carolina-trained medical students who elect family medicine residency programs and go on to practice in the state. Physician mentors will work with students for three consecutive years to strengthen skills, offer guidance and help fast-track their healthcare leadership training and experience. North Carolina currently has approximately 2,700 family physicians, with projections indicating the state will need 2,000 more by 2020 to address the state’s healthcare needs. The program aims to increase the percentage of medical students who commit to a residency in family medicine by approximately 30 percent and increase the percentage of those who elect to stay in the state for their residency training from 56 percent to at least 66 percent during the length of the program.
Blue Cross and Blue Shield of Texas launched a Pre-Admission / Post-Discharge Outreach Program in January 2008 with the goal of reducing hospital readmission rates. Blue Care Advisors initiate telephone calls to identify members to reinforce pre- and post-operative instructions, review medication management and discuss self-management techniques. In 2009, members who received the call experienced a 23 percent lower readmission rate versus those who did not, resulting in estimated potential cost savings of $1.2 million.
