Highmark Pilot Program for National Committee for Quality Assurance

Highmark Blue Cross Blue Shield

Although improving quality of care is a laudatory goal, many health insurers' initiatives are a source of frustration to physicians because they generally require them to devote substantial time and resources to documenting care or responding to queries or requests from insurers.

In the case of the Highmark Blue Cross Blue Shield (Highmark BCBS) pilot program NCQA: Physician Recognition, the Plan developed a program to provide meaningful assistance to physicians completing an external physician recognition program from the NCQA. The NCQA program encourages physicians to improve the quality of care by having them attain recognition in one of several programs that require physicians to demonstrate systems for managing the care of patients with chronic medical conditions and also to demonstrate acceptable outcomes based on a chart review of random samples of patients. Relatively few physicians nationwide have sought such recognition because of the intense effort the process requires.

Highmark BCBS recognized the importance of encouraging physicians to seek recognition through the NCQA program. The physicians in the Highmark BCBS network oversee more than 55,000 members with chronic conditions, and the care provided to these patients did not always conform to national standards. In addition, employers are strongly supportive of such recognition programs that were first developed under the auspices of several large employers.

In this program, provided as a no-cost service to physicians, Highmark BCBS medical management consultants worked with physicians in western Pennsylvania during a one year period (2007) to help them seek NCQA recognition in diabetes, heart/stroke or physician practice connections. After the physicians completed a baseline performance assessment, the Plan consultants worked with each individual physician and/or practice to identify gaps in care and provide specific recommendations and process improvement tools that could be used to overcome these gaps.

As a result of this program, the number of physicians in the western Pennsylvania network with NCQA recognition increased from just 25 to more than 550. Physician participants in the program agreed that the program was beneficial, and 70 percent thought that their patients' experienced improved health outcomes as a result of the pilot program.

Program Contact: Twyla Johnson, Manager, Provider Performance Consulting, 412.544.5167, twyla.johnson@highmark.com