Change Incentives to Promote Better Care - What the Blues are Doing
Blue Distinction: Recognizing and Incenting Quality Care
Blue Distinction is an innovative program that assesses hospitals based on objective, evidence-based criteria. The program is designed to help enable consumers make more well-informed decisions in selecting providers, while it encourages improvement in the overall delivery of patient care. Through Blue Distinction Centers for Specialty Care, Blue members have national access to providers with Blue Distinction designations for transplants, bariatric surgery, cardiac care and, coming shortly, complex and rare cancers. Each Blue Distinction Center has been designated based on rigorous selection criteria developed in collaboration with medical specialty societies and medical experts in the field. Though individual results may vary, aggregate data confirm that Blue Distinction Centers have achieved improved outcomes. For example, the inpatient mortality rate for heart attacks at facilities that fell below the Blue Distinction criteria - and did not qualify as Blue Distinction Centers - reaches a high of as much as 40 percent. That compares to a highest mortality rate of about 15 percent at Blue Distinction Centers for Cardiac Care - a dramatic difference.
Pay for Quality: Rewarding Quality Care
Blue Plans are increasingly reimbursing providers based on outcomes and quality of care. Most Blue Plans offer some kind of Quality-Based Incentive Program (QBIP), which modifies reimbursements to hospitals and physicians based on consensus quality standards designed by third party experts such as the National Quality Forum and the Hospital Quality Alliance.
Blue Cross and Blue Shield of Illinois has seen improvement in both performance and health outcomes from implementing a program that pays and publicly recognizes physician groups in its HMOs for meeting annual clinical performance targets. The measurements include rates of Pap smears, mammography, colorectal cancer screening, influenza vaccination, childhood immunizations, and mental health follow-ups and indicators related to the management of chronic conditions, such as diabetes, asthma, hypertension and cardiovascular disease.
Blue Cross and Blue Shield of Hawaii has a Quality Service Recognition (QSR) program that is a voluntary program for its PPO participating physicians and hospitals. It provides financial incentives for meeting national clinical quality benchmarks in the delivery of care. In 2006, the program paid $16.9 million to 17 hospitals and 2,575 physicians. QSR has been in place for more than eight years. The Hawaii Plan was the first health plan in the nation to develop and implement such a pay-for-performance incentive program.
Access to Generic Drugs: Reducing Costs while Ensuring Safety and Efficacy
With prescription drug costs skyrocketing, generic drugs offer consumers a safe, equally effective and lowercost alternative to brand name prescriptions. According to estimates, the use of generics in place of brand names could save consumers between $8 billion and $10 billion each year (Congressional Budget Office, 1998). Blue Plans believe the best way to improve affordability of prescription drugs is to assure a competitive pharmaceutical market and take action to promote generic use. Of course, no drug can be helpful if not taken. Longtime adherence to drugs prescribed for chronic illnesses is essential if such diseases are to be managed effectively.
Blue Cross and Blue Shield of Michigan has been educating consumers about generic prescription drugs through the "Generic Drugs - The Unadvertised Brand" initiative since 2001. The initiative has raised use of generic prescriptions from 38 percent of total prescriptions to more than 58 percent, saving consumers more than $71 million in out-of-pocket costs. Through a consumer Website (www.theunadvertisedbrand.com), the Plan provides a cost and quality calculator, generic drug educational information and alerts about new generic drugs. It also allows users to check if their drugs are available as generics.
Patient Centered Medical Homes: Encouraging Evidence-based Care to Prevent and Manage Chronic Illness
BCBSA and Blue Plans are working with the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians and the American Osteopathic Association to pilot "patient centered medical homes" that will encourage a more "hands-on" physician approach and more active patient involvement in preventing and managing chronic conditions. The goal is to develop reimbursement mechanisms that strengthen the physician-patient relationship and assure better coordination and management of chronic care.
Medicare Advantage: Improving Care through Prevention, Coordination and Management
Blue Medicare Advantage (MA) Plans have ongoing initiatives to improve care for those with chronic conditions. MA plans identify and provide support to those who could benefit from more specialized care or who have not received recommended preventive care. Through partnerships with physicians and other caregivers, MA plans work to coordinate and improve care for these beneficiaries.
Blue Shield of California's Congestive Heart Failure Program coordinates personalized care through the collaborative effort of a team of physicians and nurses using special home monitoring equipment. The program reduced expected inpatient admissions and emergency room visits in 2005 by about 20 percent.
Among Medicare HMO members, Highmark Blue Cross Blue Shield's colorectal cancer screening program increased screening rates for members by over 9 percentage points from 2003 - 2005. During that timeframe, its osteoporosis management program had a nearly 9 percent increase in the number of members receiving management services after a bone fracture, and its diabetes disease management program demonstrated improvement in HEDIS diabetes care measures, with scores that exceeded national averages in all measured areas.
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