Blue Cross and Blue Shield Association Highlights Blue Distinction, a Major Initiative to Improve Healthcare Quality and Value
Blue Distinction is a powerful nationwide collaboration of Blue Cross/Blue Shield companies, expert physicians in many specialties, and medical organizations, doctors and hospitals, designed to move healthcare to a system that truly rewards high quality care, while delivering value to customers. And, most importantly, for our insured members, restoring trust in the healthcare delivery system.
With us today we have a distinguished panel of experts. First you'll be hearing from Dr. Carolyn Clancy, who is Director of the Agency for Healthcare Research and Quality. She's a general internist and a health services researcher. And her major areas of expertise include the study of healthcare quality, women's health, primary care, disparities, financial incentives and other issues that impact really the health and welfare of the American people.
She served us all admirably for several years. And we all hope that she will continue to do so. She's published widely in peer reviewed journals and has edited and contributed to many books.
She's a member of the Institute of Medicine and in 2004 was accorded the rare distinction of being elected a master in the American College of Physicians.
You'll hear from her first. And, unfortunately, due to a conflict, she'll have to leave after her presentation, but if there are questions we'll see that they're directed to her rather than answer them for her, which I, of course, offered to do, but...
Also joining us today is Dr. Carol Redding Flamm, the Executive Medical Director in my Office of Clinic Affairs at the Blue Cross/Blue Shield Association. And she manages and provides clinical oversight for our Blue Distinctions of Specialty Care.
She serves on a number of or has served in the past on a number of outside advisory committees, including the Medicare Evidence Development and Coverage Advisory Committee as a voting member and the Maternal and Child Health Benefits Advisory Board at the National Business Group on Health.
Following Dr. Flamm's presentation, we'll have two other speakers. And then Carol will come to the microphone to lead the discussion, chair the meeting and direct any questions to our panelists.
The next speaker will be Dr. Fred Edwards, who is a professor and the chief of cardiovascular surgery at the University of Florida Jacksonville and the Chairman of the Society of Thoracic Surgeons National Database. Dr. Edwards has been involved with the STS database for more than 15 years and was appointed chairman of the database in the year 2004.
He developed the first national risk adjustment models in cardiac surgery and has had a key role in all subsequent Society of Thoracic Surgeons risk models.
Dr. Edwards has published more than 120 papers in peer reviewed literature, most of which deal with some aspect of outcomes analysis. His present research is directed towards outcomes analysis, the use of national performance measures and quality assessment and statistical techniques to objectively measure surgical quality.
Dr. Edwards is active in several national quality organizations, including the Quality Alliance Steering Committee, the Steering Committee of the AQA, the Executive Committee of the American Medical Association Physician Consortium for Performance Improvement and the Standards Maintenance Committee of the National Quality Forum.
Our next speaker will be Mr. Ed Caillier, Vice President of the Benefit Design for US Bancorp, the diversified financial services holding company, with 54,000 employees headquartered in Minneapolis, Minnesota.
US Bancorp is the parent company of U.S. Bank, the sixth largest bank in the United States, with over 2,500 branches in 24 states. Ed is responsible for the strategy, design, vendor and financial management for the company's health, dental, life and disability management programs.
He has held various human resource management roles at other leading financial services and marketing firms in the Twin Cities.
Ed earned his MBA at the University of St. Thomas in St. Paul, Minnesota, and his undergraduate degree in psychology from the University of Minnesota.
Although not on the panel, I want to recognize Dr. Joe Singer and Dr. Andrea Devries from Health Core, Inc. a subsidiary of WellPoint, Inc., which is the holder of the Blue Cross/Blue Shield license in 14 states. Health Core is responsible for some of the cardiac effectiveness data we will share with you today and conducted our multi‑plan study with generous support from WellPoint, and it's due to their extraordinary contribution that we do have the data today to share with you.
Both Dr. Singer and Dr. Devries are here to answer questions following the briefing. Now, you know the Blue Cross/Blue Shield, the Blue Shield Blue Distinction program was launched, as I told you, three or four years ago. And if you look back, in the year 2005, six years after the IOM Report on to Err is Human, our patients were still waiting, were still waiting for the solution to the problems that they so keenly were then made aware of.
And if you step back and ask ourselves what our patients were waiting for ‑‑ and, by the way, probably still are ‑‑ there were four things.
One, security and her belief that her care will be safe. Two, someone trusted to turn to while navigating the complex healthcare infrastructure. Three, information about those who might treat her and her family.
And, four, confidence that those who treat and finance her care respect her and each other and collaborate to find the best treatment options to preserve the affordability of her premiums.
Our patients were waiting. Our patients are waiting. And we do believe, combined with some of our outpatient initiatives Blue Distinction has some enormous strides in delivering what our patients are waiting for. Carolyn.
Introduction: Dr. Carolyn Clancy, Director of the Agency for Healthcare Research and Quality
Thank you, Dr. Korn, and congratulations to the work of the Blue Distinction program participants. I'm very happy to be part of this event highlighting the accomplishments of the designees.
You know, at the Agency for Healthcare Research and Quality, ARQH, we take the practice of evidence‑based medicine very seriously. By that I mean, simply assuring patients that they get the best of biomedical science as a benefit to their care,that it's incorporated into the care that's provided to them.
And one of our primary charges is to promote evidence‑based practice in everyday care. And it's great to see sustained growth of this nature in collaborative efforts to develop evidence‑based thresholds for clinical quality. This approach really helps us to address key issues involving what I see as missing in healthcare today.
The first is real time information. We're collecting a lot of data, but we don't actually have good information to work with that gives us information about what are the best treatment options, what is the best treatment option for a particular patient and that also provides that information so patients understand what are the decisions they need to make.
We need to learn a lot more about evidence‑based management and the collaboration that's going on here between physicians and hospitals, I think, is really terrific because hospitals and physicians as part of this program will be examining the same data and developing together shared strategies for improvement
And some of those strategies will have to be adjusted. We're not going to get it right the first time. But there's a framework here that actually helps us to begin to build the kind of delivery system we need.
Because to get to a healthcare system that we all want for ourselves, one that consistently delivers high quality evidence‑based care, we have to make a commitment to a reusable or, in green terms, sustainable infrastructure, that actually makes it very easy to deliver the best and most current information to the point of care.
Allows, I'm going to emphasize that word, easy collection of data so we know we're on track or not. And feeds that information back to clinicians and front line workers so they see the connection between their daily work and those report cards.
And we don't, for the most part, see that today. In other words, this whole enterprise needs to add value for everyone. And by everyone, I mean consumers, patients as well.
The most technically perfect procedures are for naught if patients leave thinking I'm done, I'm cured, I don't have to take pills or that's kind of optional. Because we know what happens, they'll be back for more procedures particularly for those conditions where we haven't actually changed the underlying disease.
So the bottom line is we all have to be part of the solution, because information about cost and quality provided in the right way can lead to stronger and more effective partnerships that can improve patient outcomes in a value‑based environment.
Now, we're not there yet, but what I wanted to just spend a couple of minutes talking about was how I see this approach aligning with what we're doing at HHS. So ARQH is leading a number of value‑based initiatives. One of these is tightly aligned with the HHS value‑driven healthcare initiative.
And basically the overlying principles for this are that these are collaborations between key stakeholders, consumers, insurers, employers, hospitals, clinicians and so forth, so that ultimately we can build a delivery system that's information‑rich and patient‑focused.
If you've been near healthcare lately you'll know that's actually not a given. And that when evidence is continually refined and improved as a byproduct of care delivery, and that ultimately that information and evidence helps us transform our interactions from ones that are reactive, what's your problem today, to one that's proactive. In other words, where I have all your information before you arrive so that we can anticipate problems.
And that that actionable information, the information you need and only the information you need is available just in time. So our role in this HHS value‑driven healthcare initiative has been leading a group of communities that are known as chartered value exchanges.
Now, these are multi‑stakeholder collaboratives. Some of them have existed for a long time, like in Minnesota and Wisconsin. Others came together. Like in Louisiana, for this very purpose, to be part of this initiative.
Some are statewide like Louisiana. Other states have three of these community initiatives. But the bottom line is they are fostering an environment for collaboration where, again, payors, employers, clinicians, patients and hospitals can get together and get beyond finger pointing and say, okay, how do we actually begin to solve this problem.
And that's really the exciting part and why I see your initiative so exciting. In much the same manner as we're fostering through these community collaboratives, this Blue Distinction program is recognizing that collaboration is essential.
Designees can play a key role in building a road map for the future of value‑based healthcare, and they can keep this enterprise inclusive. There's no limitation to how many hospitals can become part of the Blue Distinction program. And they can address gaps such as value‑based measures across episodes of care in patient centered outcomes. Just even reading the first level of details, you realize this is only the beginning.
And ultimately we'll understand how real incentives drive behavior and outcomes. At the end of the day what makes me very excited here is that it's aligning the best of medical professionalism with the interests of hospitals with the interests of patients, and that is a win‑win solution.
So I want to congratulate you again and the designees for your work and your successes in improving healthcare quality across the nation and at ARQH we look forward to working with you in the future.
Introduction: Dr. Carole Redding Flamm, Executive Medical Director BCBSA
Thank you so much, Carolyn. I'm going to spend the next 10 minutes or so talking about the Blue Cross/Blue Shield Association's Blue Distinction program and describe to you how this program aims to improve quality and value in our healthcare system.
The program is a national quality‑based designation, awarded to hospitals and medical facilities that have demonstrated their expertise in delivering quality healthcare for complex areas of specialty care.
And the designation is based on objective, credible evidence based selection criteria developed in collaboration with medical experts and medical organizations.
Nationally, we've developed Blue Distinction programs in the areas of cardiac care, bariatric surgery, complex and rare cancers and transplants. There are more than 800 designations across about 650 facilities, spanning 45 states.
In the Blue Distinction programs are developed through a clinically‑driven process that encourages continuous quality improvement. And we're collaborating with the medical community to identify criteria across a broad range of quality metrics, including structures of care, processes of care and outcomes of care.
We align wherever possible with nationally established quality measures such as those endorsed by the National Quality Forum and other quality organizations. And we recognize various national accreditation or certification processes that have been developed by independent organizations.
So what do we evaluate when we look at facilities? We're looking at dedicated quality improvement processes and data management systems. We're looking at multi‑disciplinary teams and physician and surgeon experience and training.
We also examine a program's experience including case volumes, which has been found to correlate with better outcomes for a number of complex surgical procedures.
We also look at clinical data on processes and outcomes. Processes such as adherence to evidence‑based care and guidelines and clinical outcomes such as survival, mortality rates and complication rates.
All of our selection criteria and scoring methods are publicly listed on our website showing our commitment to transparency in our process. We don't predetermine the number of centers that will be designated. And after completing the detailed evaluation process, we offer the Blue Distinction center designation to facilities that successfully meet our objective program selection criteria and thresholds.
And in addition, in an effort to support ongoing and continuous quality improvement, we provide detailed feedback to each facility that has applied through our process. Including identifying opportunities for quality improvement and creating opportunities for our local Blue Cross/Blue Shield plans to collaborate with facilities in their local regions to support ongoing quality improvement.
We hope that facilities will continuously improve and strive to meet the criteria which will serve to raise the bar on quality overall. One of the very important features of our approach with Blue Distinction is to focus on clinical data and measures.
And to develop our selection criteria and collaboration with expert physicians and medical organizations, our relationships across physicians and medical organizations are broad, deep and expanding.
And we are dedicated to an open collaborative approach as we develop new programs and identify opportunities to improve healthcare quality. Just to recognize some of the key organizations that have provided input through this collaborative process, I want to mention that in the areas of the Blue Distinction Centers for Cardiac Care, we have very successfully collaborated with the Society of Thoracic Surgeons. And Dr. Fred Edwards is here representing that organization today. And the American College of Cardiology. This afternoon Dr. Edwards will talk about our collaboration and how the measures that we include in Blue Distinction can encourage medical facilities to raise the bar and provide the best cardiac care.
Blue Distinction Centers for Bariatric Surgery was developed with input from the American Society for Metabolic and Bariatric Surgery, the Surgical Review Corporation and the American College of Surgeons.
Blue Distinction Centers for Complex and Rare Cancers was developed in collaboration with the National Comprehensive Cancer Network.
And the Blue Distinction Centers for Transplant Programs have received input from the Centers for International Blood and Marrow Transplant Research, Scientific Registry of Transplant Recipients and the Foundation for the Accreditation of Cellular Therapy. And it's collaborations like these that drive creation and adoption of evidence‑based measures and national clinical registries which can be important sources of robust risk adjusted clinical outcomes data, the core of what we are looking at.
Where these resources exist, Blue Distinction will utilize them. And where they do not, we will help to stimulate their development. Next I'd like to share with you some of the outcome findings we've observed based on analysis comparing aggregated data across Blue Distinction centers compared to other facilities. When we compared important outcomes such as mortality and complications we find significantly better overall outcomes at Blue Distinction centers.
For cardiac bypass surgery, mortality at 30 days averages around two percent at Blue Distinction centers versus three percent at other centers. For heart transplants, mortality at one year averages at 11 percent at Blue Distinction versus 19 percent at other centers. For bariatric surgery, complications at 30 days average five percent at Blue Distinction versus eight percent at other facilities.
It's important to note that Blue Distinction centers do not use claims data to choose our centers, and we don't factor in cost data in selecting the centers. However, because there is great interest to better understand the relationship between quality and cost, we've performed additional program evaluation studies to examine the patterns and costs of care using administrative claims data.
As Dr. Korn mentioned earlier, we turn to Delaware‑based health Corp. to conduct a multi‑plan study with the cardiac specialty program. The Health Corp research which was generously supported by WellPoint is comprehensive and includes aggregate data from 24 plans in 23 states where Blue Distinction centers for cardiac care exist. According to the Health Corp. research, there are real differences in both quality and cost outcomes at the Blue Distinction centers compared to nondesignated facilities. Specifically, some of the findings that we're sharing today are 26 percent lower readmission rates for bypass surgery and 37 percent lower for outpatient angioplasty based on 30‑day cardiac readmissions.
When we look at a 90‑day cardiac readmission rate, the difference is still there and statistically significant, 21 percent at Blue Distinction centers after bypass surgery and 32 percent for outpatient angioplasty.
Just to reiterate, the actual results at 90 days, we're seeing a 13.2 percent readmission rate at Blue Distinction centers, versus 16 percent at the other centers after bypass surgery. And a 10.6 percent rate at Blue Distinction centers versus 15.5 percent rate at other centers after angioplasty when performed on an outpatient basis.
We're also observing lower risk adjusted costs of care. Five percent for bypass procedures, or 12 percent less for outpatient angioplasty, looking at a 90‑day episode of care.
These lower costs equate to $2,259 less per case for bypass surgery and $2,542 less for outpatient angioplasty.
Given these favorable overall outcomes for quality and value, we feel it is very important to help raise awareness across our members and more broadly across healthcare stakeholders.
Some of the ways we're supporting better awareness is to publicly list the names of our Blue Distinction centers on our national and local plan websites and provider finders.
And we have developed some user friendly search tools to help make the process of finding BDCs easier. In fact, the kiosk we have in the room today are demonstrating that one of those tools.
We have begun to see individual Blue Cross/Blue Shield plans and their accounts beginning to look for ways to identify ways to align incentives towards quality.
We're also hopeful that sharing this kind of information with all of you today will engage other stakeholders in collaboration to improve healthcare outcomes. Blue Distinction is a truly unique proposition, because it is a win‑win for all. As Carolyn mentioned earlier for providers and facilities, Blue Distinction is a key competitive differentiator based on quality.
For employers, Blue Distinction is a valuable tool in designing benefits with an eye toward outcomes. For local Blue Cross/Blue Shield plans, Blue Distinction helps support our overall objectives of quality access and affordability in healthcare.
And for patients, Blue Distinction seeks to improve the quality of care we have access to and support the decision making between doctors and our patients.
Where are we going from here? Blue Distinction will expand considerably over the next few years. We have new designations planned in the areas of spine surgery and knee and hip replacement surgery.
And then we'll be expanding our designations to include more common types of cancer and transplants. We look forward to working closely with our existing collaborative partners as well as many new organizations and expert physicians who will help us in those efforts.
We've come a long way in a relatively short period of time. And we do have much to be proud of. But there is so much yet to accomplish. For as Alan said succinctly, our patients are waiting. Thank you. I'm going to turn it over to Fred Edwards.
Introduction: Dr. Fred Edwards, Chair of Workforce on National Databases, The Society of Thoracic Surgeons
Thank you, Carol, and good afternoon to everyone. On behalf of the Society of Thoracic Surgeons, STS, I'd like you for the opportunity to present our perspective on quality measurement, quality improvement and our collaboration with the Blue Cross/Blue Shield.
STS is the largest professional organization of physicians that specialize in surgery of the chest, to include heart surgery. And we've always had this firm conviction that objective measurement of quality has got to be one of the highest priorities.
And that's been centered primarily on statistical models that we've used. They use patient risk factors to calculate the probability of an outcome. And that in turn allows us to really establish national benchmarks.
So this gives us a way to allow the local hospitals to pinpoint areas of improvement.
Now, that, of course, requires clinical data. And where does that come from? Our vehicle for data collection has been the STS national database. This is a database that rolled out in 1989 and now has well over three and a half million patients enrolled in it with a ton of clinical information on each one of the patients.
Today we have over 960 surgery centers across the country that participate in the database, and that turns out to be right at 90 percent of all the cardiac surgery centers in the country.
Several years ago, STS, along with several other organizations to include Blue Cross/Blue Shield recognize the importance of using national performance measures to objectively measure quality.
And we work with the National Quality Forum (NQF) to gain a measured set of 21 performance measures for cardiac surgery. That's a measure set we've used since then to assess quality in cardiac surgery all across the country.
Now, around this same time it became apparent that both STS and the Blues had common ground for our respective quality programs. The two organizations logically started to explore ways to work together to make a real impact on cardiac surgery care.
And, of course, we were glad to see that Blue Cross/Blue Shield recognizes the limitations of administrative data and the real value of clinical data. And both of us recognized the potential of merging this administrative data with the clinical data to make a more powerful data set.
While we were in these discussions STS leadership started to embrace the concept of composite measures. For those not familiar with that, these are measures that statistically account for the net impact of a variety of individual performance measures to come up with one single score that represents a quality score.
And typically this provides an index of quality for an entire episode of care as opposed to a more focused, for example, measure of outcome operative mortality, operative morbidity for a given operation.
So we recognize the value of these composite scores, and we started on a two‑year process to develop our composite measure for coronary artery bypass surgery. And since that composite as it turns out is the most heavily weighted criterion for Blue Distinction Center designation, probably ought to mention a couple other characteristics of it.
The composite is based on the 11 NQF measures that we have in our measure set that are based on coronary bypass surgery. We use preoperative, intra operative and postoperative characteristics that are based on process and outcomes measures in this composite model.
Now, I think it is important to note that the outcomes are all based on peer reviewed NQF endorsed and nationally validated risk adjustment.
After we turn the crank on this model, then we have a one, two, or three star rating at the hospital level. And the way we've developed the calibration of this initial model is that one can say with a 99 percent certainty if you've got a one star rating you in fact belong in that one star group. If you have a three star rating, then you can say with a 99 percent probability that you truly belong in that three star category.
So we're to see that the Blue Distinction Center calculations place a real high risk on this STS measure. And we think this represents the spirit of collaboration that really seems so essential to improve quality today.
As we know in the past, there have been some times when some large organizations have developed their quality programs without input from the medical community. And I think we all know the results have been predictably poor.
It's clear that the incentive program should be based on objective, credible and clinically meaningful data. If we're going to have provider acceptance and buy in to these programs, it's also important to have the input from the physicians, the guys that are out there in the trenches and understand the challenges of current medical practice.
The Blue Distinction Center initiative for cardiac care has used these principles to design a nationwide program that appears to be making a difference, as Carole mentioned.
For a variety of important parameters Blue Distinction Center institutions do have better results than centers that do not have that BDC designation.
Ideally this should just be the start. Large organizations like Blue Cross/Blue Shield are in a position to influence the quality and value of care through a variety of different incentives and feedback systems. And likewise the professional societies can influence the quality by focusing on other entry points like clinical registries, research and quality and defining national benchmarks.
So it looks like we have an opportunity for real synergism here. By that, I mean the yield of working together should be greater than the sum of our independent efforts.
And we're still pretty far from our full potential, I think, but collaborations like this have to be a strong step in the right direction. And thank you again for the opportunity to share our thoughts on this.
Introduction: Ed Caillier, Vice President for Benefit Design U.S. Bancorp
Hello. And thank you very much for the opportunity to be here today. Thank you, Dr. Korn. I wanted to give you some perspective around US Bancorp and our concerns around the delivery of quality and value in healthcare and why the Blue Distinction centers show real promise from our perspective.
As Dr. Korn mentioned U.S. Bancorp is a diversified financial services company headquartered in Minneapolis, we are the sixth largest bank in the country, although the rankings have been changing rapidly in the last few months. In fact, we've seen some companies wanting to become banks recently.
Our business is both regional with U.S. Bank being one of the largest consumer banks in the country. We operate nationally and commercially in corporate banking and we operate globally with payment services.
We have about 55,000 employees. My responsibility is to revolve around providing health coverage for about 87,000 employees, retirees and their family members at a cost of over $250 million annually.
I would like to applaud both Blue Cross and medical provider groups that have been collaborating on Blue Distinction centers to improve quality, affordability and patient outcomes.
Most of us have probably seen studies and reports that compared to other developed countries, the U.S. really pays too much for care that's highly uneven in quality and value. In fact, some of the estimates have shown that the amount of unnecessary or duplicative or inefficient care could run as high as a third of total annual healthcare spending.
So healthcare reform, of course, is not just about coverage for the uninsured. It's also about improving value and patient outcomes. And the Blue Distinction Centers are a significant reform initiative with demonstrated results.
For the last several years U.S. Bank has been a member of the national business group on health located here in Washington. The business group represents large employers who are working to find innovative forward thinking solutions to healthcare solutions.
I'm very happy to see that Blue Distinction Centers are aligned with some of the key business group principles. And there's three in particular. One is that evidence‑based medicine must be used to enhance health and quality of life and improve the return on our benefit investment.
Second, that healthcare reform is indeed a shared responsibility among the key stakeholders, health plans, employers, individuals, as well as the provider community.
And, third, that we're taking evidence‑based assessments that are working in one area and we're finding ways to adapt and transfer those to medical practices in other areas to help reduce the use of unproven or ineffective treatments.
Like most large companies, U.S. Bank spends a fair amount of time analyzing our claims data to determine what's working, what's not working, and what to do next.
And here's some of the things that we're finding. In terms of what's working, our plan design tries to incent our employees to do the right things, or, if they use more care, to pay more out of their pocket, because part of what we're concerned about is to the extent that our healthcare cost trends have a negative effect on affordability, those potentially who use little or no healthcare as premiums continue to increase beyond their ability to pay may choose to drop out of the plan.
And that's the last thing we need is to add to the numbers of uninsured and not have those folks in our plan. So we see things working like preventive office visits are actually increasing we cover preventive office visits at 100 percent with all other services being subject to deductible and co‑insurance.
We're also a part of business healthcare action group in Minneapolis, where we're measuring care delivery and we're rewarding providers who adhere to treatment guidelines, specifically for improving care of diabetics and those with heart problems.
And, finally, we see our generic drug use is increasing to help us moderate cost trends. But what are some of the things that are not working? Well, for us a big category is high cost claimants.
And these are claims that generally start at the 50 to $100,000 range, can easily move up to half a million dollars or a million dollars for a single claim. We see high cost biotech drug use and cost that's increasing at about twice the rate of conventional drugs.
In fact, we have a handful of members who are single biotech drug is costing about half a million dollars each per year. We see the price of services for emergency room inpatient/outpatient treatment increasing.
In 2007, about 99.5 percent of those who used our health plan accounted for about 80 percent of our total cost. The other one half of one percent accounted for a full 20 percent of our healthcare cost.
Another way to think about that is that we had about 470 high cost claimants that spent two and a half times as much as 42,000 other lower cost claimants.
What's my point of talking about high cost claimants and the fact that that's an area that we feel isn't working? Well, we feel we need to pay attention to the big things. We feel there's a significant payoff to focus on the small number of claims that are generating large plan costs.
And the Blue Distinction Centers are right in the middle of that. We've been using Blue Distinction Centers for transplants for over 10 years. We only have about anywhere between three and five of those a year, among our population, but the average cost runs about $250,000.
In 2006, we began using Blue Distinction Centers for bariatric surgery. At that time it was voluntary as to whether or not an employee needed to use them. Bariatric surgeries run 20 to $30,000 each. As we went through '06 and saw information and reports that using, that performing bariatric surgery at locations where quality measures have been put in place resulted in lower readmission rates, fewer complications, and just naturally as a result of that lower cost, we decided in 2007 to have bariatric surgery at a Blue Distinction Center be mandatory. It was no longer a choice.
And beyond that, the physicians that performed the bariatric surgeries, we required that they be participating providers in the Blue Cross network.
In 2008, we began using Blue Distinction Centers for both cardiac care and complex and rare cancers. Again, these are cases that start in the 50 to $100,000 range and can easily move up to half a million dollars a case.
So what's next from U.S. Bank's perspective as we look at our healthcare data? Well, we certainly see the value in many different ways of Blue Distinction Centers. We're looking forward to implementing the new Blue Distinction Centers in 2009 and beyond for spine and joint surgery and common cancers.
We're going to continue to support these kinds of efforts to improve quality and value and where the focus is on the highest quality and the most effective care.
We think that if we can get some of the big things right, that improving more of the small things associated with healthcare reform will easily follow. Thank you very much.
Carol Redding Flamm: We'd like to move into a question‑and‑answer period. We're happy to take questions. I'd like to make a couple of announcements. One is this briefing is being live webcast. For those joining us over the web you can enter in questions, we will receive them here and be happy to address those questions as well.
There are a couple of microphones for those of you who have questions in the room here. So please wait to receive a microphone. When you stand up please tell us your name and the name of your organization before your question.
Okay. We have a question from the web: Will the Blue Distinction Centers eventually steer patients to the participating institutions based on superior evidence‑based results? This is from Nancy Smith at Northwestern Memorial Hospital.
One thing I would like to describe, though, in the Blue Cross/Blue Shield system, decisions about how the Blue Distinction information is used is made by local plans working with employers like U.S. Bank and determining how the information is best used.
So I don't have one answer from a Blue Distinction perspective, but that's something that we're going to learn over time what kind of opportunities to promote value and quality work best and we'll be learning more information about those types of innovations as we move forward.
Any other questions?
Question: Todd Leeuwenburgh with Thompson Publishing. And I notice, at least on the ‑‑ there seems to be not any evidence‑based results on the cancer, from the cancer facilities. And I was wondering why that is. And I can ask further questions. Is it more difficult to set and recognize protocols that would distinguish a center of excellence type of a place, or has it been any more difficult to create alliances with practitioners or could it be the, you might say ever‑changing ways that cancer's treated with new developments all the time and off label uses and so on?
Carol Redding Flamm: Well, let me take the beginning part of that question and say that part of why we don't have results from that program yet is it was just launched in March of 2008. And we haven't conducted the analysis. But we are committed to doing those analyses and we'll be coming out with information in the future on that.
So you have hit on a number of points. And this is a program in complex and rare cancers. And cancer is a very complex area, indeed. But there are a lot of opportunities. And research that's ongoing, it's one of the very active communities in evidence‑based kind of studies and we're looking forward to working collaboratively with our various collaborating oncology organizations as we try to do those analyses and learn together where we are from a quality perspective and what we can improve.
Okay. Another question on line. Do you rate individual physicians and are those ratings related to the Blue Distinction? From Julie Miller, Managed Healthcare Executive.
No, we do not rate individual physicians. This is a hospital level designation program. And it is a quality‑based designation program based on a objective level of criteria and evaluation. So any Blue Distinction Center that meets our criteria is listed publicly. We don't rate, rank or do that sort of thing. It's a designation program at the hospital level.
Question: Norm Levey with the Los Angeles Times. Is there any system right now for rewarding institutions financially for attaining this distinction, or are there any plans in the future to do that?
Carol Redding Flamm: Well, I think one of the questions that a lot of our collaborating stakeholders have is: What's the business case for quality? And how can we work together to align incentives to support quality, quality improvement and to sustain that?
And I think several of the panelists made comments related to needing to get at that. There is not one system right now as I alluded to earlier. This is being explored on a case‑by‑case basis with our local plans trying to figure out what kind of incentives will help members and physicians and all of the stakeholders to engage in the type of quality improvement and using this type of quality information to achieve better value.
Question: Can I follow‑up? What would be some of the problems or some of the challenges with establishing a system that would actually incentivize quality outcomes?
Carol Redding Flamm: I think there's a lot of interest in exploring it. Looking at different opportunities like waving co‑pays or different kinds of benefit differentials, some of the processes that Ed described. I think there's not necessarily a problem with trying to do those things, but it's really the way our Blue Distinction program is organized, that's something that will happen at the local plan with our plans.
Are all Blue Distinction locations considered in‑network through Blue Cross/Blue Shield companies? But I don't have the name of the person or the organization.
Well, one of the program requirements is that to be a Blue Distinction Center you need to be a participating provider with the local Blue Cross/Blue Shield plan. So, yes, all Blue Distinction centers are considered network providers.
And I think that basically addresses the question.
Todd Leeuwenburgh: Very quick question. Is there anything about eliminating medically unnecessary procedures, did I say that right? Is there anything ‑‑ do you have any results in terms of sparing the patient medically unnecessary procedures that you might get at an unregulated facility?
Carol Redding Flamm: The focus of the criteria that we're looking at right now are structure measures, comprehensive care services and experience of the facility, processes of care. And insofar as those process measures look at adherence to evidence‑based guidelines and sort of providing the right care and outcome measures that if you're alluding to things like complications or unnecessary procedure resulting from a poor outcome, those types of things are included.
But I think you're getting at appropriateness of care and how do we look at the kind of care that's being delivered. I think that's something that, over time, we are interested in in looking at in companionship with the quality measures that we're including in the program today.
But I think that's an ongoing work in progress.
This is an active group on the web. Can other large and small carriers access Blue Distinction Centers for their plan and ASO clients that do not use Blue Cross/Blue Shield? From Edwin Child's Institute For Healthcare Quality.
Well insofar as Blue Distinction centers are public information, and we have them on our public website on BCBS.com anybody can look at that information and access the information about Blue Distinction Centers that exist today.
Are there different tiers in terms of quality? From an anonymous. This is not a program that yields tiering information. This is, as I mentioned, it's one set of criteria and a minimum threshold for scoring and absolute requirements and any program that meets those requirements is designated as a Blue Distinction center and we do not have quality tiering within the Blue Distinction center program.
All right. I think we've covered our questions. I want to thank our panelists and thank all of you for coming today. We really appreciate your interest in Blue Distinction. Thank you.
(Applause).
