Alabama Quality Initiatives
Blue Cross and Blue Shield (Blue Cross) of Alabama is committed to the development, implementation, administration, and monitoring of programs designed to promote the delivery of quality healthcare and services. As a result, Blue Cross maintains a Quality Management (QM) program to oversee compliance of quality standards mandated by regulatory and accrediting entities and corporate quality initiatives. Through systematically monitoring and evaluating care and service, the QM program supports corporate efforts on improving quality care delivery to members. Our multidimensional approach guides Blue Cross’ direction on opportunities to improve health status and outcomes. Areas of emphasis include member experience and satisfaction, provider performance, and internal operational processes. The QM program promotes a balance of system and individual accountability of all employees, delegates, and network providers for the care and service provided to our members.
The goals of the QM Program are to:
- Provide the structure and key processes that enable Blue Cross to carry out its commitment to ongoing improvement of care and service and improvement of the health of its members.
- Provide a collaborative approach that links key departments to provide a forum to monitor performance, discuss quality initiatives, facilitate decision-making, coordinate program activities across functional areas and make effective and efficient use of organization resources.
- Improve the quality, appropriateness, availability, accessibility, coordination and continuity of the healthcare and service provided to members.
- Design and maintain programs that improve the care and service outcomes within identified member populations, ensuring the relevancy through the analysis of the health plan’s demographics and epidemiological data.
- Maintain a high level of satisfaction among members, providers and customers about the services Blue Cross provides.
- Ensure that care and service are delivered in a culturally competent manner.
- Maintain accreditation, which assures our members, groups and providers a QM Program that adheres to national standards of excellence
- Maintain compliance with local, state and federal regulatory requirements.
The QM Program objectives that support attainment of these goals include:
- Complying with regulatory and accreditation requirements regarding QM Program activities.
- Measuring and reporting performance using measurement tools required by CMS, regulatory, and accrediting bodies and those that are standard in the managed care industry.
- Continuous monitoring and evaluation of clinical and service quality indicators that reflect important aspects of care and service using benchmarks and performance goals.
- Administering a Chronic Care Improvement Program (CCIP) to meet the needs of a defined population, including CCIPs as mandated by CMS.
- Developing and monitoring a Quality Improvement Strategy (QIS) for the Marketplace population.
- Assessing members’ cultural, linguistic and health literacy needs, and delivering of care and services in a culturally and linguistically appropriate manner to meet members’ needs.
- Providing timely and convenient access and availability of care via a comprehensive provider network that is credentialed and re-credentialed in a timely manner that complies with regulatory requirements.
- Ensuring the participation of practitioners in the planning, design, implementation and review of QM Program activities.
Quality Management Programs and Initiatives
- National Committee for Quality Assurance (NCQA) Accreditation
NCQA is a nationally recognized not-for-profit organization dedicated to improving healthcare quality. NCQA is a central figure in driving quality improvement throughout the healthcare system. For consumers and employers, the NCQA seal is a reliable indicator that an organization is well-managed and delivers high-quality care and service.i Blue Cross first passed NCQA’s rigorous, comprehensive review to achieve accreditation in 2015 and achieved NCQA accreditation again in October 2018. Blue Cross will continue to meet NCQA standards and report on its performance annually.
- Member Management
Blue Cross is dedicated to providing programs and services to positively impact the health and improve the quality of care for our members. The member management staff is available to provide assistance by offering member-centric services across the entire healthcare continuum, from wellness to catastrophic illnesses. Our approach is one that incorporates member health advocacy at its forefront.
Early identification and member engagement are important aspects of our Member Management programs. Through our Clinical Engagement Strategy, data analysis of our membership is performed to explore overall health and utilization patterns which provide strategic insights that drive member engagement opportunities. Blue Cross’ comprehensive Clinical Engagement Strategy is designed to provide focused campaigns and management interventions for our members.
- BlueCare Customer Advocacy Program
Our BlueCare Advocacy model assists members with customer service concerns including claims, billing, benefits, providers and services. Customer Service Representatives have access to member-specific data that allows them to provide services not included in the standard service model. While providing the services offered in the standard model, the BlueCare Advocacy model provides additional services that include:
- Contacting providers to resolve complex claims issues.
- Outreach to a provider when additional information is required to answer benefit questions.
- Assistance with selecting and scheduling appointments with primary care physicians.
- Review of preventive services when a gap in care exists.
- Education of members about available programs when key indicators are identified.
- Hospital and Physician Quality and Transparency Program
The movement to improve patient safety and quality care are driving the need for transparency in healthcare. Part of the Blue Cross response to this movement is the Physician Quality and Transparency Program. The goal of this program is to establish a statewide agenda to advance quality and improve clinical outcomes through the use of physician quality indicators, patient satisfaction and hospital performance data.
Enhancing accountability and efficiency in the healthcare marketplace will ultimately lead to better patient outcomes, more informed healthcare decision-making by consumers, and cost savings through best medical practices. Blue Cross continues to explore and implement opportunities to improve the quality of care delivered by our providers and practitioners. Some examples include:
- Hospital Choice Network: Blue Cross differentiates hospitals and encourages improved performance through our Alabama Hospital Choice Network. The goal of this network is to identify hospitals that can provide high-quality, cost-effective care by focusing on quality, cost and patient experience. This model provides transparency and empowers members to become more actively engaged in making informed choices about their care. Results are available to members, as applicable, through our “Find a Doctor” tool at AlabamaBlue.com
- Primary Care Value-Based Payment Program: Blue Cross supports a comprehensive value-based payment program targeting primary care physicians. The goal of this effort is to better align payment with value and quality. In order to qualify for additional payment opportunity, physicians are required to meet criteria related to advanced quality recognition (NCQA Medical Home Recognition or NCQA Diabetes Recognition), patient satisfaction performance, the ability to close gaps-in-care, and cost-efficiency performance.
- Primary Care Select Program: Blue Cross supports and collaborates with primary care physicians to help members meet their long-term health goals. Primary Care Select physicians are offered benefits in tools and resources from a customizable support model. The support model includes tools and exclusive support needed to help improve overall patient health. The Primary Care Select Program is one way Blue Cross is supporting and collaborating with primary care physicians and members looking to meet their long-term health goals. Primary Care Select providers are denoted on the Blue Cross website by the symbol adjacent to the physician’s name.
- Rate Your Doctor Survey: In an effort to help our members make more informed decisions, satisfaction surveys are collected for practitioners who treat Blue Cross patients. The questions have three focus categories: overall experience, communication, and appointments. Surveys are linked to a claim and only members who have a documented encounter with a practitioner will be allowed to complete a survey. Survey results are available to anyone searching for a doctor in Alabama.
- New Directions Behavioral Health Program
Blue Cross has partnered with one of the fastest growing behavioral health companies in the industry, New Directions Behavioral Health. With over 20 years of experience providing behavioral health and substance use services, New Directions offers URAC and NCQA accredited programs to promote continuity of care, member satisfaction and coordination of participants. Blue Cross’ relationship integrates behavioral health services and member management services to co-manage members who are identified as having co-morbid behavioral and medical conditions. Members have toll-free access to the Behavioral Health Contact Center 24 hours a day, 7 days a week. The Contact Center provides assistance to caller-in-crisis or for those in need of an urgent referral.
- Wellness Programs
The mission of the Blue Cross wellness program is to engage members and the community to improve health across all stages of life by providing tools and support to make better decisions about health. Blue Cross strives to provide solutions that address the entire health continuum of a population, from those who are healthy to those with complex healthcare needs. As such, Blue Cross actively engages each member in steps to evaluate and improve their health through healthy lifestyle choices and positive behavior changes, while helping members manage cost. This is accomplished through numerous programs, design to address the needs of both at-risk and healthy members through various wellness resources, incentive programs and online health information tools. Many of these services are provided free of charge, including the following:
- The Baby Yourself® Maternity Program helps ensure expectant mothers and their babies receive the best possible healthcare during pregnancy. This program is available to expectant mothers regardless of whether the pregnancy is normal or high-risk.
- myBlueWellness is a health and wellness website that provides information and tools to help individuals take control of their health. Individuals can learn about physical activity, nutrition and stress management, read the latest health news, and reference a symptom checker and health library to research health conditions and illnesses. There are videos, recipes, and online behavior change programs as well. Members may also have access to tobacco cessation counseling and nicotine replacement therapy. While myBlueWellness is available to everyone, Blue Cross members have access to additional personalized content, health trackers, health risk assessments and electronic newsletters. Through innovative tools on myBlueWellness, members are able to manage their health through the use of:
- myBlueRewards, an incentive program in which Blue Cross tracks activity completions and disributes incentives to those who meet the criteria outlined by their benefit plan.
- HealthQuotient®, a health assessment that helps members learn more about their health and find ways to address any risk identified.
- The Personal Health Record allows members to keep all of their information in one secure, centralized location. Members can choose to have data from claims and lab results automatically added to the health record, in addition to manually entering information.
- My Health Assistant Programs, a series of interactive web-based programs that offer practical information and tools for improved health and a healthier lifestyle.
- Member Education Care Reminders
Care reminders display personalized health notifications to members on myBlueCross, a secure member website on AlabamaBlue.com, as well as our Alabama Blue mobile app available for download on the App Store or Google Play. The purpose of care reminders is to educate members about recommended health services, screenings and tests. Members will see the health notifications listed below:
- Completed services
- Upcoming services due this year
- Overdue services
- Completed services that have results outside of the normal range
- Blue Distinction
Blue Cross gives members access to the nation’s largest provider network. With Blue Distinction national programs, they get access to designated providers that have met nationally consistent criteria for quality and cost.
Blue Cross plans are identifying Blue Distinction® Centers and Blue Distinction® Centers+ medical facilities and providers within Blue Cross’ provider networks. Both meet rigorous and objective clinical measures, resulting in better overall patient outcomes. Blue Distinction® Centers+ deliver quality care and treatment expertise in addition to cost-efficient specialty care. The programs cover the following areas of specialty care: bariatric surgery, cardiac care, cancer care, fertility care, maternity care, transplants, spine surgery, and hip and knee replacement surgeries.
Blue Distinction® Total Care (BDTC) is a national program recognizing physicians, group practices and certain hospitals for their efforts in coordinating total patient care. This program incorporates patient-centered and data-driven practices to better coordinate care and improve quality and safety as well as affordability of care.
- Opioid Epidemic Strategy
According to the Centers for Disease Control and Prevention (CDC), Alabama has the highest rate of opioid prescribing in the country. Higher opioid prescribing puts our members at an increased risk for addiction and overdose. Blue Cross is working to fight the opioid epidemic facing our members and the community by working in the following primary areas:
- Promoting awareness by providing ongoing education and advertising important dates through the use of social media. In addition, Blue Cross supports community efforts by partnering with several state and local awareness groups, as well as the Alabama Department of Public Health.
- Supporting appropriate prescribing of opioids for pain management by providing CDC treatment guidelines to primary care doctors and offering medication-assisted treatment options for members with opioid use disorder.
- Encouraging and supporting public outreach initiatives to prevent prescription opioid misuse, abuse, fraud and diversion. This also includes supporting and promoting “National Drug Take-Back Day” which provides free, anonymous collection of unwanted and expired medications.
- State-wide Initiatives
Blue Cross participates in the development of a variety of initiatives sponsored by the state of Alabama.
- Cardiovascular Health Program
Provides the opportunity for healthcare leaders from across the state to collaborate with the common mission of preventing death and disability from heart disease and stroke, and focusing on system changes in the worksite, healthcare and community settings. Blue Cross helps in developing resources that assist both patients who have diabetes and heart disease and their clinicians, including the Blood Pressure Task Force and Diabetes Self-Management Education (DSME) online coursework.
- Alabama Adolescent Vaccination Task Force(AAVTF)
Focuses on increasing the Alabama adolescent vaccination rates, with a specific focus on HPV vaccination. This coalition aims to help address barriers and improve human papilloma virus (HPV) rates in the state. The coalition supports the HPV vaccination as an effective cancer prevention strategy.
- Alabama Child Health Improvement Alliance (ACHIA)
Collaboration of public and private partners that uses measurement-based efforts and a systems approach to improve the quality of children’s health.
- Cardiovascular Health Program
- Be Healthy School Grant Program
Annually, Blue Cross awards grants up to $10,000 to schools across the state that enroll students in grades kindergarten through sixth. For the 2018 - 2019 school year, Blue Cross awarded grants totaling $261,000 to 27 schools. The grants are for the implementation of school-based health and wellness programs that emphasize increased exercise, nutrition education and parental involvement during the school year.
Quality Management Program Focus for 2019
- Clinical Quality Measure Improvement
Blue Cross utilizes national standards and measures to evaluate the quality of clinical care and member experiences of our Plan. The primary national standards and measures used are the Healthcare Effectiveness Data and Information Set (HEDIS®) and the Consumer Assessment of Healthcare Providers and Systems (CAHPS®). HEDIS is a set of standardized performance measures designed to ensure that purchasers and consumers have the information needed to reliably compare the healthcare quality. CAHPS® is a member survey, which measures member experience. Blue Cross continuously evaluates these outcomes to identify improvement opportunities and works to reach and exceed national benchmarks. Below are several key quality indicators that Blue Cross will focus on in 2019:
- Comprehensive Diabetes Care
Diabetic management initiatives, focusing on improving the health outcomes of our diabetic population, continues to be a top priority at Blue Cross. Diabetes is one of the most costly and highly prevalent chronic diseases in the United States, affecting approximately 30 million Americans.iii Studies show complications from diabetes can be reduced with early intervention and continuous follow-up care.
Monitoring of several key diabetes indicators including HbA1c control, diabetic eye screenings, and nephropathy screenings provides a balanced view of how providers address and members manage this complex condition. Our current outcomes are shown below.
Key Quality Indicator Marketplace Rate Commercial PPO Rate 2018 NCQA National Avg.ii HbA1c Control <8% 58.3% 62.5% 47.8% Diabetic Eye Exam 40.6% 51.4% 49.0% Diabetic Nephropathy Screening 90.5% 88.5% 88.1%
- Reduction of Plan All-Cause Readmissions
Blue Cross knows the importance of reducing unnecessary readmissions to improve quality of care. Discharge from a hospital is a critical transition point in a patient’s care. Poor care coordination at discharge can lead to adverse events for patients and avoidable hospitalization. Hospital readmissions may indicate poor care or missed opportunities to coordinate care better. Reducing readmissions represents an opportunity to improve the quality of care and reduce healthcare costs. Our current outcomes are shown below.
Key Quality Indicator Marketplace Rate Commercial PPO Rate 2018 NCQA National Avg.ii Plan All-Cause Readmissions* 10.5% 7.2% N/A *Lower rate is better
- Use of Imaging Studies for Low Back Pain
Low back pain is the most common and expensive reason for work disability in the United States and affects two-thirds of adults at some time in their lives.
When a member’s low back pain is not attributed to potentially serious spinal or other pathology, there is a poor correlation of x-ray findings with low back problems. According to the American College of Radiology, uncomplicated acute low back pain is a benign, self-limited condition that warrants no imaging studies (e.g., x-ray, MRI, CT scan). Identification of improvement opportunities for this measure will increase in 2019. Blue Cross wants to ensure members receive appropriate care, when necessary, while controlling costs and limiting unnecessary and costly medical procedures. Our current outcomes are shown below.
Key Quality Indicator Marketplace Rate Commercial PPO Rate 2018 NCQA National Avg.ii Imaging for Low Back Pain 59.2% 57.4% 75.6%
- Improved Member Experience and Satisfaction
Blue Cross is committed to increasing all quality measures related to member experience and satisfaction. In 2019, Blue Cross will continue to distribute various materials such as newsletters and wellness reminder postcards. Blue Cross will also engage members through social media (Facebook, Instagram, Pinterest and Twitter). Results of a few CAHPS® measures, which focus on member experience, are detailed below.
- Comprehensive Diabetes Care
|CAHPS Measure||2019 Results||2019 QHP National Avg.||2019 Results||2018 NCQA National Avg. ii|
|Getting Care Quickly||78.0%||75.9%||88.5%||85.7%|
|Getting Needed Care||76.3%||73.1%||87.9%||87.2%|
|Claims Processing||Not Asked||Not Asked||NA**||89.1%|
|Coordination of Care||84.2%||82.6%||84.7%||81.3%|
|Rating of Health Plan||73.5%||70.5%||70.7%||60.2%|
|Rating of All Health Care||81.3%||78.0%||85.5%||76.1%|
|Rating of Personal Doctor||87.9%||87.0%||91.0%||84.5%|
|Rating of Specialist Seen Most Often||86.7%||84.5%||84.8%||83.6%|
* Results obtained from 2019 Qualified Health Plan (QHP) Enrollee Experience Survey Results (prepared by CMS)
** Not a reportable result due to less than 100 responses
iiThe source for data contained in this publication is Quality Compass® 2018 and is used with the permission of the National Committee for Quality Assurance (NCQA). Quality Compass 2018 includes certain CAHPS data. Any data display, analysis, interpretation, or conclusion based on these data is solely that of the authors, and NCQA specifically disclaims responsibility for any such display, analysis, interpretation, or conclusion. Quality Compass is a registered trademark of NCQA. CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).
iiiAmerican Diabetes Association: www.diabetes.org
New Directions Behavioral Health is an independent company offering behavioral health solutions and services on behalf of Blue Cross and Blue Shield of Alabama.
HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).
CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).