Quality Management Program

Blue Cross and Blue Shield 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 designed to promote compliance with applicable standards and regulations by systematically monitoring, evaluating and improving the care and service delivered to customers while focusing on health status, health outcomes and experience. This multidimensional approach allows Blue Cross to focus on opportunities to improve health outcomes, member and provider satisfaction, and operational processes. The QM Program promotes the 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.
  • Conducting Quality Improvement Projects (QIPs) to improve specific aspects of care or service to members, including QIPs as mandated by CMS.
  • 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.
  • Monitoring and promoting practitioner compliance with evidence-based clinical practice guidelines.
  • Ensuring the participation of practitioners in the planning, design, implementation and review of QM Program activities.

Quality Management Programs and Initiatives

  1. 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 servicei. Blue Cross passed NCQA’s rigorous, comprehensive review to achieve accreditation in 2015. Blue Cross will continue to meet NCQA standards and report on its performance annually.

  2. 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.

    Blue Cross employs two member management identification strategies: event-based and nonevent-based. Event-based identification utilizes specific high-risk diagnoses, procedures, hospitalizations and precertifications to identify members to be referred to clinical staff for care coordination. Our proactive non-event based identification uses multiple data sources to provide risk and compliance scoring.

    Targeted interventions are employed to promote healthy habits and reinforce evidence-based standards of care for both preventive and chronic conditions. These interventions include identifying a primary care physician, locating resources to remove barriers to compliance, identifying and assisting in closing gaps in care, lifestyle change tools and educational resources.

    Member engagement is achieved through telephone outreach, mailings, emails and direction to our interactive website.

  3. 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.
  4. 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 ensure fiscal responsibility, quality and patient safety in network hospitals. This model provides transparency and will empower consumers to become more actively engaged in making informed choices about their care. Results are available to consumers, 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: In 2016, we expanded our efforts and made the value-based payment initiatives part of a larger program. 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 eligible to participate in this network only if they meet certain cost and quality thresholds in addition to other criteria. These providers have been flagged on our website using the following icon:Image of the Alabama Select icon.
    • 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; thus, only patients 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.
  5. New Directions Behavioral Health Program
    Blue Cross has partnered with one of the fastest growing behavioral health providers, New Directions Behavioral Health. With over 30 years of experience providing behavioral health and substance abuse services, New Directions offers URAC and NCQA accredited programs and services 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 service center 24 hours a day, 7 days a week. The Behavioral Health Service Center provides assistance to caller-in-crisis or for those in need of an urgent referral.

  6. Wellness Programs
    Blue Cross recognizes the importance of good health and its role across the healthcare spectrum. We strive 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 Blue Cross’ programs, which 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.
    • Walking Works® encourages participants to improve their health by incorporating walking into their daily routine. People of any fitness level can benefit from walking and can participate in this easy program. Users can log activity online or on paper tracking logs. WalkingWorks has recently been enhanced and integrates with physical activity trackers and a new mobile app.
    • 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. 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, preventive care reminders, health trackers, health risk assessments and electronic newsletters.
    • myBlueRewards is an incentive program in which Blue Cross tracks activity completions and distributes incentives to those who meet the criteria outlined by their benefit plan.
    Current outcomes of select preventive care key quality indicators are shown below.
    Key Quality Indicator Marketplace Rate Commercial PPO Rate 2016 NCQA National Avg.ii
    Preventive Screenings      
    Breast Cancer Screening 69.8% 74.2% 69.6%
    Colorectal Cancer Screening 53.7% 64.5% 57.1%
  7. 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
  8. Health Management Transition of Care (TOC) Program
    Health Management TOC nurses provide members with education, support, and resources needed during the post-discharge phase to improve members’ self-management and reduce readmissions to the hospital. Follow-up calls are made after discharge to ensure follow-up with their physician and medication adherence. The goal is to prevent emergency room visits and/or hospital readmissions.

  9. Blue Distinction
    Blue Cross gives members access to the nation’s largest provider network. With Blue Distinction, they get even more — a higher quality network.

    Blue Cross plans are identifying Blue Distinction® Centers and Blue Distinction® Centers+ medical facilities 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, complex and rare cancers, 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.

  10. 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.
  11. Cardiovascular Health Program
    Blue Cross participates in the development of a variety of initiatives sponsored by the Alabama Department of Public Health’s (ADPH) Cardiovascular Health Program. This 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.

  12. Be Healthy School Grant Program
    Annually, Blue Cross makes available $250,000 and awards grants up to $10,000 to schools across the state that enroll students in grades kindergarten through sixth. 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 2017

  1. 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 they need 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 2017:
    • Comprehensive Diabetes Care
      Several diabetic management initiatives, focusing on improving the health outcomes of our diabetic population, will be implemented in 2017. Diabetes is one of the most costly and highly prevalent chronic diseases in the United States, affecting approximately 30 million Americansiii. Studies show complications from diabetes can be reduced with early intervention and continuous follow-up care.

      Monitoring of several key diabetes indicators including HbA1c testing, 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 2016 NCQA National Avg.ii
      HbA1c Tested 89.5% 88.7% 88.8%
      Diabetic Eye Exam 41.6% 45.6% 47.1%
      Diabetic Nephropathy Screening 92.7% 89.8% 87.4%
    • 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. Blue Cross plans to implement a discharge follow-up initiative in order to reduce readmission rates. Our current outcomes are shown below.
      Key Quality Indicator Marketplace Rate Commercial PPO Rate 2016 NCQA National Avg.ii
      Plan All-Cause Readmissions* 8.8% 7.5% 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 2017. 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 2016 NCQA National Avg.ii
      Imaging for Low Back Pain 58.0% 55.3% 74.9%
    • Follow-Up After Hospitalization for Mental Illness
      Blue Cross recognizes the importance of follow-up therapy visits to members after a hospitalization for mental illness. An outpatient visit with a mental health practitioner is crucial to make sure a member’s transition to the home and work environment is supported and ensure gains made during hospitalization are not lost. A visit also helps healthcare providers detect early post-hospitalization reactions or medication problems and demonstrates continuing care.

      Blue Cross’ partnership with New Directions provides the knowledge and mental health experience to ensure members obtain the highest quality of care. New Directions recently implemented a follow-up outreach program and has staff on-site at multiple facilities throughout the state to help facilitate the transition of care process and increase follow-up visits. Over the next year, Blue Cross and New Directions will work together to monitor this outreach program and look for new ways to positively impact members. Our current outcomes are shown below.
      Key Quality Indicator Marketplace Rate Commercial PPO Rate 2016 NCQA National Avg.ii
      7-Day Follow-Up 34.1% 32.2% 48.6%
    • Medication Adherence
      Medication adherence stresses the importance of effective clinical management in increasing patients’ medication compliance, monitoring treatment effectiveness and identifying and managing side effects. Blue Cross recognizes the importance of encouraging members to fill their prescriptions as prescribed, as well as properly taking medications. Efforts around medication adherence will be expanded in order to encourage and improve member adherence. Blue Cross will also look for new ways to impact this measure such as engagement with pharmacies and pharmacists to educate members on medication adherence.
  2. Improved Member Experience and Satisfaction
    Blue Cross is committed to increasing all quality measures related to member experience and satisfaction. In 2017, 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 are detailed below.
  MARKETPLACE* COMMERCIAL
CAHPS Measure 2017 Preliminary Results 2017 QHP National Avg. 2017 Results 2016 NCQA National Avg. ii
Getting Care Quickly 79.7% 77.8% 91.1% 85.8%
Getting Needed Care 81.5% 79.0% 90.0% 87.9%
Claims Processing Not Asked Not Asked 96.8% 87.8%
Coordination of Care 85.9% 83.7% 85.7% 81.3%
Customer Service 82.8% 78.7% N/A** 87.5%
Rating of Health Plan 79.8% 73.2% 72.9% 59.5%
Rating of All Health Care 83.5% 82.3% 78.9% 76.5%
Rating of Personal Doctor 87.8% 88.7% 84.5% 84.4%
Rating of Specialist Seen Most Often 90.5% 87.4% 85.8% 83.3%

* Results obtained from 2017 Qualified Health Plan (QHP) Enrollee Experience Survey Quality Improvement Report (prepared by CMS)

** Not a reportable result due to less than 100 responses


iNCQA: www.ncqa.org
iiThe source for data contained in this publication is Quality Compass® 2016 and is used with the permission of the National Committee for Quality Assurance (NCQA). Quality Compass 2016 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

Blue Cross and Blue Shield of Alabama is an independent licensee of the Blue Cross and Blue Shield Association.

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).