Quality Management Program

Blue Cross and Blue Shield of Alabama (Blue Cross) is committed to the development, implementation, administration, and monitoring of programs designed to promote the delivery of quality health care 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.

The goals of the QM Program are to:

  • Provide 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.
  • Improve the quality, appropriateness, availability, accessibility, coordination and continuity of the health care and service provided to members.
  • Maintain a high level of satisfaction in members, providers and customers on the services provided by Blue Cross.
  • Ensure that care and service are delivered in a culturally competent manner.
  • Maintain accreditation, which assures our members, groups and providers a Quality Management 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.
  • Developing and monitoring a Quality Improvement Strategy for the Marketplace population.
  • Conducting Quality Improvement Projects (QIPs) to improve specific aspects of care or service to members.
  • Assessing members’ cultural, linguistic, and health literacy needs and the delivery 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
    Our member management staff provides assistance and offers services to our members 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 non-event based. Event based identification utilizes specific high risk diagnoses, procedures, hospitalizations and pre-certifications to identify members to be referred to clinical staff for care coordination. Our 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 telephonic outreach, mailings and electronic mailings 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 gaps in care exist
    • Education of members on 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 health care. 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 health care marketplace will ultimately lead to better patient outcomes, more informed health care decision-making by consumers, and cost savings through medical best 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 Tiering Strategy: Blue Cross differentiates hospitals and encourages improved performance through our Alabama Hospital Tiered Network. The goal of this network is to ensure fiscal responsibility, quality and patient safety in network hospitals. The majority of hospital rate increases are based on accomplishment of value based quality and utilization metrics. Tiering results are available to consumers through our Doctor Finder Tools at AlabamaBlue.com.
    • Primary Care Value Based Payment Program: Blue Cross supports a comprehensive value based payment program targeting primary care and OB/GYN 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. Additional specialties beyond primary care and OB/GYN will be explored in future years.
    • 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 a new 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 customers 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 thirty 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. Clinical Practice Guidelines
    All Blue Cross guidelines are based on the most current scientific evidence and are adapted from standards published by nationally recognized authorities. Each guideline is reviewed and approved at least annually.
    • Preventive Health Guidelines are standards of care developed to encourage the appropriate provision of preventive services to patients, according to their age, gender and risk status. These services include screenings, immunizations and physical examinations.
    • Practice Guidelines are systematically developed statements that help practitioners make decisions about appropriate healthcare for specific chronic or acute clinical circumstances.
  7. 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 health care 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 2015 NCQA National Avg.ii
    Breast Cancer Screening 72.0% 73.4% 69.9%
    Colorectal Cancer Screening 55.8% 63.2% 57.7%
  8. Member Education Care Reminders
    Care reminders display personalized health notifications to individual members on myBlueCross.com or through the Blue Cross smart phone application. The purpose of care reminders is to educate members about recommended health services, screenings and tests. Members will see the health notifications listed below:
    • Services that have been completed
    • Upcoming services due this year
    • Overdue services
    • Completed services that have results outside of the normal range
  9. Health Management Transition of Care (TOC) Program
    Health Management Transition of Care (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 ER visits and/or hospital readmissions.

  10. 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+SM medical facilities within Blue Cross’ provider networks. Both meet rigorous and objective clinical measures, resulting in better overall patient outcomes. Blue Distinction Centers+SM additionally deliver the quality plus cost-efficient specialty care. The programs cover the highly variable areas of bariatric surgery, cardiac care, complex and rare cancers, transplants, spine surgery and hip and knee replacement surgeries.

  11. Million Hearts® Campaign
    Blue Cross continues to participate in the Alabama Million Hearts Workgroup in cooperation with the Alabama Department of Public Health (ADPH). Million Hearts® is a national initiative to prevent one million heart attacks and strokes by 2017. Million Hearts® brings together communities, health systems, nonprofit organizations, federal agencies and private-sector partners from across the country to fight heart disease and stroke. Blue Cross’ Million Hearts workgroup identifies patients diagnosed with diabetes and hypertension throughout the state at the zip code level and supplies this information to public health workers and researchers to improve health outcomes. The workgroup has received special recognition from the Centers for Disease Control and Prevention (CDC) and the Association of State and Territorial Health Officials (ASTHO) for facilitating this cooperative effort.

  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 2016

  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) which measures clinical care and effectiveness and Consumer Assessment of Healthcare Providers and Systems (CAHPS), 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. Several key quality indicators Blue Cross will focus on in 2016 are listed below:
    • Comprehensive Diabetes Care
      Several diabetic management initiatives, focusing on improving the health outcomes of our diabetic population, will be implemented in 2016. 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 2015 NCQA National Avg.ii
      HbA1c Tested 90.3% 88.0% 88.3%
      Diabetic Eye Exam 38.7% 36.0% 48.8%
      Diabetic Nephropathy Screening 91.5% 83.4% 80.4%
    • 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 re-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 2015 NCQA National Avg.ii
      Plan All-Cause Readmissions* 10.1% 7.8% 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 U.S. 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 2016. 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 2015 NCQA National Avg.ii
      Imaging for Low Back Pain 58.7% 57.9% 75.0%
    • 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 Behavioral Health provides the knowledge and mental health experience to ensure members obtain the highest quality of care. Over the next year, Blue Cross and New Directions will work together to implement a follow-up 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 2015 NCQA National Avg.ii
      7-Day Follow-Up 31.1% 27.8% 49.6%
    • 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 2016, 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.
    CAHPS Measure Preliminary Results Benchmark Results 2015 NCQA National Avg. ii
    Getting Care Quickly 79.5% 77.7% 90.4% 86.2%
    Getting Needed Care 82.7% 77.9% 90.9% 88.4%
    Claims Processing Not Asked Not Asked 93.7% 87.7%
    Coordination of Care 83.8% 82.6% 79.9% 81.2%
    Customer Service N/A N/A 88.0% 86.3%
    Rating of Health Plan 80.2% 72.1% 74.7% 59.7%
    Rating of All Health Care 86.3% 80.9% 82.1% 76.7%
    Rating of Personal Doctor 89.7% 87.7% 88.4% 84.8%
    Rating of Specialist Seen Most Often 89.6% 86.2% 88.0% 83.7%
    *Represents scaled mean score (prior to case-mix adjustment).

iNCQA www.ncqa.org
iiThe source for data contained in this publication is Quality Compass® 2015 and is used with the permission of the National Committee for Quality Assurance (NCQA). Quality Compass 2015 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