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  • Blue Health Coach - BCBS of Massachusetts BCBSMA collaborated with Pfizer Health Solutions to understand how their InformaCare® web-based software system could work within a care management environment. Smoking Cessation Quitline - BCBS of Michigan BCBSM partnered with Michigan State University to test interventions for their smoking cessation quitline, applying research in a real world setting. Men’s Health Program - BCBS of North Carolina Program to improve men’s utilization of preventive care services. The key program objectives were to increase men’s preventive care screenings, educate men about their preventive health needs, determine the best method for communicating these health messages to men, and provide physicians with reminder tools. Arkansas Fitness Challenge – Arkansas BCBS The Arkansas Fitness Challenge (AFC) is a contest during which employees from opposing teams – in 2004, the Arkansas Department of Health and Arkansas Blue Cross and Blue Shield – participate in eligible aerobic exercises for a three-month period. Concierge Service Delivery Plus - BCBS of Massachusetts A pilot team of approximately 50 associates and leaders was asked to re-define the future of service. Innovations included a non-conventional interview process, an environment where risk-taking is encouraged, and a creative incentive and rewards plan. Partnerships with internal business partners are also fostered as part of the framework. Collaborative Appropriate Antibiotic Prescribing Initiative - Excellus BlueCross BlueShield A collaborative model among two competing health plans and a large physician group to reduce inappropriate antibiotic prescriptions for URIs. Out of the ER: The Tulare Project - Blue Cross of California Out of the ER: The Tulare Project was designed to reduce overuse of emergency room facilities for routine care that could be received at the primary care physician’s office by Blue Cross of California Medicaid Managed Care members in Tulare County.

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  • National Pay for Performance Summit February 7, 2006 Los Angeles, California Nat Kongtahworn Manager, Network Strategies Recognizing Physician Excellence: The Health Plans’ Perspective © 2006 Blue Cross Blue Shield Association. All Rights Reserved.
  • Gaps in Care Closing the gaps in care is the primary objective for recognizing physician excellence Patients Receiving Evidence-based Care Source: McGlynn et al, “The Quality of Health Care Delivered to Adults in the United States,” NEJM, 2003; To Err Is Human, Institute of Medicine, 1998 $ $ $ $ Source: Pham et al, “Delivery of Preventive Services to Older Adults by Primary Care Physicians ,” JAMA, July 27, 2005
  • Note: Coverage is for a family of four. Source: Calculated based on “Employer Health Benefits 2005 Annual Survey,” (#7315), The Henry J. Kaiser Family Foundation and Health Research and Educational Trust, September 2005 This information was reprinted with permission from the Henry J. Kaiser Family Foundation. The Kaiser Family Foundation, based in Menlo Park, California, is a nonprofit, independent national health care philanthropy and is not associated with Kaiser Permanente or Kaiser Industries. Average Annual Premium Contribution for Family Coverage 1999-2005 Unsustainable Rise in Premiums Savings from better outcomes and reduced waste will make insurance more affordable
  • Market Dynamics
    • Differentiated Networks
    • Consumer-directed Health Plans
    • Incentives for Better Practice & Outcomes
    Plans Responses Plans responses promote greater accountability for physicians and members
    • Affordable, Quality Healthcare
    • Members Paying Greater Share
    • Greater Transparency
    • Value-based Purchasing
    • HIT Adoption & Use
    Market Expectations © 2006 Blue Cross Blue Shield Association. All Rights Reserved. Rising Premiums
  • Recognizing Physician Excellence Incentive programs complement Blue Plans’ efforts to engage key stakeholders Employers
    • Arkansas Fitness Challenge
    • Concierge Service Delivery Plus
    Consumers
    • Blue Health Coach
    • Smoking Cessation Quitline
    • Men’s Health Program
    Providers
    • Collaborative Appropriate Antibiotic Prescribing Initiative
    • Out of the ER: The Tulare Project
    • Bridges to Excellence
    © 2006 Blue Cross Blue Shield Association. All Rights Reserved.
  • Recognizing Physician Excellence Blue Plans have implemented incentive programs across every region of the U.S.
    • Large focus on PCPs
    • Specialties include:
      • OB / GYN
      • Cardiology
      • Orthopedics
      • Endocrinology
    • Programs for additional specialties are under development
    © 2006 Blue Cross Blue Shield Association. All Rights Reserved.
  • Recognizing Physician Excellence Core values guide…
    • Measures approved by nationally recognized groups
    • Relative ease of data collection
    • Breadth of measures to ensure a valid, comprehensive picture of physician performance
    • Credible and actionable to clinicians & transparent to patients
    Measurement
    • Report by tertiles/quartiles rather than rank order
    • Reward commitment to improvement
    • Promote environment for practice transformation
    Recognition
  • Recognizing Physician Excellence
    • Urban Area: 4 million population 2 million covered lives
    • 6,000 Primary Care Physicians
    • 10 X 10 grid of primary care quality measures – 20% completed
    • 30% profiled
    Chicago Challenge: Limited claims data can preclude broader participation by network physicians, e.g., © 2006 Blue Cross Blue Shield Association. All Rights Reserved.
  • Recognizing Physician Excellence Approach: Condition-specific, self-assessment programs complement Plans’ claims-based reporting capabilities
    • Licensees of Bridges to Excellence: CareFirst BCBS & BCBS of Georgia
    • Adoption into recognition programs: BCBS of South Carolina
    • 7 more Plans exploring implementation
    NCQA Physician Recognition Programs
    • Adoption into recognition programs
    • Self-directed improvement modules
    Maintenance of Certification & Practice Improvement Modules
  • Conclusion
    • Savings from better outcomes and reduced waste will make insurance more affordable
    • Bridges to Excellence complements existing and developing Blue Plans’ strategies to improve quality and affordability
    © 2006 Blue Cross Blue Shield Association. All Rights Reserved. Closing the gaps in evidence-based care is not enough
  • Contact Nat Kongtahworn Manager, Network Strategies Office of Clinical Affairs Blue Cross and Blue Shield Association 312.297.6210 [email_address] © 2006 Blue Cross Blue Shield Association. All Rights Reserved.