QUALITY HEALTH COVERAGE
FOR YOUR EMPLOYEES
ADMINISTRATIVE SERVICES CONTRACT
Working with Employers for Affordable, Quality Healthcare
Providing quality, affordable health benefits to employees may be one of the biggest
challenges Rhode Island employers face today. We understand this, and we’re taking steps to
change healthcare in Rhode Island so you can continue to offer the quality coverage that you
and your employees expect. To get there, we have created a strategy for innovation that is
built on three principles:
1. Delivery System
2. Consumer Activation
3. Product Innovation
Serve as a leader in
of Rhode Island’s
healthcare delivery system.
• ontinued support and
expansion of patientcentered medical homes
Create incentives for your
employees to get the most
value for every dollar they
spend on healthcare.
• ntroduce more financial
responsibility for your
employees through copays/
Deliver products and
services specific to your
employee population that
help them be as healthy
• limination of financial
barriers to ensure complance
with health needs and
improve the health of your
• ssessment of specialists’
performance based on
quality and efficiency
• ew hospital contracting
paradigms that focus on
• mploy incentives and
provide quality data to help
your employees make the
right care decisions
• are coordination incentives
for physicians and providers
• ptimization of your
employee medical expense
by leveraging efficiencies
and quality outcomes
created by a virtual
We are very excited about our strategy, and firmly believe this will allow us to offer
Rhode Islanders the best possible care at the lowest cost.
Table of Contents
Opening the Door to Healthcare
See how our national network of doctors and hospitals gives your
employees access to the best care available.
Leading the Way in Member Care
e remain committed to controlling costs while providing high-quality
healthcare. Learn how we’re working with providers to do this.
Helping You Design the Right Plan
earn about medical and pharmacy options that provide additional
value to you and your employees.
Blue Cross Medical and Dental—the Power of One
y providing medical and dental coverage from the same place,
employers benefit from streamlined plan administration, and employees
get a whole-body healthcare solution.
A Big-Picture Approach to Pharmacy and Medical Management
earn how fully integrated medical and pharmacy management can
lower costs and improve employees’ overall care.
Better Health, Better Employees
hrough discount programs and wellness services, we can help your
employees save money and stay on top of their health.
Making Better Choices
iscover the consumer tools and services that will help your employees
make informed healthcare decisions.
An Integrated Approach to Health
earn about our member-centric approach to
your employees’ health.
OPENING THE DOOR TO
BlueCard® PPO Network
Finding the Right Hospital is easy.
When it comes to choosing a doctor or specialist,
your employees want someone who’s right for
them. That could mean a doctor with the special
skills they need, or simply a primary care physician
they like and find easy to talk to. Our BlueCard
PPO national network of doctors and specialists
gives our members access to thousands of providers
across the country, including:
• 6 percent of medical providers in Rhode Island
• ore than 665,000 doctors and specialists
• nd more than 5,300 hospitals across
Our Hospital Comparison Tool on BCBSRI.com can
help your employees choose the hospital that has the best
record when it comes to the type of care they need. This
interactive tool, which we developed in partnership with
WebMD, generates detailed, individualized reports based
on data hospitals provide to the government. This will
help your employees feel confident in the hospital care
BCBSRI and Hospitals:
Putting Quality First
We are collaborating with local
network hospitals to create and
implement a new Hospital Quality
Program. This program is designed
to help improve the quality, safety,
and efficiency of local hospital care
and moderate long-term healthcare costs. Ninety percent of our
network hospitals have agreed to
participate this year.
LEADING THE WAY IN
To control the rising cost of healthcare benefits, we are changing how healthcare is delivered and
paid for. The goal is to both control costs and maintain the high-quality healthcare coverage
your employees deserve.
Partnerships with Hospitals
every month. In total, this has impacted over 100,000 of
our members. This approach offers:
• fficient care coordination through personalized
• ore effective provider communication provided by
electronic health records and e-prescribing technology
We are working with hospitals to focus on
improving quality of care and health outcomes.
Our productive relationships with local hospitals
have allowed us to implement trendsetting
financial arrangements, such as contracts that
reward quality of care rather than quantity of care.
This will help to promote efficiency, quality, and
safety; control healthcare costs; create a positive
patient experience; and improve health outcomes
for our members.
• n emphasis on primary care, which is proven to be a
preventive, not reactive, approach to care
Improving the quality of care makes healthcare more
efficient and cost-effective over time, and ultimately
helps control the cost of premiums to benefit your
business and your employees.
Patient-Centered Medical Homes
We’re leading the way in establishing patient-centered medical homes (PCMH)—where members
receive coordinated care that results in better health
outcomes and lower claims costs. So far, 30 percent
of the state’s primary care physicians are involved in
PCMHs supported by BCBSRI, with more joining
Patient-Centered Medical Homes
within the country
While BCBSRI continues to establish a patient-centered medical home model in Rhode Island for members with access
to the local network, the BCBS Association has also begun work establishing similar pilots in almost all of the states
within the country.
HELPING YOU DESIGN THE
Take advantage of our wide range of options to design the best plan for your needs and budget:
A Consultative Approach
When choosing a health plan, you
should choose an insurer that gives
you more than just health insurance.
No matter which of our health plans
you select, BCBSRI adds value and
improves your bottom line by
offering a consultative approach to
help you to customize the benefits
you offer your employees.
We serve as a guide to walk you
through the process. We will create
a personalized strategy to fit
They allow your employees to take
charge of their healthcare costs.
CDHPs provide needed benefits
and the option to open a savings
account for healthcare expenses. In
a study by McKinsey Company*,
CDHP consumers were found
• 5% more likely to engage in
• 0% more likely to get an annual
• 0% more likely to ask about
n turn, you pay lower premiums,
while still knowing you’re providing
quality benefits to your employees.
Providing for Your
We offer a number of retirement
health plans, including Medicare
Advantage plans, Medicare
Supplement plans, and Part D
prescription drug plans. These
health plans offer Original
Medicare benefits, prescription
drug coverage, and much more!
* cKinsey Company, “Consumer-direct Health
Plan Report – Early Evidence is Promising”
Traditional Health Plans
Consumer-Driven Health Plans
$ $$ $$$
$ $$ $$$
BLUE CROSS MEDICAL AND DENTAL
One for All
It’s always easier to get everything you need—and the quality you
expect—at the same place. With Blue Cross Blue Shield of Rhode
Island as your medical and dental administrator, you’ll get:
• A whole-body solution that meets all of your employees’
• n account service professional who will provide consultation,
information, and strategic guidance
• Easier health plan administration, including a single bill, one plan
administration tool, and comprehensive reporting
• The comfort of knowing you’re providing for your employees, while
creating a healthier, more productive workforce
One Network, 130,000 Dentists
The Blue Cross Dental network features more than 130,000 dentists
across the country, including nearly 90 percent of dentists
in Rhode Island.
One Mouth, One Body, One Connection
Proper dental care is a key part of maintaining your employees’
overall health. Studies have shown a true mouth-body
connection. Oral health issues affect more than just your
employees’ appearance. Good oral health can help:
• Better manage chronic diseases such as diabetes and coronary
• Lower the risk of delivering low-birth weight babies
Our dental plans provide extensive benefits and cover
cleanings, dental examinations, X-rays, and more.
Did You Know?
• 164 million work hours are lost every year to dental health issues.1
• Nearly 75 percent of American adults suffer from various forms of gum disease—from simple
inflammation to severe cases—and don’t even know it.2
• ore than 90 percent of all systemic diseases have oral health symptoms.3
Your employees will have in-network coverage available wherever they live, work, and travel.
2010 report from Pew Center
American Dental Hygienist Association
Academy of General Dentistry
A BIG PICTURE APPROACH TO
The Right Medical and Speciality
Pharmacy Coverage, All in One Plan
• n 2010, Americans spent more than $307 billion on
• ealthcare costs related to drug mismanagement cost
over $200 billion per year nationally.*
• n the United States, there is a 50-60% medical adherence
rate for chronic conditions.
Three myths about carving out
prescription drug coverage
It’s no surprise that this area of healthcare is a target for
cost management initiatives. Some employers are hiring
pharmacy benefit managers (PBMs) to manage their
pharmacy programs, but PBMs only look at cost savings
from the perspective of drug costs and drug rebates. We
take it a step further by fully integrating our pharmacy and
medical management. Through this approach, we’re able to
manage both prescription and medical claims costs while
also providing more coordinated care. See the sidebar at
right for more on how an integrated approach saves money
Myth: There are better rebates available.
Truth: Every month, more generic alternatives
are available. And while generics do not pay out
rebates, they cost substantially less than brand
name drugs. Also, focusing on rebates will lead
to a formulary that emphasizes higher cost
brand name drugs.
Myth: Plan administration will be easy.
Truth: With separate medical and pharmacy
administrators, you’ll always have lag time in
the exchange of data. This hampers the ability
to identify employees for care management/
coordination services. It also burdens your
human resources staff, who will need to
provide enrollment information to two
Save Money with our Value-based
Myth: Only PBMs can provide comprehensive
Since being introduced, our Value-based Pharmacy
Approach has saved companies 7 to 8 percent on overall
pharmacy claims costs. Created to provide the best clinical
outcomes, lower cost alternatives, and overall effectiveness,
the Premier Formulary emphasizes cost-effective generic and
brand name drugs. This isn’t simply to shift costs—it helps
your employees understand that alternative medications
provide the same medical results while costing less. They
learn that more expensive, brand name drugs are not
review, recommend, and develop programs that
are fully integrated with our medical
management programs. We also have
relationships with both medical providers and
pharmacists, allowing us to provide education
Truth: We have clinical pharmacists who
* ongressional Budget Office, 2005 National Academies Press: PreC
venting Medication Errors: Quality Chasm Series, 2007 CDC, 2010.
http://www.cdc.gov/nccdphp/overview.htm — World Health
Organzation, 2003, J Amer Pharm Assoc 2001; 41:192-9
Improving the overall health of your employees can lead to
lower operating costs, increased productivity, and reduced
overall healthcare costs. That’s why we offer access to wellness
programs and a variety of discounts for health- and fitnessrelated products and services.
Good Health Benefit®
This suite of health management services focuses on prevention
and healthy living while also providing analysis that determines the
impact of wellness services on health, costs, and productivity.
• Consultative support and coordination of services
• Comprehensive reporting on aggregate health assessment data,
participation, satisfaction, and outcomes
• An online personal health assessment (PHA) that rates your
employees’ health risks, summarizes their risk factors, and provides
resources for improving their health
• On-site health fairs, which offer a variety of health screenings and
tests, as well as lifestyle management seminars, where employees
can learn how to lose weight and manage stress
The Power of PHAs
Every increase of 1 point in your company’s
aggregate PHA score equals a 2% increase
Health Wellness Institute, April 2011
Did you know?
of all diseases are
associated with modifiable health risks that could
be prevented with a healthy lifestyle.*
*Centers for Disease Control and Prevention, June 2010
BCBSRI offers a full suite of consumer tools and services to enable people to make
the best choices when they need healthcare. We focus on providing solutions across
multiple channels of delivery. This ensures that members have access to information
and support from a variety of sources. The following chart shows the range of
consumer tools offered.
Member Portal and H.I.T.S. Tracking
• Benefit and Claims
• Hospital/Doctor Finder
• Member Statements
Health And Wellness
• Personal Health Assessment
• Health Knowledge Database and Tools
• Blue365 Discounts
• MyBlue Community
• Fitness Network
• Decision Support Tools
• Incentive Tracking
• Pharmacy Savings Programs
Tailored Approach to Care
As part of our overall healthcare strategy, we provide integrated health management programs at an
appropriate level to members along the healthcare continuum, from those who are healthy to those
with chronic conditions and complex healthcare needs.
Health Risk Factors
Cost of Care
End of Life
APPROACH TO HEALTH
With BCBSRI, you have the advantage of fully integrated, member-centric care.
Through this big picture approach, we are able to leverage both prescription and
medical claims to provide a more coordinated experience for your employees. This
saves money for both employers and their employees.
• Target chronic conditions through
• Offer member education and
• Better manage care for members with
chronic and complex conditions
• uide members to patientG
centered medical homes to
provide highly coordinated medical and
• Ensure alignment of all product and
• Healthier workforce • Lower claims
We’re Here for You
If you have any questions about our products and ser vices, please
contact your Broker or BCBSRI Account Representative.
500 Exchange Street • Providence, RI 02903-2699
Blue Cross Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association.