driving to quality providing transparency

April 20, 2023Wellmark Blue Cross and Blue Shield

Presenters:Dr. Rick MillerElodie Opstad

Driving to QualityProviding Transparency

Iowa Health Buyers Alliance ConferenceOctober 15, 2008

Crossing the Chasms

The Quality Chasm» 100,000 deaths» Patients get 55% of

necessary care» 11% of patients get

potentially harmful care

The Financial Chasm» Trend is logrithmic» Medical costs exceed GDP

in 2050» Up to 30% of care is waste

Wellmark Blue Cross and Blue Shield

Health Care Continuum & Population

Wellmark Blue Cross and Blue Shield 3


Health Care Continuum & Cost

Total costs

Costs to Productivity


6Wellmark Blue Cross and Blue Shield


Wellmark Sponsored

Resources and ToolsOnline Provider Directory

www.wellmark.com


Finding a Physician on Wellmark.com

Find a Physician – Provider Directories


Find a Physician

Transparency – Provider Directory

John Doe MD Details Collaboration on Quality Program Participant Incent and Reward Best Practices (IRBP)

Clinical Care for Members with Diabetes

The clinic performance level is based on data collected on nationally-accepted measures for the care of diabetes endorsed by the National Quality Forum or other nationally recognized measurement organizations.

Overall Clinic-Level Level 3

LEVEL 1 This clinic has achieved performance levels for this measure that exceed the baseline performance of program participants.

LEVEL 2 This clinic meets and exceeds Level 1 performance for this measure.

LEVEL 3 This clinic meets the highest program performance levels for this measure.



Collaboration on Quality


Finding an Out-of-State Hospital on Wellmark.com

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Find an Out-of-State Hospital


Screen Shot #5



Symbol Key


Top 25% (hospital performed better than most other hospitals reporting information).

Middle 50% (hospital performed near the average or as can be expected).

Bottom 25% (hospital performed in the bottom group of hospitals reporting information).

Patient Safety

Did not disclose this information.

Willing to report publicly; did not yet meet Leapfrog’s criteria for a good early stage effort.

Good early stage effort in implementing Leapfrog’s recommended quality and safety practices.

Good progress in implementing Leapfrog’s recommended quality and safety practices.

Fully implemented Leapfrog’s recommended quality and safety practices.

Surgical Complications and Infection Prevention

18

Four programs currently in operation

Blue Cross and Blue Shield Association

NEW

Blue Distinctions Centers


19

National PresenceBlues achieve national presence, with nearly 800 Blue Distinction

designations spanning 43 states

WA

OR

CA

AK

HI

TX

NMAZ

UTNV

ID

MT ND

SD

NE

WY

COKS

OKAR

LA

MSAL GA

FL

SC

NCTN

KYMO

IL

IA

MN

WIMI

INOH

WV VA

PA

NY

MEVT

NH

RIMA

CTNJ

DEMD

PR

Blue Distinction Centers for Cardiac CareSM

Blue Distinction Centers for Bariatric SurgerySM

Blue Distinction Centersfor TransplantsSM

Blue Distinction Centers Complex & Rare CancersSM

Blue Cross and Blue Shield Association


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Blue Distinctions Cardiac CareOutcomes from Clinical DataBlue Cross and Blue Shield Association data

RFI data, self-reported by facilities, demonstrates better, more consistent overall outcomes

Source: Hospital RFI Data Submitted to the Blue Cross and Blue Shield Association

Inpatient MortalityPost Heart Attack

29%29%

167%

Mortality Rate One-year Post Heart Transplant

73%73%

90%

Variability from outliers

and small volume centers

Variability from outliers

and small volume centers

BDC Other

11%

30%

19%

57%

Mean Maximum

7%

15%

40%

9%

Mean Maximum

Variability from outliers and

small volume centers

Variability from outliers and

small volume centers


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Blue Distinctions Cardiac CareCumulative ReadmissionsBlue Cross and Blue Shield Association data

Note: All cardiac and cardiac related readmissions during the initial admission through 90 days, 90 day eligibility required for patient cohort

10.4% 9.5%

14.2%

10.5%10.9%

18.7%

0%

5%

10%

15%

20%

AMI CABG PCI

Pe

rce

nt

of

Pa

tie

nts

BDC vs. Other

Readmission rates lower at Blue Distinction Centers

Source: HealthCore Analysis of WellPoint Data, July 2008

n = 1741 3584 4285 2552 12864 8876

32%

5% 11%

BDC Other Statistically significant difference


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$47,723

$21,429

$39,830

$19,994

$0

$10,000

$20,000

$30,000

$40,000

$50,000

$60,000

CABG PCI

Blue Distinctions Cardiac CareCosts of Care – CABG and PCIBlue Cross and Blue Shield Association data

BDC vs. Other Allowed amount lower at Blue Distinction Centers (with same co-morbidity rates as other facilities)

n=4285 2552 12864 8876

20%

7%

BDC Other Statistically significant difference

Note: All allowable costs for initial admission through 90 days. 90-day eligibility required for patient cohort. Allowed amount = total claims from inpatient, outpatient and pharmacy services. Median value shown. Calculating Patient Co-Morbidity Index required six months pre-event

eligibility. Source: HealthCore Analysis of WellPoint Data, July 2008.



Member Facing Programs

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Whole Health Dimensions - Overview

Integrated Data Warehouse

Complex Case Management

DiseaseManagement

PregnancyCare

Wellness Services

UtilizationManagement

Collaboration on Quality

PersonalHealth

Assistant

PharmacyBenefits

Clinical Integration

Demonstrated Value (Performance, Outcomes, Quality)

Metrics and Reporting


Whole Health Dimensions OverviewPharmacy Benefits» Wellmark program aligned with CatalystRx &

CaremarkService provided to most Wellmark members

Case Management» Care coordination for the seriously ill, » Discharge outreach services initiated 07.2008Service provided to all Wellmark covered members

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Case Management

PharmacyBenefits



Whole Health Dimensions Overview Personal Health Assistant

Care Navigation 24/7 (non-clinical)» Directs member to resources

Nurse Support 24/7 (clinical)» Urgent and medical care questions

—Follow-up with primary clinician post- emergent callsService provided to some Wellmark members

26

PersonalHealth

Assessment



Whole Health Dimensions OverviewDisease Management . . . Targeting members with specific conditions

Core conditions- Asthma- Chronic obstructive pulmonary disease (COPD)- Coronary Artery Disease (CAD)- Congestive Heart Failure (CHF)- Diabetes

Impact Conditions - Acid related stomach disorders - Irritable bowel syndrome- Atrial Fibrillation - Low back pain- Decubitus ulcers - Osteoarthritis- Fibromyalgia - Osteoporosis- Hepatitis C - Urinary incontinence- Inflammatory bowel diseaseService provided to some (not all) Wellmark members

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DiseaseManagement



Whole Health Dimensions OverviewPregnancy Care

» Identification of risks through early assessment

» Care coordination

» Reduce preterm delivery and low birth weight infants

Service provided to some Wellmark members

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PregnancyCare


Utilization Management …Two types of notification programs

Precertification: Notification mandatoryPrior Approval: Notification recommendedService provided to all Wellmark members

UtilizationManagement


Whole Health Dimensions Overview Wellness Services» Personal Health Assessment» Lifestyle Management Programs

—Interactive behavior change programs

—Web tools

—QuitNet smoking cessation

» Telephonic Health Coaching» Community Coordinators

—Located throughout Iowa and South Dakota

—Web-based community resource guide

» Employer consulting

Service provided to some Wellmark members

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Wellness Services



Linking Primary Clinicians to Whole Health Dimension ProgramsImpacting Health and Outcomes

Clinical Integration Strategy

Primary Nurse ModelClinician-generated referrals

Program services as an extension of the provider office



Provider Facing Programs

Incent and Reward Best Practices

Collaboration on QualityPrimary Care Program


Clinician Volunteers to participate in the program

Patient list validated by clinician in Care Center

Clinical team sees patient and submits

data into MDdatacor Clinician

views patient or population

specific performance

dataPotential financial

awards based on

performance level

achieved

Clinical team identifies

opportunities

Clinical team Schedule

repeat visits

How Does the Program Work?


Growing Clinician Participation

Incent and Reward Best Practices: Growing Clinician Participation

Incent and Reward Best Practices: 2006 compared to 2007

*2006 Results are an average of 12 & 17 months data, due to program not have the same reporting period for all participants. This is self-reported data by clinics, collected and compiled by MDdatacor.

Diabetes Process Measures*


Incent and Reward Best Practices: 2006 compared to 2007

* These results are based on clinical information submitted to MDDatacor by clinics. * 2006 Results are an average of 12 & 17 months data, due to program not have the same reporting period for all participants.

Diabetes Outcome Measures*


2007 Cost Outcomes



Percent of Diabetic Patients Receiving All Necessary Tests


Questions?

driving to quality providing transparency

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