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May 11, 2015 Wellmark Blue Cross and Blue Shield Presenters: Dr. Rick Miller Elodie Opstad Driving to Quality Providing Transparency Iowa Health Buyers.

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Presentation on theme: "May 11, 2015 Wellmark Blue Cross and Blue Shield Presenters: Dr. Rick Miller Elodie Opstad Driving to Quality Providing Transparency Iowa Health Buyers."— Presentation transcript:

1 May 11, 2015 Wellmark Blue Cross and Blue Shield Presenters: Dr. Rick Miller Elodie Opstad Driving to Quality Providing Transparency Iowa Health Buyers Alliance Conference October 15, 2008

2 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

3 Health Care Continuum & Population Wellmark Blue Cross and Blue Shield3

4 4 Health Care Continuum & Cost

5 Total costs Costs to Productivity Wellmark Blue Cross and Blue Shield5

6 6

7 7

8 8

9 9 Wellmark Sponsored Resources and Tools Online Provider Directory

10 Wellmark Blue Cross and Blue Shield10 Finding a Physician on Wellmark.com Find a Physician – Provider Directories

11 Wellmark Blue Cross and Blue Shield11 Find a Physician

12 Transparency – Provider Directory Wellmark Blue Cross and Blue Shield12

13 Wellmark Blue Cross and Blue Shield13 Collaboration on Quality

14 Wellmark Blue Cross and Blue Shield14 Finding an Out-of-State Hospital on Wellmark.com Wellmark Sponsored

15 Wellmark Blue Cross and Blue Shield15 Find an Out-of-State Hospital

16 Wellmark Blue Cross and Blue Shield16 Screen Shot #5 Find an Out-of-State Hospital

17 Wellmark Blue Cross and Blue Shield17 Symbol Key Find an Out-of-State Hospital 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 18 Four programs currently in operation Blue Cross and Blue Shield Association NEW Blue Distinctions Centers Wellmark Blue Cross and Blue Shield

19 19 National Presence Blues achieve national presence, with nearly 800 Blue Distinction designations spanning 43 states Blue Distinction Centers for Cardiac Care SM Blue Distinction Centers for Bariatric Surgery SM Blue Distinction Centers for Transplants SM Blue Distinction Centers Complex & Rare Cancers SM Blue Cross and Blue Shield Association Wellmark Blue Cross and Blue Shield

20 20 Blue Distinctions Cardiac Care Outcomes from Clinical Data Blue 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 Mortality Post Heart Attack 29% 167% Mortality Rate One-year Post Heart Transplant 73% 90% Variability from outliers and small volume centers BDCOther 11% 30% 19% 57% MeanMaximum 7% 15% 40% 9% MeanMaximum Variability from outliers and small volume centers Wellmark Blue Cross and Blue Shield

21 21 Blue Distinctions Cardiac Care Cumulative Readmissions Blue 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 BDC vs. Other Readmission rates lower at Blue Distinction Centers Source: HealthCore Analysis of WellPoint Data, July 2008 n = % 5% 11% BDCOtherStatistically significant difference Wellmark Blue Cross and Blue Shield

22 22 Blue Distinctions Cardiac Care Costs of Care – CABG and PCI Blue 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= % 7% BDCOtherStatistically 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 Wellmark Blue Cross and Blue Shield

23 23 Member Facing Programs

24 24 Whole Health Dimensions - Overview Integrated Data Warehouse Complex Case Management Disease Management Pregnancy Care Wellness Services Utilization Management Collaboration on Quality Personal Health Assistant Pharmacy Benefits Clinical Integration Demonstrated Value (Performance, Outcomes, Quality) Metrics and Reporting Wellmark Blue Cross and Blue Shield

25 Whole Health Dimensions Overview Pharmacy Benefits »Wellmark program aligned with CatalystRx & Caremark Service provided to most Wellmark members Case Management »Care coordination for the seriously ill, »Discharge outreach services initiated Service provided to all Wellmark covered members 25 Case Management Pharmacy Benefits Whole Health Dimensions - Overview Wellmark Blue Cross and Blue Shield

26 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 calls Service provided to some Wellmark members 26 Personal Health Assessment Whole Health Dimensions - Overview Wellmark Blue Cross and Blue Shield

27 Whole Health Dimensions Overview Disease 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 disease Service provided to some (not all) Wellmark members 27 Disease Management Whole Health Dimensions - Overview Wellmark Blue Cross and Blue Shield

28 Whole Health Dimensions Overview Pregnancy Care »Identification of risks through early assessment »Care coordination »Reduce preterm delivery and low birth weight infants Service provided to some Wellmark members 28 Pregnancy Care Whole Health Dimensions - Overview Utilization Management …Two types of notification programs Precertification: Notification mandatory Prior Approval: Notification recommended Service provided to all Wellmark members Utilization Management Wellmark Blue Cross and Blue Shield

29 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 29 Wellness Services Whole Health Dimensions - Overview Wellmark Blue Cross and Blue Shield

30 Linking Primary Clinicians to Whole Health Dimension Programs Impacting Health and Outcomes Clinical Integration Strategy Primary Nurse Model Clinician-generated referrals Program services as an extension of the provider office Wellmark Blue Cross and Blue Shield 30

31 Wellmark Blue Cross and Blue Shield31 Provider Facing Programs Incent and Reward Best Practices

32 Collaboration on Quality Primary Care Program Wellmark Blue Cross and Blue Shield32 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 data Potential financial awards based on performance level achieved Clinical team identifies opportunities Clinical team Schedule repeat visits How Does the Program Work?

33 Wellmark Blue Cross and Blue Shield33 Growing Clinician Participation Incent and Reward Best Practices: Growing Clinician Participation

34 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* Wellmark Blue Cross and Blue Shield34

35 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* 35Wellmark Blue Cross and Blue Shield

36 2007 Cost Outcomes 36Wellmark Blue Cross and Blue Shield

37 37 Percent of Diabetic Patients Receiving All Necessary Tests

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39 Wellmark Blue Cross and Blue Shield39 Questions?


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