Blue Cross and Blue Shield of Illinois 2010 Quality ... · 2010. 1. HMO ILLINOIS / BLUEADVANTAGE...

Blue Cross and Blue Shield of Illinois

2010 Quality Improvement Program Annual Evaluation

Date approved: Managed Care Quality Improvement Committee: May 2011

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

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Blue Cross and Blue Shield of Illinois 2010 Quality Improvement Program

Annual Evaluation

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TABLE OF CONTENTS

I. OUTCOMES FROM QUALITY IMPROVEMENT ACTIVITIES .......................................#3

A. HEDIS® INDICATORS ..................................................................................................................#3

B. GEOACCESS .................................................................................................................................#6 1. HMO Illinois / BlueAdvantage HMO .....................................................................................#6 2. PPO........................................................................

C. HMO CLINICAL QUALITY IMPROVEMENT STUDIES ....................................................................#7 1. Childhood Immunization QI Fund Project ..............................................................................#7 2. Diabetes QI Fund Project......3. Management of Members with Cardiovascular Conditions QI Fund Project........................#14 4. Follow-Up After Hospitalization for Mental Illness QI Fund Project ...................................#15 5. Asthma QI Fund Project ........................................................................................................6. Breast Cancer Screening QI Fund Project .............................................................................#21 7. Cervical Cancer Screening HMO QI Fund Project................................................................#23 8. Colorectal Cancer Screening QI Fund Project.......................................................................#25 9. Seasonal Influenza Vaccination QI Fund Project ..................................................................#27 10. Controlling High Blood Pressure QI Fund Project ................................................................#29 11. Adult Wellness and Prevention QI Fund Project...................................................................#30 12. Pediatric Wellness and Prevention QI Fund Project..............................................................#32

D. PPO / FEP QUALITY IMPROVEMENT PROJECTS.........................................................................#33 1. Utilization Management QI Projects .....................................................................................#33 2. FEP Case Management QI Projects.......................................................................................#34 3. Diabetes Checks & Balances Program ..................................................................................#35 4. 2010 BCBSIL PPO Practitioner Profile.................................................................................#35 5. Blue Choice Tiering ................6. Medical Management (PPO/FEP) .........................................................................................#36 7. PPO/FEP Quality Improvement Workplan Indicators...........................................................#37

E. HMO QUALITY IMPROVEMENT PROJECTS ................................................................................#37 Timely Access to Urgent Care...............................................................................................#38 Timely Access to Non-Urgent Care.......................................................................................#39 Accuracy and Timeliness of Claims Payments......................................................................#40 Courtesy of Customer Service Representatives.....................................................................#40

II. CLINICAL GUIDELINES........................................................................................................#40

REVIEW, UPDATE AND DISSEMINATION OF GUIDELINES...........................................................#40

III. PATIENT SAFETY....................................................................................................................#42

A. 2010 BCBSILHOSPITAL PROFILE .............................................................................................#42 B. ANALYSIS OF SAFETY MEASURES (2010 BCBSIL HOSPITAL PROFILE)....................................#42

IV. TRANSPARENCY.....................................................................................................................#43

A. BLUE STAR SM

HOSPITAL REPORT.............................................................................................#44 B. BLUE STAR

SM MEDICAL GROUP/IPA REPORT..........................................................................#44

V. 2010 BLUE DISTINCTION CENTERS OF EXCELLENCE................................................#45

VI. CREDENTIALING / RE-CREDENTIALING........................................................................#46

VII. SURVEYS ...................................................................................................................................#46

A. MEMBER...........1. 2010 Member Survey by Medical Group (HMO) .................................................................#46 2. Continuous Tracking Program (HMO, PPO, CDH) ..............................................................#47 3. 2010 CAHPS Survey (HMO) ................................................................................................#47

B. PRACTITIONER/PROVIDER .........................................................................................................#47


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#47

1. 2010 PPO Physician Survey ..................................................................................................#47 2. 2010 PPO Non-Physician Clinician Survey ..........................................................................#47 3. 2010 HMO PCP Survey ........................................................................................................4. 2010 Contract Entity Survey (HMO).....................................................................................#47

VIII. OVERSIGHT OF DELEGATION ...........................................................................................#48

A. 2010 OVERSIGHT OF DELEGATED VENDORS.............................................................................#48 B. 2010 OVERSIGHT OF HMO UTILIZATION MANAGEMENT .........................................................#48

IX. ACCREDITATION....................................................................................................................#48


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I. OUTCOMES FROM QUALITY IMPROVEMENT ACTIVITIES

A. HEDIS® INDICATORS: Of the 51 indicators for which comparative results from previous years are available: Indicators showing improvement (> 1 percentage point): 24

Statistically significant improvement: 15 Indicators remaining the same: (increase/decrease within 1 percentage point): 9

Statistically significant change: 3 Indicators not showing improvement (> 1 percentage point): 16

Statistically significant decrease: 6 Indicators rotated: 2

29 HEDIS Effectiveness of Care Indicators and 5 Access/ Availability of Care Indicators met or exceeded the established goals. Tests for statistical significance were performed comparing the HEDIS 2010 to HEDIS 2009. Those indicators with p<0.05 are noted with an (*).

Effectiveness of Care Indicators 2010 Goal

2010 Result

Met / Exceeded 2010 Goal

Improvement Compared to 2009 Results

Adult BMI Assessment Establish Baseline

77% NA NA

Weight Assessment and Counseling for Nutrition & Physical Activity for Children/Adolescents – BMI Percentile

Establish Baseline

53% NA NA

Weight Assessment and Counseling for Nutrition & Physical Activity for Children/Adolescents – Counseling for Nutrition

Establish Baseline

46% NA NA

Weight Assessment and Counseling for Nutrition & Physical Activity for Children/Adolescents – Counseling for Physical Activity

Establish Baseline

46% NA NA

Childhood Immunization Status - Combination 3 >77% 75% No No

Childhood Immunization - Hepatitis A Vaccination

Establish Baseline

20% NA NA

Childhood Immunization - Rotavirus Vaccination

Establish Baseline

48% NA NA

Childhood Immunization - Influenza Vaccination Establish Baseline

46% NA NA

Immunizations for Adolescents - Meningococcal Establish Baseline

33% NA NA

Immunizations for Adolescents – Tdap/Td Establish Baseline 39% NA NA

Breast Cancer Screening - ages 42-69 >69% 72% Yes Yes*

Cervical Cancer Screening Establish Baseline

75% NA NA

Colorectal Cancer Screening Establish Baseline

59% NA NA

Chlamydia Screening in Women – Total >25% 35% Yes Yes*

Appropriate Treatment for Children with Pharyngitis

>63% 68% Yes Yes*

Appropriate Treatment For Children With Upper Respiratory Infections

>77% 80% Yes Yes*

Avoidance of Antibiotic Treatment in Adults >16% 18% Yes Yes*


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With Acute Bronchitis Use of Spirometry Testing In The Assessment and Diagnosis of COPD

>26% 30% Yes Yes

Pharmacotherapy Management of COPD Exacerbation – Corticosteroid Within 14 Days

>62% 67% Yes Yes

Effectiveness of Care Indicators 2010 Goal

2010 Result

Met / Exceeded 2010 Goal


Pharmacotherapy Management of COPD Exacerbation – Bronchodilator Within 14 Days >75% 80% Yes Yes

Use of Appropriate Medications For People With Asthma – Ages 5-50

Establish Baseline

93% NA NA

Cholesterol Management For Patients With Cardiovascular Conditions LDL-C Screening >92% 91% Yes No

Cholesterol Management For Patients With Cardiovascular Conditions LDL-C Control (<100mg/dL)

>68% 64% No No*

Controlling High Blood Pressure - <140/90mmHg

>60% 63% Yes Increase/decrease within

1 percentage point

Persistence of Beta Blocker Treatment After a Heart Attack


1 percentage point Comprehensive Diabetes Care HbA1c Testing >88% 89% Yes No

Comprehensive Diabetes Care HbA1c Poor Control (>9)

<29% 30% No No

Comprehensive Diabetes Care HbA1c Control (<8%)

>60% 60% Yes No

Comprehensive Diabetes Care LDL-C Screening >86% 85% No No

Comprehensive Diabetes Care LDL-C Control (<100mg/dL)

>44% 47% Yes Yes

Comprehensive Diabetes Care Retinal Eye Exam >60% 62% Yes No

Comprehensive Diabetes Care Medical Attention for Nephropathy

>80% 85% Yes Yes

Comprehensive Diabetes Care Blood Pressure Control (<140/80mmHg)

NA 33% Yes NA

Comprehensive Diabetes Care Blood Pressure Control (<140/90mmHg)


1 percentage point Disease Modifying Anti-Rheumatic Drug Therapy In Rheumatoid Arthritis

>88% 92% Yes Yes*

Use of Imaging Studies in Low Back Pain >72% 73% Yes Increase/decrease within

1 percentage point Antidepressant Medication Management – Effective Acute Phase Treatment

>59% 60% Yes No

Antidepressant Medication Management – Effective Continuation Phase Treatment

>43% 44% Yes No

Follow-Up Care For Children Prescribed ADHD Medications – Initiation Phase

NA 30% NA Yes*

Follow-Up Care For Children Prescribed ADHD Medications – Continuation & Maintenance Phase

NA 31% NA Yes

Follow-up After Hospitalization for Mental Illness- (7-day rate)

NA 78% Yes Yes

Follow-up After Hospitalization for Mental Illness - (30 -day rate)

NA 84% NA Yes*

Annual Monitoring For Patients On Persistent Medications – Ace Inhibitors or ARBs

NA 77% NA Yes*

Annual Monitoring For Patients On Persistent Medications – Digoxin

NA 84% NA Yes

Annual Monitoring For Patients On Persistent NA 75% NA Yes*


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Medications – Diuretics Annual Monitoring For Patients On Persistent Medications – Anticonvulsants

NA 56% NA Yes

Annual Monitoring For Patients On Persistent Medications – Total

NA 76% NA Yes*

Flu Shots For Adults >40% 51% Yes Yes*

Access & Availability of Care Indicators 2010 Goal

2010 Result Met /

Exceeded 2010 Goal


Call Answer Timeliness >80% 76% No No*

Call Abandonment <3% 2% Yes Increase/decrease within

1 percentage point Initiation and Engagement of Alcohol & Other Drug Dependence Treatment – Initiation of Treatment

>43% 46% Yes Yes*

Initiation and Engagement of Alcohol & Other Drug Dependence Treatment – Engagement of Treatment

>8% 12% Yes Yes*

Prenatal Care >96% 96% Yes NA

Rotated

Post Partum Care >80% 80% Yes NA

Rotated Adults’ Access To Preventive/Ambulatory Health Services – 20-44 years

NA 89% NA No

Adults’ Access To Preventive/Ambulatory Health Services – 45-64 years

NA 92% NA Increase/decrease within 1 percentage point *

Adults’ Access To Preventive/Ambulatory Health Services – 65+ years

NA 95% NA No*

Children and Adolescents’ Access To Primary Care Practitioners - 12-24 months

NA 89% NA No*

Children and Adolescents’ Access To Primary Care Practitioners - 25 months to 6 years

NA 79% NA No*

Children and Adolescents’ Access To Primary Care Practitioners - 7-11 years


Children and Adolescents’ Access To Primary Care Practitioners - 12-19 years


Well-Child Visits In The First 15 Months of Life – 6 or more visits

NA 64% NA Yes*

Well-Child Visits In The Third, Fourth, Fifth and Sixth Years of Life

NA 59% NA No*

Adolescent Well-Care Visits NA 35% NA Increase/decrease within 1 percentage point

B. GEOACCESS Geoaccess standards were assessed and reported to the Managed Care Quality Improvement Committee in July 2010.

1. HMO ILLINOIS / BLUEADVANTAGE HMO All HMO Geoaccess standards were met in 2009 as reported in 2010.

Analysis of primary care practitioners (Family Practice, Internal Medicine, Pediatrics, and Obstetrics/Gynecology) demonstrates that the standard of 85% of subscribers having access to not less than two practitioners within an 8-mile radius (urban/suburban) or a 30 mile radius (rural) was exceeded for all practitioner types.

Analysis of high volume and other key specialties demonstrates that the standard of 85% of subscribers having access to not less than two practitioners within an 8 mile radius (urban/suburban) or a 30 mile radius (rural) was met and/or exceeded in both the urban/suburban and rural service areas.


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Analysis of all facility types demonstrates that the standard of 85% of subscribers having access to not less than one facility in each category within an 8 mile radius (urban/suburban) or a 30 mile radius (rural) was met except for Skilled Nursing Facilities for HMOI and BlueAdvantage HMO.

2. PPO This was not reported due to methodology changes. PPO is scheduled to be reported again for 2011. It must be noted that the HMO reports include only credentialed physicians. C. HMO CLINICAL QUALITY IMPROVEMENT STUDIES Twelve HMO clinical studies were in progress during 2010. They include:

1. Childhood Immunization QI Fund Project 2. Diabetes Flowsheet QI Fund Project 3. Follow-up After Hospitalization for Mental Illness QI Fund Project 4. Asthma QI Fund Project 5. Breast Cancer Screening QI Fund Project 6. Cervical Cancer Screening QI Fund Project 7. Colorectal Cancer Screening QI Fund Project 8. Seasonal Influenza Vaccination QI Fund Project 9. Management of Members with Cardiovascular Conditions QI Fund Project 10. Controlling High Blood Pressure QI Fund Project 11. Adult Wellness and Prevention QI Fund Project 12. Pediatric Wellness and Prevention QI Fund Project

1. Childhood Immunization QI Fund Project

The purpose of the HMO Childhood Immunization QI Fund Project is to increase the percentage of children receiving timely and complete immunizations by their 2nd birthday. The 2010 goal for this project was a Combination 3 Rate of >74%. Combination 3 includes 4 DTaP, 4 Pneumococcal Conjugate Vaccines, 3 IPV, 3 Hepatitis B, 3 HiB, 1 MMR, and 1 VZV. IPAs could earn additional funds if >35% of the members identified for the project received at least 2 doses of Hepatitis A vaccine and at least 2 doses of Influenza vaccine, as well as at least 2 doses of Rotavirus vaccine prior to the child’s second birthday.

The 2006-2010 Network results are outlined in the following table. Year Initial

Population Exclusions Final

Population # of Members

with Combination 3

Vaccines

Combination 3 Rate

2006 8,159 227 7,933 5,435 68% 2007 8,014 142 7,872 5,911 75% 2008 7,561 136 7,425 5,665 76%

2009* 7,119 89 5,586 4,193 75% 2010 6,389 31 6,358 4,818 76% *Reflects the number of children identified for the second, third and fourth quarters of 2009 due to a data error in the first quarter.

Year # of Members with 2

Doses of Hepatitis A Vaccine and 2 Doses of Influenza Vaccine

Members with 2 Doses of Hepatitis A Vaccine

and 2 Doses of Influenza Vaccine Rate

# of Members with 2 Doses of Rotavirus

Vaccine

Members with 2 Doses of Rotavirus Vaccine

Rate

2009* 1,748 /7,030 26% 2010 1,197/6,358 19% 3,967/6,358 62% *Reflects the number of children identified for the second, third and fourth quarters of 2009 due to a data error in the first quarter.

Identified Barriers to Childhood Immunizations:


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Members: Concern about potential vaccine side effects Lack of familiarity with the pediatric vaccination schedule and the importance of timely and complete

childhood immunizations May not be aware that childhood immunizations are a covered benefit of the HMO Missed appointments due to competing priorities

Physicians: May fail to identify children who are behind on their immunizations May find combination vaccines can be difficult to track if an electronic system is not used May not have reminder or recall programs in place May not have systems in place to track pediatric immunizations

IPAs: May not be performing member outreach May not be monitoring physician performance regarding vaccination rates May not be rewarding physicians for providing complete and timely childhood immunizations

Interventions Implemented to Address Identified Childhood Immunization Barriers: Members:

Distributed “Welcome to the Family”to parents of newborns.

2010 Number of Members “Welcome to the Family” 10,304

Mailed monthly reminders to parents of 15 month old members.

2010 Number of Members

Parent Reminders 8,373

The Fall/Winter 2010 edition of blueprints for health for HMO members included an article “Feel Well at Every Age, Preventive Care is the Key to a Healthier Life”. The article included information about childhood immunizations.

Provided online resources, including the Personal Health Manager. IPAs/Physicians:

Awarded a Childhood Immunization Blue StarSM to IPAs with a 2009 Childhood Immunization Combination 3 Rate of >67%

Sent lists of 12-month-old members to IPAs Sent IPA member-specific results from the 2009 QI Fund Project summarizing whether all immunizations

in a series were documented and whether the immunizations met HEDIS timeframes Conducted HMO QI Fund Training for the IPAs in February 2010 Reviewed best practices to improve childhood immunization rates at the quarterly QI Forums Conducted IPA training

An analysis of the results for the 2010 Childhood immunization QI Fund Project demonstrates that there are opportunities for improvement in the number of children who receive at least two doses of Hepatitis A vaccine and at least two doses of Influenza vaccine, as well as at least two or three doses of Rotavirus vaccine prior to the child’s second birthday. 2. Diabetes QI Fund Project The purpose of this program is to improve the outcomes for members with diabetes by increasing the percentage of members who receive recommended diabetes services and achieve control of HbA1c, LCL-C and blood pressure. One focus of the program is to motivate physicians to track diabetes services on a flowsheet, one-page summary or


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electronic medical record. The documentation system must be organized to track information regarding HbA1c testing, LDL cholesterol screening, blood pressure screening, retinal eye exam and medical attention for nephropathy. The information must be organized to trend results over time and to remind the practitioner when a service is due. The 2010 goals for the diabetes indicators were:

HbA1c Control <8.0%: >60% Eye Exam: ≥55% LDL-C Control <100 mg/dL: ≥50% Blood Pressure control <140/90mmHg: ≥70% Screening for Depression: ≥60% Medical Attention for Nephropathy: >75% Overall Diabetes Care: Establish baseline

The 2006-2010 Network results are outlined in the following table.

Diabetes Indicator 2006 2007 2008 2009 2010

HbA1c Control <9.0% 71% (13,454/18,862)

70% (20,176/29,039)

74% (22,293/30,056)

NA NA

HbA1c Control <8.0% 59% (11,054/18,862)

59%1

(17,231/29,039) 63%

(18,867/30,056) 65%

(21,091/32,521) 66%

(25,092/38,293) Eye Exam 58%

(10,923/18,862) 56%

(16,147/29,036) 55%

(16,502/30,056) 59%

(18,844/31,727) 57%

(21,796/38,293)

LDL-Cholesterol <100 mg/dL

51% (9,615/18,862)

46%1 (13,454/29,036)

52% (15,633/30,056)

54% (17,202/31,727)

55% (25,092/38,293)

Blood Pressure Control <140/90mmHg

N/A 62%1 (18,125/29,036)

74% (22,165/30,056)

76% (24,160/31,727)

80% (30,681/38,293)

Screening for Depression

58% (10,222/17,647)

57% (15,630/27,252)

64% (18,368/28,535)

75% (22,231/29,480*)

82% (28,857/35,189)

Medical Attention for Nephropathy

75% (14,182/18,862)

74% (21,443/29,036)

81% (24,251/30,056)

86% (27,365/31,727)

86% (32,906/38,293)

2008 Overall Diabetes Care HbA1c <9.0% LDL <100 mg/dL Eye Exam Medical Attention for

Nephropathy

N/A 24%

(6,877/29,036) 28%

(8,278/30,056) 31%

(9,747/31,727) N/A

2009 Overall Diabetes Care HbA1c <8.0% LDL <100 mg/dL Eye Exam Medical Attention for

Nephropathy

N/A N/A N/A 29%

(9,173/31,727) 28%

(10,874/38,293)

2010 Overall Diabetes Care ** HbA1c <8.0% LDL <100 mg/dL Eye Exam Medical Attention for

Nephropathy Blood Pressure

< 140/90mmHg

N/A N/A N/A N/A 56%

(21,484/38,293)

1 Most recent value was required *Members with a previous history of depression are excluded from the screening measure. **Elements for 2010 Overall Diabetes Care were changed to confirming that four of the five listed criteria were met.


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The program results have shown significant improvements in the process and intermediate outcome measures. To assess the impact on clinical outcomes (ER and inpatient admission rates), BCBSIL performed a longitudinal analysis on the cohort of the 9,094 diabetics who were included in the program each year from 2006 to 2009. BCBSIL claims were used as the data source to assess inpatient and emergency room utilization. For 510 members complete utilization data were not available. These were members of one IPA that paid its own ER and inpatient claims. These members were excluded from this analysis. Results for the process and intermediate outcome measures for the final cohort of 8,584 diabetics are displayed in the table below. There was a significant improvement (p < .001) for all the measures. Process and Intermediate Outcome Measures for the Cohort (N = 8,584)

Measure 2006 2007 2008 2009 % point

change from 2006 to 2009

2009 vs. 2006, 2007 &

2008comparisonHbA1c Control < 8% 62% 60% 62% 63% 1% *07 LDL-C Control < 100 mg/dL 53% 50% 56% 59% 6% *06, *07, *08 Eye Exam 61% 60% 61% 67% 6% *06, *07, *08 Medical Attention For Nephropathy 77% 78% 84% 89% 12% *06, *07, *08 Depression Screening 61% 62% 67% 69% 8% *06, *07, *08 Overall Diabetes Care* NA 35% 51% 58% 23% *07, *08

* Statistically significant (p < .001) results key: *06: 2009 vs. 2006, *07: 2009 vs. 2007, *08: 2009 vs. 2008 At least 4 out of 5 elements meeting requirement: HbA1c Control < 8%, LDL-C Control < 100 mg/dL, Eye Exam, Medical Attention for Nephropathy and Blood Pressure < 140/90 mm Hg

Clinical outcome measures include: ER visits/1,000 diabetics Inpatient admissions/1,000 diabetics

Numerator and Denominator Definition for Clinical Outcome Measures

Clinical Outcome Measure Numerator Denominator ER visits/1,000 diabetics Number of ER visits for members in

the denominator (for each of the years 2005 – 2009)

Inpatient admissions/1,000 diabetics

Number of inpatient admissions for members in the denominator (for each of the years 2005 – 2009)

Number of members who were included in the diabetes disease management program for each of the four years from 2006 to 2009

For the cohort of 8,584 diabetics, both ER visit and inpatient admission rates have trended upwards from 2005 to 2009, as displayed below. ER Visit and Inpatient Admission Rates for the Cohort (N = 8,584)

Clinical Outcome Measure 2005 2006 2007 2008 2009 ER Visits/1,000 Diabetics 160.5 162.5 164.4 170.0 173.7 Inpatient Admissions/1,000 Diabetics 169.6 173.7 176.4 178.7 181.6

The cohort was segregated into five groups based upon the number of years that HbA1c was controlled (HbA1c < 8.0%) from 2006 to 2009. The relationship between ER and inpatient rates and the number of years HbA1c < 8.0 % for the cohort of 8,584 diabetics is displayed below.


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Relationship Between the Number of Years HbA1c < 8% and ER Visit Rate/1,000 Diabetics

F Hea

200.0178.6167.9163.8160.52 years

(n = 1,215)

230.6211.9176.2165.1162.61 year

(n = 1,175)

127.1146.1159.9163.3161.63 years

(n = 1,739)

ER Visit Rate/1,000 Diabetics

276.3226.1183.3162.5159.9None

(n = 1,495)

115.9135.5151.4160.5159.54 years

(n = 2,960)

20092008200720062005rom 2006 – 2009 bA1c was < 8 % in ch of:

200.0178.6167.9163.8160.52 years

(n = 1,215)

230.6211.9176.2165.1162.61 year

(n = 1,175)

127.1146.1159.9163.3161.63 years

(n = 1,739)

ER Visit Rate/1,000 Diabetics

276.3226.1183.3162.5159.9None

(n = 1,495)

115.9135.5151.4160.5159.54 years

(n = 2,960)

20092008200720062005From 2006 – 2009 bA1c was < 8 % in ch of:

Hea

0

50

100

150

200

250

300

2005 2006 2007 2008 2009

4 years 3 years 2 years 1 year None

Relationship Between the Number of Years HbA1c < 8% and ER Visit Rate/1,000 Diabetics

192.6187.7178.6174.5170.42 years

(n = 1,215)

254.5220.4200.9176.2171.11 year

(n = 1,175)

141.5154.1163.9171.9168.53 years

(n = 1,739)

Inpatient Admission Rate/1,000 Diabetics

266.9230.8206.0173.2168.6None

(n = 1,495)

128.7146.6158.1173.6169.94 years

(n = 2,960)

20092008200720062005From 2006 –2009 HbA1c was < 8 % in each of:

192.6187.7178.6174.5170.42 years

(n = 1,215)

254.5220.4200.9176.2171.11 year

(n = 1,175)

141.5154.1163.9171.9168.53 years

(n = 1,739)

Inpatient Admission Rate/1,000 Diabetics

266.9230.8206.0173.2168.6None

(n = 1,495)

128.7146.6158.1173.6169.94 years

(n = 2,960)

20092008200720062005From 2006 –2009 HbA1c was < 8 % in each of:

Relationship Between the Number of Years HbA1c < 8% and Inpatient Admissions/1,000 Diabetics


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0

50

100

150

200

250

300

2005 2006 2007 2008 2009

4 years 3 years 2 years 1 year None

Relationship Between the Number of Years HbA1c < 8% and Inpatient Admissions/1,000 Diabetics

There was an inverse relationship between the number of years that HbA1c has been controlled (< 8%) and utilization rates. In 2005 and 2006, ER and inpatient rates were similar across all groups, but from 2007 to 2009 both ER and inpatient rates increased significantly (p < .01 using a chi-square test) for diabetics whose HbA1c < 8.0% in zero to two years and significantly decreased (p <.01 using a chi-square test) for diabetics with HbA1c < 8.0% in 3 or 4 years. The analysis shows that for the consistently managed diabetics (HbA1c < 8.0 % in at least three out of four years), from 2005-2009 there was a decline of:

21% - 27% in the ER rate; and 16% - 24% in the inpatient admission rate.

By contrast, for the poorly managed diabetics (HbA1c < 8.0 % in 0 to 2 years), from 2005 to 2009 there was an increase from:

42% - 73% in the ER rate 49% - 58% in the inpatient admission rate

The results from the program and the longitudinal analysis of the cohort show significant improvement in the process measures and the intermediate outcome measures. The clinical outcome measures improved for those controlled in three to four years. Glucose Meter Program:

Glucose meters were offered to members identified with a diagnosis of diabetes free of charge. The number of meters distributed to HMO members in 2010 is summarized below.

2010 Number of HMO Members

Total Number of Glucose Meters Distributed 1,441 Annually, the HMO selects a random sample of members identified with diabetes. The Diabetes Care Survey is mailed to the sampled members to obtain the member’s perspective of their diabetes care. 2010 survey results are displayed in the table below. 2010 Diabetes Care Survey - Survey Question Result >1 day missed from work/self-care/recreation in the past 30 days 28% Pupil dilation/enlargement done by specialist within 2 years 93% Provider skill scale (0-100 point scale) 77.6 Provider treatment explanation scale (0-100 point scale) 80.4 Provider quality of treatment scale (0-100 point scale) 73.3


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2010 Diabetes Care Survey - Survey Question Result Overall health care rating scale (0-100 point scale) 83.2 Influenza vaccination rate for members with diabetes 62% Identified Barriers to Diabetes Care: Members:

Members may not be aware of American Diabetes Association recommendations. Members may not be aware that diabetes services (i.e. eye exam, glucose meters) are a covered benefit. Members may be non-compliant with PCP recommendations. Some diabetic members may not be motivated to seek routine care or fill their prescriptions based on

economic restrictions. Physicians:

Physicians may lack systems to promote recommended diabetic care for members. Some physicians may not provide care in accordance with the American Diabetes Association guidelines. It may be challenging to cover all the diabetes care services when members are coming in only for acute

care. IPAs:

It may be difficult to motivate physicians to utilize flowsheets or electronic medical records (EMR) to track services.

It may be difficult to facilitate member care within the confines of the operation of the health care team. Interventions Implemented to Address Identified Barriers: Members:

Published an article in the Fall/Winter 2010 issue of blue prints for health entitled “Feel Well at Every Age: Preventive Care is the Key to a Healthier Life” which included information for members at increased risk for diabetes.

Provided online resources, including Personal Health Manager and Ask a Nurse Educational materials were distributed to members identified with a diagnosis of diabetes through quarterly

reminder cards. The topics covered in 2010 and the number of members who received the information are summarized in the following table.

2010 Number of

Members “Decrease Your Risk of Heart Disease” 35,753 “Your Guide to Good Diabetes Care” with Diabetes Care Card” 42,604 “Foot Care is Important to Good Diabetes Care” with Flu Shot Reminder” 42,604 “Diabetes Can Affect Your Vision” with Diabetes Care Card” 40,996 Physicians/IPAs:

A Diabetes Blue Star was awarded to IPAs meeting at least five of seven payment thresholds in 2009. A QI Fund payment was made to IPAs with project results that met or exceeded established thresholds. The BCBSIL Guidelines for the Prevention and Early Detection of Complications of Diabetes Mellitus

were updated and made available to all network physicians. A sample flowsheet for tracking diabetes care is available on the Provider section of www.bcbsil.com. Quality Improvement staff conducted educational trainings for IPAs as requested. The Diabetes QI Project was completed. Feedback provided to the IPAs included IPA results, patient specific reports and network results. The HMO QI Fund Training was conducted for the IPAs in February 2010. The Quality Improvement staff hosted quarterly QI Forums.

IPAs were rewarded for providing member and physician outreach to members who were identified for the project. The goals of the 2010 Diabetes Physician and Member Outreach portion of the 2010 QI Fund Project were to:

http://www.bcbsil.com/


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• encourage PCPs and WPHCPs to recommend diabetes care services to their patients • motivate IPAs to develop and maintain systems to perform outreach • communicate to members recommendations regarding asthma care • close gaps in care for members who have not received the recommended services

The 2010 Diabetes Physician and Member Outreach results are as follows: Submission of a completed Attestation Form with required supporting documentation of all required elements.

Number of IPAs Meeting Project Requirements

2010 100% (75/75) Identified Barriers for Outreach:

Some IPAs voiced concern about competing priorities. Although many tasks related to Physician and Member outreach are administrative, effective clinical

leadership is required for successful outcomes. Many IPAs lack understanding of the importance of outreach.

Effective Outreach Requires: A culturally sensitive approach A team effort with engaged providers Good communication between clinical and non-clinical staff Evaluating the results and using the information to improve the process

Interventions: A QI Fund payment was available to IPAs for completion of physician and member outreach. The QI Staff provided educational programs, including the QI Forum.

Analysis of the 2010 results for the Diabetes QI Fund Project demonstrates that the project and the interventions implemented have had a positive effect on routine diabetes care. All goals for the project were met. 3. Management of Members with Cardiovascular Conditions QI Fund Project The focus of the project is to improve the outcomes for members with cardiovascular conditions by increasing the percentage of identified members who have had cardiovascular risk factors assessed and controlled. The data from the 2010 Management of Members with Cardiovascular Conditions QI Fund and the 2010 goal for each indicator are displayed in the following table:

Risk Factor 2010 Goal 2010 Result

LDL-C Control <100mg/dL >70% 73%

(3,963/5,397)

BP Control <140/90mmHg >78% 89%

(4,818/5,397) 2009 – 2010 Advice to Quit Smoking Rate

(2-Year Rate) Establish Baseline

75% (1,493 /1,995)

Identified Barriers to Management of Members with Cardiovascular Conditions: Member:

May not seek follow-up after a cardiovascular event or for a chronic condition May believe their cardiovascular condition is “under control” May not be aware that the risk of cardiovascular events is reduced if cardiovascular risk factors are

controlled May be non-compliant with PCP recommendations regarding behavior modification

Physicians: May lack systems to promote care for patients with cardiovascular disease. May not provide care in accordance with the BCBSIL Guidelines for Primary & Secondary Prevention of

Atherosclerotic Cardiovascular Disease and the Guidelines for Treating Tobacco Use and Dependence.


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May fail to document or assess smoking status, which may result in patients no being advised to quit. IPA:

May lack a systematic approach to improving data collection and/or performance May not reward and/or recognize their physicians based on performance May not have a process in place to improve data collection and performance

Interventions Implemented to Address Identified Barriers: Members:

HMO Member Mailings Healthy Habits for Healthy Hearts brochure was sent to 3,270 members in October 2010 to members

identified for the 2010 Management of Members with Cardiovascular Conditions QI Fund Project who were still enrolled.

Published an article in the Fall/Winter 2010 issue of blue prints for health entitled “Feel Well at Every Age: Preventive Care is the Key to a Healthier Life” which included information for members at increased risk for heart attack and cholesterol screening.

On-line resources (bcbsil.com) Personal Health Manager Ask-a-Nurse

IPAs: IPAs were provided a list of members from the 2009 QI Project who did not have cardiovascular disease

risk factors assessed and/or controlled. The QI Department conducted trainings for IPAs. A program description for the Cardiovascular Disease Management Program was sent to the IPAs and is

also made available on the website at bcbsil.com. IPAs who have achieved a high level of performance were awarded a Blue Star for Management of

Cardiovascular Conditions. Physicians:

The Cardiovascular Condition Management Program Summary and Physician Enrollment Form was mailed to HMO Physicians with the HMO PCP Survey in August 2010 and made available on bcbsil.com/provider.

The BCBSIL "Guidelines for Primary and Secondary Prevention of Atherosclerotic Cardiovascular Disease" and the "Guidelines for Treating Tobacco Use and Dependence“ are available on bcbsil.com/provider.

The results from the 2010 Management of Members with Cardiovascular Conditions QI Fund Project showed statistically significant improvements* when compared to the 2008 and 2009 results.

LDL-C Control < 100mg/dL: 2008 rate 70% (3,647/5,242) 2009 rate 72% (4,613/6,444) 2010 rate 73% (3,963/5,397)

Blood pressure Control <140/90mmHg: 2008 rate 86% (4,497/5,242) 2009 rate 88% (5,639/6,444) 2010 rate 89% (4,818/5,397)

= Significant improvement compared to previous year, p<0.03 All project goals were met.

4. Follow-Up After Hospitalization for Mental Illness QI Fund Project The purpose of the HMO Follow-up After Hospitalization for Mental Illness QI Fund Project is to increase the rate of behavioral health follow-up care for members age 6 and older who were hospitalized for treatment of selected mental health disorders. The results from 2010 are not comparable to 2006-2009 due to a change in the population. Members identified as having Medicare as their primary coverage are not included in the 2010 project population. The 2010 project goal for the 7-day follow-up rate was ≥75%.


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The following table displays the 2005-2009 Network results.

Mental Health Indicator*

2006 2007 2008 2009 2010

Follow-up visit with a Behavioral Health Practitioner within 7 days of Discharge

69.8% (1,637/2,344)

73.5% (1,734/2,359)

76.3% (1,771/2,320)

77.3% (1,827/2,364)

77.8%

(1,799/2,312)

Identified Barriers to Follow-Up After Hospitalization for Mental Illness: Members:

May not be compliant with follow-up May not have an appointment with a Behavioral Health Specialist scheduled within seven days of discharge May not be aware that follow-up with a Behavioral Health Specialist is recommended within seven days of

discharge May feel better after discharge and decide a follow up appointment is not necessary May lack a support system to ensure appropriate follow-up care May believe there is a stigma related to having mental health diagnosis

Behavioral Health Specialist:

May not have a previous relationship with the member in both inpatient and outpatient settings May not transition follow-up visits within 7 days of discharge with a Behavioral Health Specialist May not utilize home health services for members with a history of non-compliance May not use partial hospital programs or intensive outpatient programs for follow-up care

IPAs: May not be aware of the inpatient admission to set up a follow up appointment, particularly when the

admission is at a facility not affiliated with the IPA May not have a way to contact the member after hospital discharge to encourage follow-up care May not utilize home health services for members with a history of non-compliance May not use partial hospital programs or intensive outpatient programs for follow-up care May not arrange for follow-up visit with a with a Behavioral Health Specialist prior to discharge May not work with the hospital discharge planner to arrange for follow-up care


Information on mental health issues is available on the bcbsil.com website: BeSmart. BeWell® Personal Health Manager

Physician: BCBSIL performed QI site visits for newly identified Behavioral Health Specialists. BCBSIL posted "Tips for Improving IPA Follow-Up After Hospitalization for Mental Illness Rate" on the

BCBSIL Provider website. BCBSIL posted a sample letter on the BCBSIL Provider website for IPA use to educate members on the

importance of follow-up treatment after hospitalization for mental illness. IPAs:

IPAs received a QI Fund payment for the 2009 project results that met or exceeded the established thresholds.

IPAs received a patient-specific report with their 2009 Follow-Up After Hospitalization For Mental Illness QI Fund Project results and feedback was provided.

BCBSIL included the Follow-Up After Hospitalization for Mental Illness QI Fund Project in the Blue StarSM Medical Group Report.


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As part of the BCBSIL HMO Utilization Management oversight, the nurse liaison audited HMO IPA case file documentation for mental health admissions and follow-up within 7 days. Feedback was provided to the IPAs for this indicator.

The QI Department conducted HMO QI Fund Training in February 2010 and held quarterly QI Forums. BCBSIL conducted individual IPA training as requested. BCBSIL nurses conducted ongoing training for all IPAs during data collection for the project.

Analysis of the results for the 2010 Follow-Up after Hospitalization for Mental Illness QI Fund Project shows the QI Fund Project and the interventions implemented have had a positive effect on the 7-day follow-up rate. The goal for the 7-day follow-up rate of >75% was met.

5. Asthma QI Fund Project The purpose and scope of the Asthma QI Fund Project are:

to improve asthma care and outcomes by increasing the percentage of asthmatic members who: receive an annual written asthma action plan have their asthma control assessed annually have well-controlled asthma (based on the score from a standardized and validated tool)

to encourage physician outreach for members with asthma who are due for services

The project goals were the percentage of members who: received a written asthma self-management plan: >73% had at least one assessment of asthma control was >70% have well-controlled asthma was to establish baseline

The following table summarizes the Network results for the number and percentage of members who received an acceptable asthma action plan, had at least one assessment of asthma control in 2010 and had well-controlled asthma based on the score from a standardized tool.

2008 2009 2010 Asthma Action Plan 74%

(5,073/6,823) 75%

(7,037/9,427) 80%*

(6,668/8,289) Assessment of Asthma Control

68% (4,647/6,823)

74% (6,971/9,427)

80%* (6,616/8,289)

Well Controlled Asthma

61% (5,080/8,289)

*Statistically significant increase from 2009 (p <0.001)

16

Percentage of HMO Members with Asthma Who Received a Written Asthma Action Plan

69% 75% 80% 74% 74% 75% 80%55% 74%21% 36%

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Public ReportingBegins

QI Fund Project Initiated

Plan within 1 yearPlan within 2 years

Plan Within One Year

Assessment of Control Added as a

Requirement

11 Year Results:

+59percentage point increase

Added a Threshold for Members with Well-Controlled Asthma

Plan within 2 years


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To further evaluate the possibility that the impact of asthma action plans came from receiving multiple plans, BCBSIL needed to track a population over a period of time. Therefore, utilization was assessed for the cohort of members who met asthma identification criteria and were included in the asthma program each year from 2005 through 2009. For the 1,196 members who met these criteria, utilization data (based upon BCBSIL claims) and clinical information (presence or absence of an acceptable asthma action plan based upon IPA QI Fund project submissions) were available for each of five years (2005 through 2009). Asthmatics who received a written asthma action plan in 3 of the years from 2004- 2009 have a:

33% to 50% lower ER visit rate 43% to 55% lower hospital admission rate 50% to 94% lower likelihood of an ER visit and 33% to 67% lower likelihood of a hospital admission

compared to asthmatics who received a written action plan in fewer than 3 years. The Asthma QI Fund Project has stimulated improvements in quality that are correlated with lower utilization.

100.085.785.771.471.41 year (n = 70)

47.158.466.674.771.44 years (n= 616)

93.883.383.372.972.92 years (n = 96)

53.864.568.175.368.13 years (n = 279)

Inpatient Admission Rate/1,000 asthmatics

103.486.286.269.069.00 year(n = 58)

39.051.964.977.964.95 years (n = 77)

20092008200720062005From 2004-2009, member received an asthma action plan in each of:

Relationship Between Frequency of Asthma Action Plan and Asthma Inpatient Admissions

0

20

40

60

80

100

2005 2006 2007 2008 2009

Rat

e pe

r 1,0

00 a

sthm

atic

s

5 years 4 years 3 years 2 years 1 year 0 year

Relationship Between Frequency of Asthma Action Plan and Asthma Inpatient Admissions


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185.7171.4157.1142.9128.61 year (n = 70)

95.8107.1121.8131.5128.24 years (n= 616)

177.1166.3156.3145.8125.02 years (n = 96)

118.3125.4129.0136.2132.63 years (n = 279)

ER Visit Rate/1,000 asthmatics

189.7172.4155.2137.9120.70 year(n = 58)

77.9103.9116.9142.9129.95 years (n = 77)

20092008200720062005From 2004-2009, member received an asthma action plan in each of:

Relationship Between Frequency of Asthma Action Plan and Asthma ER Visits

0

40

80

120

160

200

2005 2006 2007 2008 2009

Rat

e pe

r 1,0

00 a

sthm

atic

s

5 years 4 years 3 years 2 years 1 year 0 year

Relationship Between Frequency of Asthma Action Plan and Asthma ER Visits

Annually, the HMO selects a random sample of adult and pediatric members identified with asthma. The Asthma Care Survey is mailed to obtain the member’s perspective of their asthma care. 2010 survey results are displayed in the tables below. 2010 Asthma Care Survey (Adult) - Survey Question Result Doctor or other health care provider gave or reviewed a written asthma plan - All asthmatics 64% Controller medication use rate - All asthmatics 90% Overall Asthma Care scale - All asthmatics (0-100 point scale) 86.3 Provider Communication/Skill Scale - All asthmatics (0-100 point scale) 84.8 2010 Asthma Care Survey (Pediatric) - Survey Question Result Doctor or other health care provider gave or reviewed a written asthma plan - All asthmatics 77% Controller medication use rate - All asthmatics 89% Overall Asthma Care scale - All asthmatics (0-100 point scale) 85.6 Provider Communication/Skill Scale - All asthmatics (0-100 point scale) 76.0


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Identified Barriers to Asthma Care: Members:

May not seek routine care when asymptomatic May be non-compliant with practitioner recommendations regarding asthma medications May not understand the benefit of using controller medication regularly May not be aware of their asthma triggers May not avoid their asthma triggers May not realize that asthma control should be evaluated at each visit and the treatment plan be updated as

needed May not be aware of the asthma diagnosis

Practitioner Some practitioners may not provide an asthma action plan may not assess control may not adjust the treatment plan when asthma is not well controlled

IPAs: may not have a process in place to promote assessments of asthma control or the use of asthma action plans may not reward their physicians to improve asthma care


• The “Personal Asthma Management” brochure with the Asthma Condition Management Program was mailed to all identified members with asthma.

• The Asthma Care Survey for adults and children was sent to a random sample of identified members. • Flu shot reminders were mailed to all members identified with asthma. • Additional resources provided to members include information on managing asthma available through the

Personal Health Manager and “Ask a Nurse” on Blue Access® for Members at www.bcbsil.com Published an article in the Spring 2010 issue of blue prints for health entitled “Spring is Here: Nip Allergies

in the Bud” which included information on asthma control.

2010 All Asthmatics Newly Diagnosed Asthmatics

Personal Asthma Management Brochure 8,569 1,966

Flu Shot Reminders 8,534 N/A

Physicians:

Posted the Guidelines for the Diagnosis and Management of Asthma in the Provider Manual on bcbsil.com Posted sample asthma action plans and assessment tools on bcbsil.com Mailed the Asthma Condition Management Program Summary and an enrollment form to HMO PCPs Posted the Asthma Condition Management Program Summary and an enrollment form on the BCBSIL web

site, bcbsil.com\Providers IPAs:

Awarded an Asthma Blue Star for the 2009 Asthma QI Fund Project to IPAs with at least 68% of asthmatic members receiving an asthma action plan and assessment of asthma control

Made a QI Fund payment to IPAs with project results that met or exceeded established thresholds. Continued the Asthma QI Project and provided feedback to IPAs. Updated and made available the Guidelines for the Diagnosis and Management of Asthma to all network

physicians. Provided IPAs with a training in February 2010 on the QI Fund Project, the importance of an Asthma

Action Plan, the assessment of asthma control and well-controlled asthma. Conducted individual training for several IPAs


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Quality Improvement staff held Quarterly QI Forums IPAs were rewarded for providing member and physician outreach to members who were identified for the project. The goals of the 2010 Asthma Physician and Member Outreach portion of the 2010 QI Fund Project were to:

• encourage PCPs and WPHCPs to recommend asthma care services to their patients • motivate IPAs to develop and maintain systems to perform outreach • communicate to members recommendations regarding asthma care • close gaps in care for members who have not received the recommended services

The 2010 Asthma Physician and Member Outreach results are as follows: Submission of a completed Attestation Form with required supporting documentation of all required elements.





Effective Outreach Requires:

A culturally sensitive approach A team effort with engaged providers Good communication between clinical and non-clinical staff Evaluating the results and using the information to improve the process

Interventions: A QI Fund payment was available to IPAs for completion of physician and member outreach. The QI Staff provided educational programs, including the QI Forum.

The percentage of members who receive an asthma self-management plan has significantly increased from 2000-2010. Analysis of the data for the Asthma QI Fund Project demonstrates that 80% of members received an asthma action plan in 2010. This rate exceeds the 2010 goal of >73% for the Asthma QI Fund Project. Compared to 2009, there was a statistically significant increase in the percentage of members who received a written asthma action plan and in the percentage who had at least one assessment of asthma control. Overall, the QI Fund Project and interventions implemented have had a positive effect on the clinical care of asthmatic members by educating members and providers on the current guidelines for asthma and self management through the use of an agreed upon self management plan, assessment of asthma control and well-controlled asthma. 6. Breast Cancer Screening QI Fund Project The purpose of the Breast Cancer Screening QI Fund Project is to promote breast cancer screening for early detection of breast cancer in women age 42 to 69. This project was based on a two-year rate, assessing services performed in 2008 and 2009. The 2010 goal was >69%. Project

Year Reporting

Year Initial

Population Total Number of

Exclusions Final

Population Number of Women

with a Mammogram (2-Year Rate)

Breast Cancer Screening

Rate 2007 2005-2006 115,751 129 115,622 80,139 69% 2008 2006-2007 114,269 243 114,026 78,615 69% 2009 2007-2008 129,690 52 129,638 91,173 70% 2010 2008-2009 128,518 197 128,321 91,904 72%


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For the 2010 project, Medicare Primary members were excluded. A sub-analysis of data from the 2009 project was performed to assess the potential impact of this change. While the original 2009 project results had been reported for women age 42-69, the data was re-analyzed to determine the rate for women age 42-64. The analysis demonstrated that the exclusion of women age 65-69 made little difference in the breast cancer screening rate.

Population Age 42-69

Breast Cancer Screening Rate For Women Age 42-69

Population Age 42-64

Breast Cancer Screening Rate For Women Age 42-64

129,690 70.33% 121,802 69.93% Identified Barriers to Breast Cancer Screening: Members:

May not be aware that mammograms are a covered benefit May not have accurate information about screening recommendations May dislike the pain/discomfort experienced during the mammogram procedure May have experienced scheduling conflicts May fear a negative outcome of the mammogram

Physicians: May not routinely recommend mammograms to their patients May not have a systematic method to track preventive services

IPAs: May not have a method to motivate their physicians to improve care Some IPAs may not understand the process regarding administrative data.


Mailed the “Celebrate Healthy Birthdays!” mammography reminder cards to women age 40-69 during their birthday month.

The reminder: provides information on the screening recommendations for mammography encourages members to discuss the starting age and frequency of mammography with their physicians

Published an article in the Fall/Winter 2010 issue of blue prints for health entitled “Feel Well at Every Age: Preventive Care is the Key to a Healthier Life” which included information on breast cancer screening

The number of members who received the monthly mailing is detailed in the table below.

Year Number of Members 2010 126,130

Physicians/IPAs:

Awarded a QI Fund payment for those IPAs who met or exceeded thresholds Completed the Breast Cancer QI Project and provided feedback to IPAs QI staff conducted IPA HMO QI Fund Training in February 2010 and continued to hold quarterly QI

Forums Continued public reporting through the Blue StarSM Medical Group/IPA Report Reviewed best practices on ways to improve breast cancer screening at the quarterly QI Forums Conducted IPA training as needed

The Physician and Member Outreach portion of the QI Fund continued in 2010. IPAs were rewarded for providing member and physician outreach for female members age 40-69 who were identified as needing breast cancer screening. The goals of the 2010 Breast Cancer Screening Physician and Member Outreach portion of the QI Fund Project were to:

encourage PCPs and WPHCPs to recommend preventive care services to their patients


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motivate IPAs to develop and maintain systems to perform outreach communicate to members recommendations regarding preventive care close gaps in care for members who have not received the recommended services

The 2010 Breast Cancer Screening Physician and Member Outreach Results are as follows: Submission of a completed Attestation Form with required supporting documentation of all required elements.






Interventions: A QI Fund payment was available to IPAs for completion of physician and member outreach. The QI Staff provided educational programs, including the QI Forum. The IPAs were required to consult with their physicians to develop the IPA plan for outreach.

The percentage of women screened for breast cancer increased by two percentage points over the 2009 project results, exceeding the goal of >69%. Several factors contributed to the increase in the Breast Cancer Screening rate.

More timely submission of encounters by the IPAs More complete submissions of encounters by the IPAs Improved quality of information on the encounters Continued outreach efforts by the IPAs

7. Cervical Cancer Screening HMO QI Fund Project The purpose of the Cervical Cancer Screening QI Fund Project is to promote cervical cancer screening for early detection of cervical cancer in women age 24 to 64. The project is based on a three-year rate, services in 2007-2009. The goal of the project was >70%.

Project Year

Measurement Period

Initial Population

Total Number of Members

Excluded

Final Population

Number of Members

with a Pap Test

Cervical Cancer

Screening Rate

2009 2006-2008 166,567 2,680 163,887 115,677 71% 2010 2007-2009 175,595 3,277 173,318 128,781 75%

Identified Barriers to Cervical Cancer Screening: Members:

Mailed the reminder cards “Make an Investment in Your Health” and “Celebrate Healthy Birthdays” during the member’s birthday month. The reminder cards: Provide information on the screening recommendations for Pap tests Encourage female members to contact their PCP or WPHCP to discuss the starting age and frequency

of Pap tests with their physicians


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Physicians: May not routinely recommend Pap smears to their patients May not have a systematic method to track preventive services May not code with a specified Pap test code

IPAs: May not understand the process regarding administrative data May not have a method to motivate their physicians to improve care May not be receiving provider encounters for each visit May not include lab data with submission of encounters


Mailed the reminder cards “Make an Investment in Your Health” and “Celebrate Healthy Birthdays” during the member’s birthday month. The reminder cards: Provide information on the screening recommendations for Pap tests Encourage female members to contact their PCP or WPHCP to discuss the starting age and frequency

of Pap tests with their physicians Published an article in the Fall/Winter 2010 issue of blue prints for health entitled “Feel Well at Every Age:

Preventive Care is the Key to a Healthier Life” which included information on cervical cancer screening. The number of members who received the monthly mailing is detailed in the table below.

Year Number of Members 2010 183,798

Physicians/IPAs:

Continue public reporting through the Blue StarSM Medical Group/IPA Report. Provide feedback to the IPAs regarding performance. Conduct an annual IPA HMO QI Fund Training and quarterly QI Forums. Provide individual training for IPAs as needed. Make the HCSC Preventive Care Guidelines available on the BCBSIL website. Continue the member outreach portion of the Cervical Cancer Screening Project. Continue the member educational outreach with the birthday reminder mailers.

The Member and Physician Outreach portion of the QI Fund continued in 2010. IPAs were rewarded for providing member and physician outreach for female members age 40-69 who were identified as needing cervical cancer screening. The goals of the 2009 Cervical Cancer Screening Physician Outreach portion of the 2008 QI Fund Project were to:

encourage PCPs and WPHCPs to recommend preventive care services to their patients motivate IPAs to develop and maintain systems to perform outreach communicate to members recommendations regarding preventive care close gaps in care for members who have not received the recommended services

The Cervical Cancer Screening Member and Physician Outreach Results are as follows: Submission of a completed Attestation Form with required supporting documentation of all required elements.




leadership is required for successful outcomes.


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Many IPAs lack understanding of the importance of outreach. Effective Outreach Requires:

A culturally sensitive approach A team effort with engaged providers Good communication between clinical and non-clinical staff Evaluating the results and using the information to improve the process


The percentage of women screened for cervical cancer increased by four percentage points over the 2009 project results, exceeding the goal of >70%. Several factors contributed to the increase in the Cervical Cancer Screening rate.


8. Colorectal Cancer Screening QI Fund Project The purpose of the Colorectal Cancer Screening QI Fund Project is to promote colorectal cancer screening for prevention and early detection of colorectal cancer in members age 51–75. The 2010 goal was >53%. The results for the project are summarized in the following table:

Year # of Sampled Members for all IPAs Combined

Total Number of Exclusions

Final # of Sampled Members

# Members Screened for Colorectal Cancer

2008 20,875 518 20,357 9,870 2009 19,107 44 19,063 10,085 2010 20,333 71 20,262 11,482

A Network Rate for Colorectal Cancer Screening was calculated based on a random sample of members. The results are as follows:

Year Initial Sample


Final Sample

# Members Screened for Colorectal Cancer

Network Rate

2008 449 10 439 200 (members age 51-80)

46% (200/439)

2009 450 1 449 253 (members age 51-75)

56% (253/449)

2010 450 1 449 276 61%* (276/449)

*There was significant improvement from 2007 to 2009 (p<0.001.) Identified Barriers to Colorectal Cancer Screening: Members:

Members may have inaccurate information about screening recommendations. Members may fear discomfort experienced during a screening procedure. Members may be unaware that colorectal cancer screening tests are a covered benefit. Members might have insufficient information on importance of screening.


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Physicians: Practitioners may not routinely recommend colorectal cancer screening to their patients. Practitioners may lack a systematic method to track preventive services. Some practitioners may not understand that an FOBT done on a specimen obtained at the time of digital

rectal exam is not considered to be adequate screening for colorectal cancer. IPAs:

There may be few members for whom IPAs have ten years of claim and/or medical record data. The IPA may not have systems in place to improve data collection and/or performance.


BCBSIL provided on-line resources such as Personal Health Manager and Ask A Nurse. Published an article in the Fall/Winter 2010 issue of blue prints for health entitled “Feel Well at Every

Age: Preventive Care is the Key to a Healthier Life” which included information on colorectal cancer screening

IPAs: BCBSIL paid IPAs based on the IPA colorectal cancer screening rate. BCBSIL awarded IPAs with a colorectal cancer screening Blue Star for the 2008 Colorectal Cancer

Screening Rate of >50%. BCBSIL provided IPAs with a tool to identify populations for outreach based on eligibility and

administrative data. BCBSIL conducted QI Forums and onsite/in house one-on-one trainings for several IPAs.

IPAs were rewarded for providing member and physician outreach to members age 50-75 who were identified as needing colorectal cancer screening. The goals of the 2010 Colorectal Cancer Screening Physician Outreach portion of the 2008 QI Fund Project were to:

encourage PCPs and WPHCPs to recommend preventive care services to their patients motivate IPAs to develop and maintain systems to perform outreach communicate to members recommendations regarding preventive care close gaps in care for members who have not received the recommended services

The results for the Physician and Member Outreach Portion of the 2010 Colorectal Cancer Screening HMO QI Fund Project are as follows: Submission of a completed Attestation Form with required supporting documentation of all required elements.








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The percentage of members screened for colorectal cancer increased by five percentage points over the 2009 project results, exceeding the goal of >53%. Several factors contributed to the increase in the Colorectal Cancer Screening rate.


9. Seasonal Influenza Vaccination QI Fund Project The purpose of the 2010 Seasonal Influenza Vaccination QI Fund Project is to assess and improve the influenza vaccination rate for members who were identified as having asthma, diabetes, cardiovascular disease and age 65 and older, who are at a greater risk of complications from influenza. A random sample of these high risk members was selected for each IPA. The 2010 goal was a Network rate of >45%. The 2010 Seasonal Influenza Vaccination QI Fund Project results for the IPA random samples are presented in the following table.

Project Year

Measurement Period

# of Sampled Members for

Participating IPAs

Exclusions Final Number of Sampled Members

Number of Flu Shots

2008 2007-2008 Influenza Season 15,381 273 15,108 7,005 2009 2008-2009 Influenza Season 15,502 235 15,267 7,720 2010 2009-2010 Influenza Season 13,001 99 12,902 6,099

In order to report an HMO Influenza Vaccination Network rate, data was collected from a sample of high risk members in the HMO network. The following table displays the details for the 2010 HMO Influenza Vaccination Project Network rate.

Project Year

Measurement Period

Initial Sample


Final Sample

# Members Who Had a

Flu Shot

Network Rate

2008 2007-2008 Influenza Season 444 16 428 187 44% (187/428)



Identified Barriers to Influenza Vaccination QI Fund Project: Members:

Member had difficulty getting an appointment. Member thought that getting a flu shot might be unpleasant. Member was concerned about the cost. Member was informed by their physician’s office that influenza vaccination was not available. Members’ physician did not recommend a flu shot. Member thought getting a flu shot could cause the flu. Illness prevented the member from receiving a flu shot.


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Physicians: Members may get a flu shot from a source other than the PCP office. This makes documentation

challenging and makes it difficult for the PCP to anticipate how much vaccine will be needed. Some practitioners may have hesitated to order an adequate supply of vaccine due to shortages in some

previous flu seasons. Some offices may lack a systematic method to track preventive services.

IPAs: IPAs may not have a process in place to assist practitioners in obtaining a supply of the vaccine. IPAs may not require practitioners to obtain their own supply of influenza vaccine. IPAs may not reward their physicians based on performance.

Healthcare System: Inconsistency in the annual supply of influenza vaccine may impact member and practitioner behavior and

this may influence the influenza vaccination rate even after the vaccine shortage has been resolved BCBSIL Interventions Implemented to Address Identified Barriers: Members:

Mailed influenza vaccination reminders to 79,072 high risk members in November Published an article in the Fall/Winter 2010 issue of blue prints for health entitled “Why You Should Get a

Flu Shot This Year.” Provided online resources, including Personal Health Manager and Ask a Nurse

Physicians/IPAs: BCBSIL provided a list of high risk members to IPAs to facilitate outreach to members who would benefit

from a flu shot in September Flu shot stickers, sample physician reminders, and “Why You Should Consider Receiving A Flu Shot”

brochure to IPAs were made available Disseminated relevant influenza vaccination information from the CDC regarding seasonal flu and H1N1 Held quarterly QI Forums and presented QI updates and best practices on the Influenza Vaccination QI

Fund Project BCBSIL published a flu shot article in the November 2009 Provider Newsletter Blue Review Conducted IPA training as needed

IPAs were rewarded for providing member and physician outreach to members who were identified as having asthma, diabetes, cardiovascular disease and age 65 and older, who are at a greater risk of complications from influenza. The goals of the 2010 Influenza Vaccination Physician and Member Outreach portion of the 2010 QI Fund Project were to:

encourage PCPs to recommend flu shots to their patients motivate IPAs to develop and maintain systems to perform outreach communicate to members recommendations regarding influenza vaccination close gaps in care for members who have not received the recommended services

Identified Barriers for Outreach:




Interventions: A QI Fund payment was available to IPAs for completion of physician and member outreach.


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The QI Staff provided educational programs, including the QI Forum. The IPAs were required to consult with their physicians to develop the IPA plan for outreach. The IPAs were required to consult with their physicians to develop the IPA plan for outreach.

In 2010, ACIP revised its recommendations for influenza vaccination. Flu shots are now recommended annually for all persons age 6 months and older. Therefore, to reduce the burden of medical record review for IPAs, BCBSIL has incorporated influenza vaccination into the Adult Wellness and Prevention Project and the Pediatric Wellness and Prevention project. For 2010, the QI Fund payments are based upon submission of data. In 2012, the payments will again be based upon the IPA’s influenza vaccination rates. 10. Controlling High Blood Pressure QI Fund Project The purpose of the HMO Controlling High Blood Pressure QI Fund Project is to promote blood pressure control in members age 18-85 diagnosed with hypertension. The 2010 goal was>78%.

The 2010 Controlling High Blood Pressure QI Fund Project results for the IPA random samples are presented in the following table.

Year # of Sampled Members For All IPAs Combined

Exclusions Final # of Sampled Members

# of Members Identified Having Blood Pressure

Control ( <140/90mmHg) 2008 10,828 44 10,784 7,865 2009 13,286 54 13,232 10,432 2010 12,321 16 12,305 9,771

In 2010, an HMO Controlling High Blood Pressure Network Rate was calculated based on a random sample of members. The results are as follows:

Year Initial Sample


Final Sample

# Members with a blood pressure <140/90mmHg

Network Rate

2008 450 0 450 324 72% 2009* 450 0 450 362 80%

2010 450 1 449 362 81% *The 2009 QI Fund Project had a different timeframe (15 months) for documentation of a controlled blood pressure. Identified Barriers to Improving Controlling High Blood Pressure Members:

Members may be non-compliant because of cost of treatment, including medications. Members may not follow practitioner’s advice on medication, diet, stress reduction, or exercise. Members may not understand the complications that may develop as a result of hypertension such as

cardiac disease, renal disease, stroke and hypertensive retinopathy. Physicians/IPAs:

Practitioners may not make changes to the treatment plan if the member’s blood pressure is not controlled. Practitioners may not track services on a flowsheet or electronic medical record for easy review of the

member’s blood pressure measurements.


BCBSIL provides and promotes online resources, including Personal Health Manager. The Summer 2009 Issue of blueprints for health included an article on “How to Save Money on

Prescription Drugs.” Physicians/IPAs:

Made a QI Fund payment to IPAs with project results that met or exceeded established thresholds


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Updated and made available the BCBSIL Guidelines for Primary and Secondary Prevention of Atherosclerotic Cardiovascular Disease.

Provided a summary report of members in the IPA-specific sample from the Controlling High Blood Pressure QI Fund Project who: did not have blood pressure control had no blood pressure documented within the required timeframe

Conducted IPA HMO QI Fund Training in February 2010 and held quarterly QI Forums Conducted IPA training as needed

The 2010 Controlling High Blood Pressure QI Fund project rate of 81% was nine percentage point increase over the 2008 rate of 72%. The goal of >78% was exceeded. 11. Adult Wellness and Prevention QI Fund Project The purpose of this project is to promote the health and wellness of HMO members and encourage physicians to routinely assess BMI and screen for alcohol use and smoking. The 2009 Wellness and Prevention Project included adults and children. For 2010, there were two separate projects. The goal for the Adult Wellness and Prevention QI Fund Project was to establish baseline. The 2010 results for the IPA samples for each indicator are displayed in the following tables. BMI

2009 2010 Number of Members with an assessment of BMI 5,119 6,177 BMI Results (5,119/9481) (6,177/9275) Smoking Cessation Advice

Number of Confirmed Non-

Smokers

Number of Confirmed Smokers

Smoking Status not Assessed or

Insufficient Supporting

Documentation

Final Population for Smoking

Cessation Advice*

Number of Smokers who

received Smoking

Cessation Advice2009 5,514 1,175 2,792 3,967 806 2010 5,940 1,051 2,268 3,319 805 The denominator for the Smoking Cessation Advice Rate includes members who are known to be smokers and the members who

were not assessed for smoking status or who had insufficient documentation to support the non-smoking status. Screening for Problem Drinking

Indicator 2009 Members who had an assessment of alcohol use, and if positive, were screened using a standardized assessment tool

(5,150/9,481)

Indicator Done Not Done 2010

Members who had an assessment of alcohol use 7,279 1,980 (7,279/9,259)

The 2010 Network project results for each indicator are displayed in the following tables. BMI

2009 2010 Number of Members with an assessment of BMI 249 314

BMI Results 55%

(249/450) 70%

(314/449)


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Smoking Cessation Advice Number of

Confirmed Non-Smokers

Number of Confirmed Smokers

Smoking Status not Assessed or

Insufficient Supporting

Documentation

Final Population for Smoking

Cessation Advice*

Number of Smokers who

received Smoking Cessation

Advice

Smoking Cessation

Advice Rate

2009 277 55 118 173 41 24%

(41/173)

2010 326 44 79 123 33 27%

(33/123) The denominator for the Smoking Cessation Advice Rate includes members who are known to be smokers and the members who

were not assessed for smoking status or who had insufficient documentation to support the non-smoking status. Screening for Problem Drinking

Indicator 2009 Members who had an assessment of alcohol use, and if positive, were screened using a standardized assessment tool

51% (229/450)

Indicator Done Not Done 2010

Members who had an assessment of alcohol use 342 107 76%

(342/449) Barriers identified in the project include the following. Members: May not understand the benefits of living a healthy lifestyle including:

maintaining a healthy weight regular physical activity not smoking avoid alcohol or use in moderation proper nutrition

Physicians: May not educate patients about the benefits of living a healthy lifestyle May not routinely assess health and wellness indicators:

BMI and BMI Percentile Smoking status Physical activity Alcohol assessment

May not be comfortable with alcohol screening tools and addressing positive screening results May not routinely discuss smoking cessation, including medication and/or cessation strategies

Interventions Implemented to Address Identified Barriers: Member Provided online resources with wellness information, including Personal Health Manager and Ask a Nurse Published an article in the Fall/Winter 2010 issue of blue prints for health entitled “Feel Well at Every Age:

Preventive Care is the Key to a Healthier Life” which included information on making basic health choices including eating a healthy diet, regular exercise, avoiding smoking and limiting alcohol use.

Practitioner IPAs were required to use a standardized tool for assessment of alcohol use. The BCBSIL Preventive Care Guidelines were made available to physicians. BCBSIL included assessment of wellness and prevention indicators as part of the biennial HMO medical record

audits.


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Physicians received individual feedback on the wellness and prevention indicators based on the chart audits results.

IPA A QI Fund payment was made available to IPAs. The QI staff provided educational programs including QI Forums to inform IPAs about the project. Sample tools for assessment of alcohol use were provided to the IPAs. IPAs were encouraged to educate physicians about documentation requirements. BCBSIL held quarterly QI Forums and presented QI updates and best practices. The QI staff conducted one-on-one trainings for IPAs as needed.

The 2010 Adult Wellness and Prevention QI Fund Project will continue in 2011. 12. Pediatric Wellness and Prevention QI Fund Project The purpose of the project is to promote the health and wellness of children age 2-17 enrolled in HMO and encourage physicians to routinely assess BMI, and counsel for physical activity and nutrition. The 2009 Wellness and Prevention Project included adults and children. For 2010, there were two separate projects. The goal for the Pediatric Wellness and Prevention QI Fund Project was to establish baseline. The 2010 results for the IPA samples for each indicator are displayed in the following tables. IPA Results for BMI Percentile/BMI Indicator 2010 BMI Percentile (age 2-17) 5,252 BMI (age 16-17) 372 Number of members in the IPA samples 9,120 IPA Results for Counseling for Physical Activity and Nutrition Indicator 2010 Counseling for Physical Activity 3,975 Counseling for Nutrition 4,024 Both Counseling for Physical Activity and Counseling for Nutrition 3,333 Number of members in the IPA Samples 9,120 The 2010 Network project results for each indicator are displayed in the following tables. Network Results for BMI Percentile/BMI Indicator 2010 BMI Percentile (age 2-17) 284 BMI (age 16-17) 19 Percentage of members in the Network Sample with BMI percentile/BMI 67%

(303/450) Network Results for Counseling for Physical Activity and Nutrition Indicator 2010 Counseling for Physical Activity 218 Counseling for Nutrition 208 Percentage of members in the Network Sample with both Counseling for Physical Activity and Counseling for Nutrition

38% (170/450)


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Barriers identified in the project include the following. Member: Parent may not understand the benefits of a healthy lifestyle including:

Maintaining a healthy weight Maintaining a healthy diet Regular physical activity Complete and timely immunizations, including influenza vaccinations

Parent may not take child to a health care provider for the recommended wellness and/or preventive care

Practitioner: May not educate parents and/or children about the benefits of living a healthy lifestyle May not routinely assess health and wellness indicators:

BMI percentile / BMI Physical activity Nutrition

May miss opportunities to discuss issues due to time constraints IPA: It may be difficult to get providers to incorporate Wellness, BMI, Nutrition and Physical Activity into routine

care. Data collection requires medical record review. The retrospective focus of care delays the impact of current IPA intervention on results. BCBSIL provided online resources with wellness information, including Personal Health Manager and Ask a

Nurse. Interventions Implemented to Address Identified Barriers: Member Provided online resources with wellness information, including Personal Health Manager and Ask a Nurse Published an article in the Fall/Winter 2010 issue of blue prints for health entitled “Feel Well at Every Age:

Preventive Care is the Key to a Healthier Life” which included information on making basic health choices including the importance of good eating habits and being active.

Practitioner BCBSIL Preventive Care Guidelines were made available to physicians. BCBSIL included assessment of wellness and prevention indicators as part of the biennial HMO medical record

audits. Physicians received individual feedback on the wellness and prevention indicators based on the chart

audits results. IPA A QI Fund payment was made available to IPAs. IPAs were encouraged to educate physicians about documentation requirements. BCBSIL held quarterly QI Forums and presented QI updates and best practices.

The 2010 Pediatric Wellness and Prevention QI Fund Project will continue in 2011. D. PPO / FEP Quality Improvement Projects 1. Utilization Management Quality Improvement Projects

Care Coordinator documentation of Members Discharge Plan Care Coordinator Non-Utilization of Error Prone Abbreviations for Member Safety


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The goals and results for the projects are as follows: INDICATOR Goal 2007 2008 2009 2010

Care Coordinator (CC) documentation of members Discharge Plan, 4 indicators

New Project

Q4 #1. Did the CC document the request for the d/c plan at the time of the request for the initial clinical review?

90% NA 100% 100% Q1-99% Q2-98%

#2. If the request for the d/c plan was not received, did the CC make another attempt to obtain the d/c plan?

90% NA 74% 87% Q1-100% Q2-67%

#3. If the request for the d/c plan was not received, did the CC develop & document an anticipated discharge plan?

90% NA 92% 88% Q1-0% Q2-67%

#4. Did the CC document the final discharge plan at case closure? 90% NA 74% 86% Q1-99%

Q2-98%

Care Coordinator Non-Utilization of Error Prone Abbreviations for member safety

10% improvement

until 90%

Q2-70% Q4-78%

Q2-76% Q4-84%

Q2-82% Q4-72%

Q2-64% Q4 72%

2. FEP Case Management Quality Improvement Projects BCBSIL participated in three quality improvement projects for FEP Case Management. The projects are selected based on findings from the case file reviews and the recommendation of the FEP CM Quality Oversight Committee. The FEP Director’s Office has identified the goal for all of the Quality Improvement Projects as a 10% increase for each quarter. The 2010 projects were:

Improving Documentation of an Individualized Care Plan for Each Member Improving Documentation of Medication Adherence Improving Documentation of Screening for Life Care Planning

The results for the projects are as follows:

Project Name 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter* Goal Improving Documentation of an Individualized Care Plan for Each Member

74% 71% 84% 88% 10%

increase per quarter

Improving Documentation of Screening for Life Care Planning

66% 69% 97% 10%

increase per quarter

Improving Documentation of Medication Adherence 80% Closed

10% increase per

quarter * Management of FEP cases was transitioned to the Texas Plan effective November 2010. Therefore, the 4th quarter results are not comparable to the previous quarters. Analysis of the data from the FEP Quality Improvement Projects demonstrates continuous improvement across all four projects. Interventions implemented include additional training on the appropriate policies, supervisor review of cases with appropriate feedback to and coaching of individual Case Managers. The FEP Case Management staff was restructured to provide optimal CM services to FEP members. Transition of FEP Case Management to Texas was finalized November 22, 2010.


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3. Diabetes Checks & Balances Program BCBSIL continued the Diabetes Checks & Balances Program in 2010. The Program encourages people with diabetes to contact their physicians and arrange for diabetic care services, including blood sugar control (HbA1c), LDL-cholesterol management, blood pressure control, eye exam, and screening for kidney disease. The program goals are to educate members with diabetes about the importance of these key screenings and to reward physicians who provide the recommended services. The 2006-2009 results are outlined in the following table.

Diabetes Indicator 2006 2007 2008 2009

HbA1c Screening 65% 79% 78% 83% HbA1c Control <9.0% 57% 70% 68% 73% HbA1c Control <8.0% NA NA 61% 64%

Eye Exam 23% 41% 40% 45%

LDL-Cholesterol Screening 62% 76% 74% 79%

LDL-Cholesterol <100 mg/dL NA NA 50% 46%

Medical Attention for Nephropathy 58% 71% 71% 81%

Overall Diabetes Care HbA1c <8.0% LDL <100 mg/dL Eye Exam Medical Attention for Nephropathy

N/A N/A 20% 19%

Interventions Implemented to Increase Public Awareness and Improve Diabetes Care BCBSIL participated in face-to-face workgroup meetings with the employers, hospitals and physicians Members:

Members included in the program received four educational mailings on diabetes care topics. Physicians:

Continued the Pay for Performance program. Provided contracted providers with patient-specific reports regarding care provided in 2009, the

measurement year (2010 reporting year) Employer Communications:

Several large local employers participate in the Committee that provides oversight to the program. Glucose Meter Program:

Glucose meters were offered to all PPO/FEP members identified with a diagnosis of diabetes free of charge. The number of meters distributed to PPO/FEP members in 2010 is summarized below.

2010 Number of PPO/FEP Members

Total Number of Glucose Meters Distributed to PPO/FEP Members 3,200 4. 2010 BCBSIL PPO Practitioner Profile BCBSIL assessed performance for the following 17 Clinical Quality Indicators for physician practices in Internal Medicine, Family Practice, OB/Gynecology, Pediatrics, Mixed Specialties Groups, and Cardiology.

Breast Cancer Screening Colorectal Cancer Screening Cervical Cancer Screening Comprehensive Diabetes Care: (HbA1c) Testing Comprehensive Diabetes Care: Medical Attention to Nephropathy Comprehensive Diabetes Care: LDL- C Screening Childhood Immunization Status: Varicella-Zoster Virus (VZV)


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Childhood Immunization Status: Measles, Mumps, Rubella (MMR) Use of Appropriate Medications for People With Asthma Cholesterol Management for Patients With Cardiovascular Conditions: LDL-C Screening Appropriate Testing for Children with Pharyngitis Chlamydia Screening in Women Annual Monitoring for Patients on Persistent Medications: Members on Diuretics Annual Monitoring for Patients on Persistent Medications: Members on ACE Inhibitors /ARB Annual Monitoring for Patients on Persistent Medications: Members on Digoxin Annual Monitoring for Patients on Persistent Medications: Members on Anti-Convulsant Drugs Annual Monitoring for Patients on Persistent Medications: Total

5. Blue Choice Tiering The BlueChoice payment tiers are based on quality and cost performance relative to peer group. Up to fifteen (15) quality indicators were used to determine quality scores. The 2010 Tiers were determined as follows:

PCPs were evaluated relative to overall peer group. Quality & Cost scores were placed in rank order and reported as percentiles. Both BlueChoice and PPO claims data were included. Quality & Cost percentiles were put on Performance and Tier Assignment Grid to determine Tier. Those with insufficient Quality or Cost data are assigned to the White Tier.

1,703 providers received a tier assignment in 2010. 6. Medical Management (PPO/FEP) The Medical Management 2010 Utilization Management Program Evaluation has been completed. Utilization Management achieved notable improvements in operations, technology, training, and collaborating amongst Medical Management partners.

2010 Accomplishments: Implemented the Milliman Hospital Inpatient Profiler, “Gold Card” process as a means of evaluation of

hospital performance and improved selection for medical management review Implemented another on-site Care Management program in the metropolitan Chicago area Increased Physician Advisor Dialogue at Medical Centers with larger BCBSIL patient volumes Automated Care Coordinator audit tools Streamlined applicable educational in-services to UM, CM, WCM and CCCC programs Implemented an additional onsite UM program at an urban, academic medical center that serves a large

volume of BCBSIL members, making a total of 2 Increased Physician Advisor Dialogue at Medical Centers with larger BCBSIL patient volumes Enhanced Physician Advisor and Care Coordinator collaboration through designation of a daily Physician

for N consultation on complicated cases Implemented a weekend Utilization Management function. Key weekend responsibilities are coverage for

the mandated expedited appeal process and calls to members discharged from acute care facilities on Thursday and Friday

Continued to restructure UM to improve accountability, collaboration, consistency, and efficiency by forming 4-8 member self contained work teams

Standardized the process for Neonates Enterprise wide, including both the Utilization and Case Management functions.

Increased Physician Advisor Dialogue at Medical Centers with larger BCBSIL patient volumes Enhanced Physician Advisor and Care Coordinator collaboration through designation of a daily Physician

for RN consultation on complicated cases Implemented MD coverage for State and Federal requirements for Expedited Appeal and External Review Implemented the Milliman Hospital Inpatient Profiler, a software that analyzes claims data to evaluate

hospital performance relative to area and national benchmarks Implemented VDI technology for telecommuters


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Conducted training for case review according to the Milliman Hospital Inpatient Profiler, “Gold Card” process

Conducted training to support NICU case initiation and review Conducted 7 UM new hire training classes Conducted UM training for 3 physician advisors Customized training program and materials for new custom business Leadership training track implemented and 4 leadership trainings were conducted in 2010 In addition to the monthly in-services offered to staff, twenty one additional educational in-services /

training sessions were offered to the applicable program staff Worked with external vendors on technical transition to webinars to ensure the staff working from home

were provided with the same educational opportunities Hosted an Asthma and Cardiovascular Health Fair in which there were over 200 attendees 100% of all Care Coordinators and Customer Care Call Center Staff trained on UM URAC Standards Collaborated with Training and Medical Management on review and revision of Medical Management

policies 100% of UM Care Coordinators and Clinical Supervisors were assessed for Inter-rater Reliability 2010 Non-Certification audit results met and exceeded the goal of 95% 2010 Retrospective Case Audit results exceeded goal of 90%

7. PPO/FEP Quality Improvement Workplan Indicators The following table summarizes the results of the PPO/ FEP Quality Improvement Workplan indicators for utilization management. INDICATOR Goal 2007 2008 2009 2010 Cases reviewed by RN Trending 102,454 118,361 126,524 107,040 RN-PA Referral Rate ≤ 35% 18% 36% 28% 32% Percentage of appeals overturned ≤ 50% 11% 5% 4% 7.29% Retrospective Case Audits (% Compliance) 90% 90% 100% 96% 100% Monitor Care Coordinator (CC) Delivery of Service (Turnaround time) Upon receipt of case in CC's queue, CC request initial review w/in 1 business day

90% 90% 95% 84% Through Q2- 93%

Inter-rater Reliability Assessment Appropriate ORG ID'd by RN. Optimal Recovery Guideline

90% Case #1-82%

Case #2-100%

Case #1-86% Case #2-

100%

Case #1-100% Case

#2-100%

Case #1-94%Case #2-

100% PA Medical Non-Certification Rate ≤ 35% 12% 14% 11% 13% Monitor the consistency of Physician Advisors making UM decisions

Annual Report 79% 80% 89% 86%

Annual review of Medical Management policies 100% 100% 100% 100% 99%

UM staff attendance for external seminar related to Medical Management 90% 89% 87%

E. HMO Service Quality Improvement Projects Four HMO Service Quality Improvement Projects were identified in 2010.

Improving Timely Access to Urgent Care Improving Timely Access to Non-Urgent Care Improving Accuracy & Timeliness of Claims Payments Improving Courtesy of Customer Service Representatives


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The ability to schedule an urgent appointment with a doctor without having to go to the emergency room can have an impact on the member’s level of satisfaction with the HMO. The CAHPS Survey and the HMO Member Survey identified some potential opportunities for improvement in timely access to urgent care with Specialists and timely responses to emergency phone calls. Since member satisfaction scores in these areas seem to be changing little over time, improving timely access to urgent care was a newly identified project in 2010. Waiting an excessive amount of time for a routine appointment with a doctor has the potential to impact the member’s satisfaction with the physicians in the HMO network. The CAHPS Survey and the HMO Member Survey showed a poor member satisfaction score for length of time waited for a routine appointment with a Specialist. Although this score showed significant improvement from 2008 to 2009, nearly one third of members still rate this item as an issue, so improving timely access to non-urgent care was also a newly identified project in 2010. Claims-related complaints constitute the majority of complaints received by BCBSIL, accounting for over 84% of complaints in 2009. The level of complexity of claims payment and processing is due to shared risk between BCBSIL and the IPAs which requires IPAs to authorize and pay for professional services and to authorize facility services for payment by HMO. Claims payment has the potential to impact the entire HMO population. In view of these factors, this project has been continued to improve member satisfaction in this area. The courtesy of a customer service representative can impact the member’s level of satisfaction with customer service. Because the member’s experience with customer service can impact satisfaction with the HMO, this refocused customer service project has been identified for 2010 to improve member satisfaction with this area. Following is the causal analysis, as well as the existing, ongoing, future, and potential interventions identified for each project. Timely Access to Urgent Care Causal Analysis:

1. While BCBSIL has contractual requirements with IPAs for access standards, the physicians with whom access is an issue contract with the IPA (not BCBSIL), making implementation of interventions more complex.

2. Although the Medical Service Agreement has clear requirements for early morning, evening, and weekend access, IPA compliance has not been audited.

3. Available appointment times may not be convenient for members, impacting members’ perception regarding access to care.

4. There are no current incentive programs in place to address access to Specialists. Existing and Ongoing Interventions:

1. A Quality Improvement Fund payment is awarded to IPAs that meet the contractual thresholds for satisfaction with the IPA.

2. Access questions from the HMO Member Survey are a factor in determining whether IPA sites receive public recognition in the form of a Blue Ribbon.

3. Site visits are conducted with PCPs every two to three years. During these site visits, PCP appointment books are audited for openings for urgent visits within 24 hours. If the PCP fails the site visit, a re-audit is scheduled. If both audits are failed, BCBSIL requests a corrective action plan from the PCP. IPAs receive feedback regarding these visits.

4. BCBSIL provides results regarding member perception of urgent access from the HMO Member Survey to IPAs.

Future Interventions:

1. Beginning in 2011, every IPA will be audited each year to ensure after-hours standards are met. BCBSIL requests corrective action plans from those IPAs who fail the audit.


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2. Some IPAs are planning to implement alternate access options, such as open-access scheduling and after hours triage.

Potential Interventions:

1. BCBSIL will consider auditing IPAs for compliance with early morning, evening, and weekend access standards.

2. BCBSIL will consider expanding early morning, evening, and weekend access standards so they apply not only to IPAs but also to individual IPA Physicians.

3. BCBSIL is considering a new Blue Star for access beginning in 2012. The Access Blue Star could be based on a composite of questions from the HMO Member Survey, results from the early morning, evening, and weekend office hours audit, and results from the IPA After Hours audit.

Timely Access to Non-Urgent Care Causal Analysis:

1. While BCBSIL has contractual requirements with IPAs for access standards, the physicians with whom access is an issue contract with the IPA (not BCBSIL), making implementation of interventions more complex.

2. Although the Medical Service Agreement has clear requirements for early morning, evening, and weekend access, IPA compliance has not been audited.

3. Available appointment times may not be convenient for members, impacting members’ perception regarding access to care.

4. Negative responses to the questions regarding length of time waited for a routine appointment do not necessarily indicate that members were unable to get an appointment within two weeks if desired.

5. There are no current incentive programs in place to address access to Specialists. Existing and Ongoing Interventions:

1. A Quality Improvement Fund payment is awarded to IPAs that meet the contractual thresholds for satisfaction with the IPA.

2. Access questions from the HMO Member Survey are a factor in determining whether IPA sites receive public recognition in the form of a Blue Ribbon.

3. Site visits are conducted with PCPs every two to three years. During these site visits, PCP appointment books are audited for openings for non-urgent visits within 2 weeks. If the PCP fails the site visit, a re-audit is scheduled. If both audits are failed, BCBSIL requests a corrective action plan from the PCP. IPAs receive feedback from the visits.

4. BCBSIL provides results regarding member perception of non-urgent access from the HMO Member Survey to IPAs.


1. Some IPAs are planning to implement alternate access options, such as open-access scheduling. 2. BCBSIL will re-evaluate questions for the 2011 HMO Member Survey to clarify member perception of

non-urgent access to care. Potential Interventions:

1. BCBSIL will consider auditing IPAs for compliance with early morning, evening, and weekend access standards.

2. BCBSIL will consider expanding early morning, evening, and weekend access standards so they apply not only to IPAs but also to individual IPA Physicians.

3. BCBSIL is considering a new blue star for access beginning in 2012. The Access Blue Star could be based on a composite of questions from the HMO Member Survey, results from the early morning, evening, and weekend office hours audit, and results from the IPA After Hours audit.


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Accuracy and Timeliness of Claims Payments Causal Analysis:

1. Based on the data presented above, BCBSIL seems to be doing well, especially compared with the national average, for accuracy and timeliness of claims payments, however, BCBSIL strives to continue to improve scores in this area.

2. The split risk model employed by the HMOs of BCBSIL may contribute to the member’s complaints regarding claims payments in the following ways:

a. The split risk model requires that IPAs be contacted to resolve outstanding claims or other issues. b. The split risk model may be confusing to members.

3. A large volume of claims BCBSIL receives from providers must be manually re-routed to the IPA, increasing the time to process the claims. The re-routing is due to:

a. The need for IPAs to authorize claims that are at the risk of BCBSIL b. The need for IPAs to receive claims that are their risk

4. At times, an IPA fails to pay claims in a timely manner. Existing and Ongoing Interventions:

1. BCBSIL has a Past-Due Claims process in place to promptly resolve any claims that an IPA fails to pay in a timely manner.


1. Plans are in place to implement the usage of Medical Group claims encounter data to allow CSAs to view claims that are the risk of the Medical Groups. This system is scheduled for implementation in late 2010.

2. Development of CCSP/PRAP redirect process to allow claims to be electronically re-routed has begun, and the implementation of this tool is set for the end of the first quarter 2011.

Courtesy of Customer Service Representatives Causal Analysis:

1. BCBSIL is doing well overall in the area of courtesy of customer service representatives, however, BCBSIL strives to continue to improve scores in this area.

Existing and Ongoing Interventions:

1. BCBSIL has implemented a Concierge Customer Service initiative with the goal of providing a seamless, customized, and personalized member experience by using everything known about the member and providing answers and guidance even when the member’s questions are unasked.

2. As part of the Concierge Customer Service initiative, BCBSIL has developed a Concierge Service Analytics program which tracks the length of time a customer is put on hold, identifies customer distress by tone of voice, identifies positive customer comments, and more. This program helps BCBSIL improve customer service by identifying concerns and addressing them immediately on the call.

II. CLINICAL GUIDELINES Review, Update and Dissemination of Guidelines Clinical guidelines are revised based on a review of current clinical literature as well as input from network physicians, including the BCBSIL Clinical Management Committee. The following table depicts the clinical guidelines that were reviewed and approved by the Clinical Management Committee in November 2010.

2010 Guideline Title

Date of Last Review Prior to November

2010

Guideline Source

Status of Guideline Source As of November 24, 2010

Current Actions Approved by Clinical Management Committee

November 2010 Guidelines for Treating Tobacco Use and

CMC: 11/18/08 Effective: 1/1/2009

U.S. Public Health Service

Issued May 2008 Corrections and Additions most recently

Update guideline to incorporate 11/09 revisions from USPHS


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2010

Guideline Source



November 2010 Dependence updated in November

2009 Revised guideline effective 12/1/10

Guidelines for the Diagnosis and Management of Asthma

CMC: 11/10/09 Effective: 1/1/2010

National Asthma Education and Prevention Program

Issued July 2007; document with corrections as of 8/5/2008 is current as of 11/24/10

Guideline reviewed; no changes

Guidelines for the Prevention and Early Detection of Complications of Diabetes Mellitus

CMC: 11/10/09 Effective: 1/1/2010

American Diabetes Association

Updated ADA guideline issued January 2010; current as of 11/24/2010

Update guideline to incorporate 2010 revisions from ADA Revised guideline effective 12/1/10

Guidelines for the Diagnosis and Treatment of Patients with Depression in the PCP Setting

CMC: 11/10/09 Effective: 1/1/2010

Institute for Clinical Systems Improvement

ICSI issued a new version in May 2010. The American Psychiatric Association published an updated guideline in October 2010.

HCSC is using the revised APA guideline for enterprise behavioral health programs. Therefore, recommend that BCBSIL adopt the enterprise guideline. Since the enterprise guideline does not address referral from PCP to behavioral health, incorporate referral recommendations from ICSI. New guideline effective 12/1/10

Guidelines for Heart Failure in the Adult

CMC: 11/10/09 Effective: 1/1/2010

American Heart Association

2005 guideline with focused update in 2009; current as of 11/24/2010


AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update

2006 guideline current as of 11/24/2010

AHA Guidelines for Primary Prevention of Cardiovascular Disease and Stroke: 2002 Update


Guidelines for Primary and Secondary Prevention of Atherosclerotic Cardiovascular Disease

CMC: 11/10/09 Effective: 1/1/2010

Exercise and Physical Activity in the Prevention and Treatment of Atherosclerotic Cardiovascular Disease



Screening Adults for Depression Clinical Practice

CMC: 11/10/09 Effective: 1/1/2010

U.S. Preventive Services Task Force

USPSTF update: December 2009

Update guideline based upon 12/09 USPSTF guideline


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2010

Guideline Source



November 2010 Guideline Revised guideline effective

12/1/10

CMC = date of BCBSIL Clinical Management Committee review The updated documents are available to network practitioners through the BCBSIL Provider Web site. The clinical practice guidelines are applicable to all BCBSIL products. III. PATIENT SAFETY A. 2010 BCBSIL Hospital Profile The 2010 Annual BCBSIL Hospital Profiles were disseminated to 175 contracted hospitals, 111 in Peer Groups 1-6 and 64 in Peer Group 7. (Previously, hospitals were categorized as urban, peer groups 1-5, and rural, peer groups 6 & 7.) The goal of the annual BCBSIL Hospital Profile is to stimulate quality improvement within hospitals, as well as to provide members with information that will assist them in selecting a hospital. Changes to components of the 2010 BCBSIL Profile are the following:

Leapfrog Adding two new scored indicators: Reduce Pressure Ulcers Reduce In-Hospital Injuries

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey Scoring the HCAHPS Survey

Hospital Quality Alliance (HQA) Adding two new scored measures to “Surgical Infection Prevention”: Cardiac Surgery Patients With Controlled 6 A.M. Postoperative Blood Glucose Surgery Patients with Appropriate Hair Removal

Participation in State and National Quality Improvement Initiatives (Extra Credit) Seven new indicators added Blue Distinction Centers – two components added

Hospital-Based Physicians New non-scored indicator added; Blue Star indicator only.

B. Analysis of Safety Measures (2010 BCBSIL Hospital Profile) BCBSIL Hospital Survey:

The percent of Peer Group 1-6 hospitals reporting data on near misses, performing root cause analysis and having a non-retaliation policy related to the reporting of near misses was 78%.

American Heart Association Get With The Guidelines Program: The percent of Peer Group 1-6 hospitals participating in the program: Action-Get With The Guidelines Registry was 10% Heart Failure (HF) was 3% Stroke program was at 23%.

Illinois Hospital Association (IHA) Patient Safety Collaborative: The percent of Peer Group 1-6 hospitals participating in the program was 41%.

Leapfrog Group The number of Peer Group 1-6 hospitals that reported Fully Meets Standards or Other Reporting Efforts in

2010 were: Prevent Medication Errors: 5 (Reported for Peer Groups 1-5) Appropriate ICU Staffing: 29 (Reported for Peer Groups 1-5)


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Steps to Avoid Harm: 9 Managing Serious Errors: 27 Transparency Indicators: 61 Reduce Pressure Ulcers: 10 Reduce In-house Injuries: 8.

Data Source Measure Reported on the 2010 Profile

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey

April 2008 – March 2009

Hospital Participates 98% (109/111)

BCBSIL Hospital Survey o Report data on Near Misses o Perform Root Cause Analysis o Have a non-retaliation / non-

retribution policy related to the reporting of near-misses

78% (87/111)

BCBSIL Hospital Survey / American Heart Association Get With The Guidelines Program

Action-Get With the Guidelines Registry 10% (11/111)

Heart Failure (HF) 3% (3/111)

Stroke 23% (25/111)

BCBSIL Hospital Survey / Illinois Hospital Association (IHA) Patient Safety Collaborative

“IHA/National Initiative – Stop Central Line Associated Blood Stream Infections”

Hospital Participates 41% (45/111)

The Leapfrog Group Website As of 1/15/2010

Prevent Medication Errors (Reported for Peer Groups 1-5)

o Fully Meets Standards 5% (5/93)

Appropriate ICU Staffing (Reported for Peer Groups 1-5)


Steps to Avoid Harm


Managing Serious Errors


Transparency Indicators

o Other Reporting Efforts 55% (61/111)

Reduce Pressure Ulcers


Reduce In-Hospital Injuries



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IV. Transparency A. Blue StarSM Hospital Report The 2010 Blue Star Hospital Report – based on the 2010 Annual BCBSIL Hospital Profile – summarizes the results of quality and safety performance measures for 91 contracted Illinois hospitals in peer groups 1-5. Changes to components of the 2010 BCBSIL Blue Star Hospital Report are the following:

Efficiency Utilization Efficiency – Removed due to methodology changes

Informed Decision-Making Hospital-Based Physicians – Newly added

BCBSIL Member Survey – Replaced with HCAHPS survey HCAHPS indicators are:

Patient Experience: Patient Hospital Experience Overall Satisfaction

Stars were awarded for the following 6 categories representing 10 indicators. Hospitals are awarded blue stars when they meet or exceed criteria in each category.

Structure Accreditation/Board Certification: Hospital is accredited and documented that at least 85% of active

medical staff members are board certified Participation in state and national quality improvement initiatives: Hospital submitted documentation

that met criteria for participation in multiple state and national programs designed to improve the quality of patient care and/or patient safety.

Process Leapfrog: Hospital publicly reported to Leapfrog, and received recognition for either Fully Meeting or

Substantial Progress on at least one of the following Leaps: Prevent Medication Errors, Appropriate ICU Staffing, Steps to Avoid Harm and Managing Serious Errors.

Hospital Quality Alliance Indicators: Hospital scored higher than the state mean, for most process of care measures.

Outcomes Agency for Healthcare Research and Quality (AHRQ) Inpatient Quality Indicators: Hospital was in the

best quartile within its peer group for mortality rates for six specific medical conditions. AHRQ Patient Safety Indicators: Indicators showed that hospital complication rates were lower than

many peer hospitals. Patient Experience Patient Hospital Experience: Hospital results were better than the state average for at least five of eight

questions about communication, care and service. Overall satisfaction: Hospital results were better than the state average for two indicators: rating of

hospital and recommendation of the hospital to family and friends. Efficiency Administrative Efficiency: The hospital submitted at least 95% of its claims to BCBSIL electronically.

Informed Decision-Making Hospital-Based Physicians: Hospital-based physicians have contracts with BCBSIL PPO and with each

of the HMO medical groups and IPAs that are affiliated with the hospital. B. Blue StarSM Medical Group/IPA Report The Blue Star Medical Group/IPA Report recognizes HMO contracting medical groups/Independent Practice Associations (IPAs) that have documented high levels of performance in providing patient care. Each year, Blue Cross and Blue Shield of Illinois (BCBSIL) assesses medical group performance based upon national clinical practice and preventive care guidelines. Groups earn a “blue star” each time they meet the target care goal. HMO


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members can use the Blue Star Medical Group/IPA Report – along with the Blue Star Hospital Report – to help them choose health care providers that best meet their needs. This information is linked to the Provider Finder®. The Blue Star Medical Group/IPA Report recognizes HMO contracting medical groups/Independent Practice Associations (IPAs) that have documented high levels of performance in providing patient care. Annually, Blue Cross and Blue Shield of Illinois (BCBSIL) assesses medical group performance based upon national clinical practice and preventive care guidelines. HMO members can use the Blue StarSM Medical Group/IPA Report – along with the Blue StarSM Hospital Report – to help them choose health care providers that best meet their needs. To make it even easier for members to use the Report, this information is also linked to the Provider Finder®. Performance Measures and Results Groups earn a “blue star” each time they meet or exceed the target care goal in each of the reporting categories. The number and percentage of groups earning a blue star are listed below. The criteria are: ▪ Asthma: At least 65 percent of members with asthma received a written asthma action plan and had an

assessment of asthma control. 82 medical groups (85%) earned a blue star ▪ Diabetes:A high level of performance in providing routine diabetes care was demonstrated by meeting at least

five of seven care thresholds. 77 medical groups (80%) earned a blue star ▪ Breast Cancer Screening: At least 70 percent of women age 42-69 had a mammogram between 1/1/2008 and

12/31/2009. 51 medical groups (53%) earned a blue star ▪ Childhood Immunization: At least 67 percent of children who turned two years of age received recommended

immunizations by their second birthday. 77 medical groups (80%) earned a blue star ▪ Mental Health Follow-Up: At least 65 percent of members had a follow-up visit with a behavioral health

practitioner within seven days of hospital discharge for a mental health diagnosis. 67 medical groups (70%) earned a blue star

▪ Influenza Vaccination: At least 50 percent of high risk members had a flu shot during the 2008-2009 flu season. 43 medical groups (45%) earned a blue star

▪ Controlling High Blood Pressure: At least 62 percent of members with hypertension had their blood pressure controlled (<140/90 mmHg). 93 medical groups (97%) earned a blue star

▪ Colorectal Cancer Screening: At least 50% of members age 51-75 were current on screening for colorectal cancer in 2008. 64 medical groups (67%) earned a blue star

▪ Management of Cardiovascular Conditions: A high level of performance in providing care for members identified with cardiovascular disease was demonstrated by meeting at least two of three care thresholds. 87 medical groups (91%) earned a blue star

▪ Cervical Cancer Screening*: At least 72 percent of women age 24-64 had a Pap test between 1/1/2007 and 12/31/2009. 53 medical groups (55%) earned a blue star

▪ Patient Safety*: At least 55 percent of PCPs or at least 30 percent of all IPA physicians completed the American Board of Medical Specialties Patient Safety Improvement Program. 32 medical groups (33%) earned a blue star

All percentages are rounded. * New Blue Stars in 2010 Summary of Results Of the 96 medical groups/IPAs included in the Blue Star report:

8 medical groups (8%) received all eleven blue stars 37 medical groups (39%) received eight to ten blue stars

V. 2010 BLUE DISTINCTION CENTERS OF EXCELLENCE BCBSIL participates in Blue Distinction, a nationwide initiative between independent Blue Cross and Blue Shield Plans and the Blue Cross and Blue Shield Association. Blue Distinction® is a designation awarded by the Blue Cross and Blue Shield companies to medical facilities that have demonstrated expertise in delivering quality


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healthcare, under objective selection criteria. The designation is based on rigorous, evidence-based selection criteria established in collaboration with expert physicians' and medical organizations' recommendations. Its goal is to help consumers find quality specialty care on a consistent basis, while enabling and encouraging health professionals to improve the overall quality and delivery of healthcare nationwide. Blue Distinction Centers in Illinois include:

Blue Distinction Centers for transplant services Blue Distinction Centers for bariatric surgery Blue Distinction Centers for cardiac care Blue Distinction Centers for Complex & Rare Cancers Blue Distinction Centers for Spine Surgery Blue Distinction Centers for Knee & Hip Replacement

For more information and a complete list of Blue Distinction Centers, nationwide, visit the BCBSA website: http://www.bcbsil.com/getting_started/making_insurance_work/blue_distinction.html

VI. CREDENTIALING / RE-CREDENTIALING

In 2010, PCP applications for initial credentialing were processed within an average of 24 days; which exceeded the goal of 30 days. PSP applications for initial credentialing were processed within an average of 22 days, which also exceeded the goal of 30 days.

The following table depicts the number of PCPs and PSPs appointed and reappointed to the HMO and POS Networks through year-end 2010:

2010 Provider Selection Committee Activities HMO and BlueChoice

POS Credentialed HMO and BlueChoice POS Recredentialed

PCP 140 PCP 1401 PSP 178 PSP 2064

Total 318 Total 3465

HMO and BlueChoice POS Appointed

HMO and BlueChoice POS Reappointed

PCP 276 PCP 1263 PSP 364 PSP 1842

Total 640 Total 3105 VII. SURVEYS Member and provider surveys are performed as part of the quality improvement program. Most are conducted on an annual basis, thereby providing the opportunity to trend data and track performance. The following surveys were performed in 2010: A. Member:

1. 2010 Member Survey by Medical Group (HMO)

More than 90% of members gave a rating of Excellent, Very Good or Good for: IPA, PCP, and Specialist overall PCP Thoroughness of exams; Explanation of medical tests; Advice to stay healthy; Respect shown and

attention to privacy; and Medical care received Specialist Thoroughness of exams; Explanation of medical tests; Advice to stay healthy; Respect

shown and attention to privacy; and Medical care received Availability of office hours and Understanding of health care benefits from PCP’s office personnel


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Understanding of health care benefits from Specialist’s office personnel. More than 90% of members found the information contained in the Blue Star MG/IPA Report and Blue Star

Hospital Report useful. IPA-specific results were provided to each IPA

2. Continuous Tracking Program (HMO, PPO, CDH)

Survey respondents are Illinois in-state group members across 3 products. Note: Statistical tests compared 2010 full-year top 3 box rating against 2009 and 2008. All results mentioned are statistically significant at p<.05. Overall Evaluation: PPO and CDH rated lower than last year (2010>2009). HMO and PPO near their

averages. Service Overall: HMO in 2 year uptrend (2010>2008) Satisfaction with Waiting Room Time: CDH in 2 year uptrend. PPO in 2 year downtrend. Referral Process (HMO only): No changes. HMO just above its average. After Hours Contact Attempts: Between 17-24% made attempts; CDH lowest attempts. Acceptable Response: No changes. Timely Paid Claims: No changes. CDH non significant downward movement over 4 years Satisfaction with Time to Reach Service Rep: HMO in 2 year uptrend. PPO rated lower than last year. Likelihood to Recommend: CDH rated lower than last year. HMO and PPO at their average. Likelihood to Stay/Switch: PPO in 2 year uptrend. All products above their average. Health and Wellness Info Availability: No changes. HMO tends to rate higher. Health and Wellness Info Trustworthiness: PPO in 2 year downtrend. Condition Management Overall: HMO lower than last year Condition Management Ease of Participation: HMO lower than last two years

3. 2010 CAHPS Survey (HMO)

Member satisfaction with claims processing by the HMOs of BCBSIL has increased each year since 2003 Significant increase in members reporting satisfaction with their specialist from 2009 to 2010 Four year statistically significant increase in members reporting satisfaction with their personal doctor Percent of members who felt their doctor explained things in an understandable way increased significantly

fro 2009 to 2010 Overall satisfaction with the health plan is significantly higher than NCQA national average in 2010

B. Practitioner/Provider: 1. 2010 PPO Physician Survey

Physicians’ rating of the PPO Program Overall is 94%. Physicians’ rating of the Quality of the Specialist Network is 95%.

2. 2010 PPO Non-Physician Clinician Survey

Clinicians’ rating of the PPO Program Overall is 96%. Clinicians’ rating of the Quality of the Specialist Network is 97%.

3. 2010 HMO PCP Survey

Physicians’ rating of the IPA’s managed care operations Overall is 94%. Physicians’ rating of the IPA’s UM process is 90%. Physicians’ rating of the quality of the specialist network is 94%. Physicians’ rating of the IPA’s referral process overall is 90%. IPA-specific detail reports were provided to each IPA.

4. 2010 Contract Entity Survey (HMO)

Satisfaction with HMO Support Staff ranges from 84% - 100% on various attributes.


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Satisfaction with the CAU ranges from 81% - 91% on various attributes. Satisfaction with HMO Processes ranges from 77% - 97% on various attributes. Satisfaction with HMO Reports ranges from 78% - 100% on various attributes. Satisfaction with QI Fund Projects ranges from 69% - 100% on various attributes. Overall satisfaction with the BlueReviewProvider Newsletter compared with provider newsletters of other

area health plans is 98%. Overall satisfaction with the new BCBSIL Provider Website is 81%. Satisfaction with HMO Services ranges from 59% - 94% on various attributes. Satisfaction with Credentialing ranges from 72% - 98% on various attributes. Significant improvements from 2009 to 2010 were seen in the following areas:

HMO Support Staff Chicago Customer Assistance Unit (CAU) HMO Process HMO Reports

Results are distributed to senior management and staff at the plan for possible intervention planning.

VIII. OVERSIGHT OF DELEGATION A. 2010 Oversight of Delegated Vendors As part of the delegate oversight process, the delegated vendors, Women’s Infertility Network (applicable to HMO only) and Magellan Behavioral Health submitted the required documentation for review by the BCBSIL QI staff quarterly. Each delegated vendor reported to the Managed Care QI Committee. No significant deficiencies were reported for Women’s Infertility Network orMagellan Behavioral Health. For Prime Therapeutics, a deficiency was identified concerning the reporting of accuracy of pharmacy benefit information provided on the web site. BCBSIL has worked with Prime to develop a report that will meet the requirements. Unfortunately, the web site reports were not available for 2010, but will be submitted quarterly in 2011 and moving forward. B. 2010 Oversight of HMO Utilization Management Various activities related to oversight of delegated functions occurred during 2010. Highlights include:

The HMO UM Workgroup reviewed utilization statistics for the HMO networks quarterly. Potential utilization issues were identified, and UM staff and BCBSIL Medical Directors worked with the IPAs to identify opportunities for improvement.

All 2010 IPA UM Plans were audited to ensure compliance with the HMO UM standards. All IPA UM Plans were reviewed and approved by the required deadline.

IPAs undergo an annual UM adherence audit. Groups that do not meet the established standards are placed in corrective action and are re-audited in six months. In 2010, all IPAs passed the audit; therefore, none were placed in corrective action.

Member satisfaction survey data regarding utilization issues was reviewed. Intervention plans were required for IPAs not meeting the satisfaction with the referral process question requirement.

PCP satisfaction survey data regarding utilization was reviewed. Intervention plans were required for IPAs not meeting the requirements for the utilization process questions.

Complex case management logs and cases were reviewed. Education and training was performed to ensure HMO 2010 Complex Case Management Program requirements were met.

IX. Accreditation ▪ HMO Illinois and BlueAdvantage HMO received the NCQA accreditation rating of “Commendable”. ▪ BCBSIL, under the Blue Cross and Blue Shield Association's umbrella application to URAC, received Full

Accreditation for FEP Case Management Accreditation. ▪ The most recent URAC accreditation for Utilization Management was effective through May 1, 2010. The re-

accreditation for URAC's Utilization Management was "in-process" for the remainder of 2010.

Blue Cross and Blue Shield of Illinois 2010 Quality ... · 2010. 1. HMO ILLINOIS / BLUEADVANTAGE...

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