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Blue Cross Health Plans Expand Value-Based Care Reimbursement

Multiple Blue Cross Blue Shield health plans around the country have been investing time and resources in advancing value-based care reimbursement.

By Vera Gruessner

Along with other national payers, Blue Cross Blue Shield health plans have been investing in expanding value-based care reimbursement. For example, New York-based Excellus Blue Cross Blue Shield has partnered with vendors to use analytics and population health management software to advanced value-based care reimbursement, according to a company press release.

Blue Cross Blue Shield

The health plan includes 1.5 million members that will be tracked using the population health management system from the vendor Geneia. The vendor’s data analytics software has helped achieve some key outcomes that payers and providers seek in a value-based care reimbursement arrangement. For example, providers have seen a 7.2 percent decrease in hospital admissions and a 15 percent drop in readmissions for Medicare beneficiaries.

“This upstate New York health plan is taking a strong leadership role to improve collaboration with its provider partners and ensuring the sustainability of healthcare in the community,” said Geneia CEO Mark Caron, CHCIO, FACHE. “We look forward to helping them achieve their goals.”

Both consumers of commercial health plans and Medicare beneficiaries saw an 8 percent reduction in emergency room visits due to the value-based data analytics software. Payers saw a 2 percent drop in medical claims costs while also improving their Healthcare Effectiveness Data and Information Set (HEDIS) scores using the new technology, according to the release.

“We are committed to improving the quality and affordability of healthcare and have chosen to partner with Geneia to drive insights to achieve just that,” said Excellus BlueCross BlueShield CEO Chris Booth. 

READ MORE: How Payers Could Gain Success in Value-Based Care Models

Improving HEDIS scores goes hand-in-hand with creating a successful value-based care reimbursement platform. Last May, Nancy Mamo, AVP/Managing Director of Population Health Analytics at Blue Cross Blue Shield of Rhode Island, explained how she worked to achieve higher HEDIS scores at her company.

The first step that Mamo focused on is creating a pay-for-performance program, which is one type of value-based care reimbursement structure focused on improving quality of care and reducing volume of services along with cost. The pay-for-performance program included quality measures where providers could earn higher reimbursement rates if they succeeded in closing gaps in care.

To advance value-based care reimbursement and meet HEDIS quality scores, Blue Cross Blue Shield of Rhode Island adopted cloud-based analytics technology and built a population health registry. This allowed the payer to identify members who are at higher risk of complications and send that information to primary care providers and nurse care managers to improve engagement and general wellness.

“We have created a longitudinal disease registry,” Mamo explained. “Any member that falls into the top six disease brackets are entered into the longitudinal disease registry. We identify new members every month with those patients who fall into those diseases.”

“These are the members who have a high overall spend and high-risk,” Mamo added. “We put this in our population health registry for primary care physicians to manage, but we also have put in place nurse care managers that we actually embedded into some of these practices. We send them these lists on a monthly basis.”

READ MORE: Why HEDIS Quality Measures Matter for Value-Based Care

These steps enabled Blue Cross Blue Shield of Rhode Island to improve the quality of care among their members and reduce the volume of services and cost in a value-based care arrangement.

Another Blue Cross health plan from Michigan also advanced value-based care reimbursement in recent years. In November, David Share, M.D., the Senior Vice President for Value Partnerships at Blue Cross Blue Shield of Michigan, spoke with about his work to improve value-based care and consumer engagement through the patient-centered medical home.

Blue Cross Blue Shield of Michigan is planning to expand their value-based care reimbursement strategies throughout 2017 using a “personal choice value-based product” and expanding their patient-centered medical home model. Share explained that the payer will be working to broaden the definition of value among their product lines as well as build more financial risk into provider contracts to achieve quality improvement goals.

“We will be working hard with organized systems to evolve our approach in measuring value so that in the future duration of the product, value will be defined more broadly,” Share stated. “Also, we’re working to develop methods not just to tier the organized systems on a value scale and vary the number liability but also to attract more members.”

“We also want to develop the method to build risk into the contract so that organized systems do well on achieving cost goals and quality improvement,” Share concluded.

READ MORE: UnitedHealth’s Value-Based Care Reimbursement Improves Outcomes

Blue Cross Blue Shield health plans across the country have been advancing the transition to value-based care reimbursement among their provider networks in recent years through new technologies, pay-for-performance contracts, population health management, and healthcare delivery reforms such as the patient-centered medical home.


Dig Deeper:

How Payers Should Prepare for Value-Based Reimbursement

How to Overcome the Challenges of Bundled Payment Models


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