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PubMed1992

New methods for evaluating utilization management programs.

Blue Cross and Blue Shield of Massachusetts, Inc (BCBS), has developed two new methods for measuring the effect of utilization management (UM) in reducing unnecessary hospital use. The "program component" method measures the separate effect of preadmission review, concurrent review, and discharge planning. The "savable days" method produces a composite measure of the effectiveness of the program as a whole. The use of these two methods is illustrated with five years of utilization review data from the BCBS nongroup insurance product. The results can be used by operations managers and policymakers to measure the performance of individual UM components and the program as a whole, to establish goals and monitor program performance, to modify the program in response to changing utilization patterns, to assist in developing premiums, to establish risk-sharing agreements with employers or providers, and to demonstrate the effectiveness of the program for use in marketing.

Blue Cross Blue Shield Insurance Plans↗
PubMed1984

Use of ambulatory care services in three provider plans: interactions between patient characteristics and plans.

A previous study of low-income enrollees in a closed-panel health maintenance organization (HMO) and a Blue Cross/Blue Shield (BC/BS) plan showed that the effect on the use of health services of the age, sex, health status, previous health care use, race, and family size of the enrollees was different in the two plans. We have replicated this study using the same two provider plans but studying a different group of white collar, middle class enrollees. A third plan, an experimental independent practice association (IPA), was also available for analysis. Utilization was defined as use (yes/no) and the quantity of use for those who used services (in standardized dollars). Significant interactions were detected between plan and all of the independent variables but race. The use of services in the HMO was least affected by enrollees' characteristics (age, sex, race, health status, prior use, family size) and use was most sensitive to patient characteristics in BC. In some respects, the IPA was more like the HMO and in other respects more like the BC/BS plan.

Adolescent↗
PubMed2003

Emergence of a new national health services research alliance.

Although underrepresented to date, PPOs have the potential to become major contributors to health services research. However, policy and health plan decision makers must be informed about the unique features and contributions of PPOs. The authors describe a unique health services research coalition established among 13 Blue Cross and Blue Shield plans nationwide and the Kerr L. White Institute for Health Services Research (Decatur, GA), in collaboration with research institutions and government agencies, that features multiple health plan products within commercial, Medicare, and Medicaid enrollments, but with a specific emphasis on PPOs.

Academies and Institutes↗
PubMed1985

Recent evidence on case-based systems for setting hospital rates.

Medicare's adoption of the Prospective Payment System (PPS) was the culmination of years of research and demonstrations to establish case-based systems for setting hospital rates. This paper examines the procedures and findings of the early programs in New Jersey and Maryland, as well as the Medicare case-based system that was established pursuant to the experience in these two states. This is followed by an examination of the recently established Medicaid case-based systems in Utah, Pennsylvania, Ohio, Michigan, and Washington and the case-based systems established by some Blue Cross and Blue Shield Plans. The strengths and weaknesses of these systems are discussed, and suggestions are made for improving the evaluations of these systems.

Blue Cross Blue Shield Insurance Plans↗
PubMed1992

Third-party reimbursement coverage for diabetes outpatient education programs.

The purpose of this study was to report on current third-party reimbursement coverage for diabetes outpatient education programs. In 1986, the Centers for Disease Control began to collect and analyze information about reimbursement of outpatient diabetes education programs. Data compiled in the Diabetes Outpatient Education Reimbursement Database represented various information sources, including contact people in 42 states, surveys, government publications, the American Diabetes Association, the American Association of Diabetes Educators, and Communicating for Agriculture. The purpose of the data base was twofold: 1) to track national reimbursement trends and 2) to support health-care professional efforts in obtaining third-party reimbursement for education services. This article analyzes the Diabetes Outpatient Education Reimbursement Database. This study is a descriptive analysis of the major carriers that reimburse, legislation for reimbursement of education programs, and state risk-sharing insurance pools. Currently, Medicaid (in 37 states), Medicare (in 49 states), Blue Cross/Blue Shield (in 43 states), and private carriers (in 48 states) reimburse diabetes outpatient education programs. Sixteen states have operational pooled risk health insurance plans. This represents an increase in the number of states that report reimbursement from 1986. Progress has been made in procuring reimbursement coverage for diabetes outpatient education programs. However, progress does not imply that third-party reimbursement is uniform nationwide or effortlessly achieved. Many challenges must be addressed before reimbursement is no longer an issue in the management of diabetes education programs and the provision of essential services for people with diabetes.

Blue Cross Blue Shield Insurance Plans↗
PubMed1986

Inpatient length of stay in Twin Cities health plans.

In this paper we examine the relationship between inpatient length of stay and the patient's type of health insurance. The data consist of discharges in seven diagnosis-related groups (DRGs) from community hospitals in Minneapolis and St. Paul during 1982. After controlling for the effects of the patient's age, sex, medical condition, and severity of illness, as well as the hospital's size, teaching and ownership status, and average annual occupancy rate, we must reject the null hypothesis that the patient's type of health plan is unrelated to inpatient length of stay in Twin Cities community hospitals. We find that, in most cases, patients in prepaid group practices and independent practice associations exhibit significantly shorter lengths of stay than similar patients in Blue Cross and commercial health insurance plans, while Medicare and Medicaid patients exhibit significantly longer lengths of stay than those of similar commercially insured patients.

Blue Cross Blue Shield Insurance Plans↗
PubMed1989

The triple option choice: self-selection bias in traditional coverage, HMOs, and PPOs.

Health care costs and utilization by salaried employees and their dependents at a large self-insured midwestern industrial manufacturing corporation were analyzed for the year before employees were first offered a triple option choice. Members had the option of retaining traditional Blue Cross and Blue Shield of Michigan (BCBSM) coverage or switching to either a number of health maintenance organizations (HMOs) or a number of preferred provider organizations (PPOs). Members who switched to HMOs or PPOs were generally younger and had lower average expenses and utilization rates than those who retained the traditional BCBSM plan. The results suggest that a selection bias does occur in this population, as lower cost members were more attracted to the HMOs and PPOs than were more expensive members. Implications for the corporation as well as for the drive toward managed care alternatives are discussed.

Age Factors↗
PubMed2006

Transparency has its limits. Questions arise about why the transparency-preaching Blues association is getting quiet about its members' fiscal results.

The Blue Cross and Blue Shield Association was touting its plans' devotion to transparency last week, unveiling a database offering insight into a variety of healthcare trends. But some are doubting the Blues' sincerity, given the association's decision to withhold aggregate plan financial results. "It seems very inconsistent with their new emphasis on transparency and empowering people with information," says Bruce McPherson, left.

Blue Cross Blue Shield Insurance Plans↗
PubMed1983

Hospice care: perspectives on a Blue Cross Plan's community pilot program.

A community approach to the provision of hospice care utilizing existing community institutions in the metropolitan Washington, DC, area was started as a pilot project among three entities: the Washington Home, a licensed, skilled nursing facility, which served as the hospice inpatient unit; Georgetown University Hospital and its home care program, which were to serve as the sole referral sources; and Group Hospitalization, Inc., the local Blue Cross Plan. Insufficient referrals resulted in expansion of referral sources to include other hospice home care providers and acute care hospitals in the general community. As other community hospices developed, the Blue Cross Plan expanded the pilot program and fostered the communitywide coordination of hospice services.

Blue Cross Blue Shield Insurance Plans↗
PubMedDate not supplied

Medicare-the development of publicly financed health insurance: Medicare's impact on the nation's health care system.

It is useful for health care managers to understand Medicare's history and the impact on providers of ever-changing Medicare payment methods. Initially, Medicare payments resembled those of commercial insurance plans and Blue Cross Blue Shield plans. When Congress became concerned about the increasing costs of Medicare, new payment methods were created to limit payments to providers. The prospective payment system, imposed on hospitals in 1987 and later on nursing homes, home health agencies, and other services, has been adapted by commercial plans, Blue Cross Blue Shield associations, and state Medicaid programs. Changes in payer reimbursements require health care managers to adjust the department's charge master and exert more control of departmental costs. The story of Medicare's beginnings and development can provide some insight into the possibility of national health insurance, given the historic and current politics that limit publicly financed social programs. This article discusses the development of Medicare and its administration and serves as an introduction to the complex realities of health care reimbursement policy.

Delivery of Health Care↗
PubMedDate not supplied

Managing biotechnology in a network-model health plan: a U.S. private payer perspective.

Emerging biotechnology poses challenges to payers, including access, coverage, reimbursement, patient selection, and affordability. Premera Blue Cross, a private regional health plan, developed an integrated cross-functional approach to managing biologics, built around a robust formulary process that is fast, flexible, fair, and transparent to stakeholders. Results are monitored by cost and use reporting from merged pharmacy and medical claims. Utilization management and case management strategies will integrate with specialty pharmacy programs to improve outcomes and cost-effectiveness. Creative approaches to provider reimbursement can align providers' incentives with those of the plan. Redesign of member benefits can also encourage appropriate use of biotechnology.

Biological Products↗
PubMed1985

Biased selection in the Federal Employees Health Benefits Program.

The existence of biased selection in health insurance markets has long been assumed by economic theorists as well as seen between classes of health plans. In this paper, we use a model of the premium rate that takes into consideration the effects of moral hazard to make empirical estimates of the extent of selection in the Federal Employees Health Benefits Program. We find that biased selection has raised the premium of the Blue Cross Plan high-option coverage by 21% and lowered the premium of the low-option coverage by 29%, both relative to premiums that would have been charged in the absence of selection.

Blue Cross Blue Shield Insurance Plans↗
PubMedDate not supplied

The Highmark Pegasus Project report: characteristics of highly successful health plans.

The Highmark Blue Cross/Blue Shield Pegasus Project was created in the fall of 1996 to benchmark best practices at health plans around the United States through extensive interviews, literature searches, and other measures. Characteristics of highly successful health plans across a number of major categories are summarized in the final recommendations presented by this report.

Blue Cross Blue Shield Insurance Plans↗
PubMed1998

Design of a privileging program for diagnostic imaging: costs and implications for a large insurer in Massachusetts.

PURPOSE: To evaluate the results of a privileging program aimed to ensure that health care providers and facilities adhere to standards of care. MATERIALS AND METHODS: Technical and professional privileging applications were mailed to more than 1,800 diagnostic imaging facilities and more than 6,000 professional providers of services to members of a health care plan. Site inspections were used to determine whether facilities met standards of care. Specialty providers were assigned a range of current procedural terminology codes for which they had privileges to bill the payer. RESULTS: Of 1,004 imaging sites inspected, 197 (20%) failed with the ability to remedy the violation, 106 (10%) failed with fundamental and serious deficiencies, and 701 (70%) passed. Site inspection pass rates varied substantially by specialty. Chiropractors and podiatrists were more likely to fail than medical and surgical specialists. A strong correlation was found between refusal to participate in the inspection and failure rate. Results suggest that reduction of the number of professional claims billed led to a 2% decline in total imaging expenditures, or a more than 10:1 return on the cost of implementing technical and professional privileging programs. CONCLUSION: Health care plans can positively influence costs and quality by developing, monitoring, and enforcing their own quality standards for diagnostic imaging.

Blue Cross Blue Shield Insurance Plans↗
PubMed1998

Fiduciary responsibility and potential liabilities in health care cost management.

This article addresses the key legal issues facing ERISA welfare plan fiduciaries in health care cost management and explores the current status of a number of fiduciary obligations particularly relevant to welfare plan trustees. The authors discuss the fiduciary issues raised by the selection of a health care delivery system, plan design decision making and provider discount arrangements with health plans, and provide suggestion for administering reimbursements for health care costs from third party recoveries and addressing provider fraud.

Blue Cross Blue Shield Insurance Plans↗
PubMed1999

Population-based management of all pregnant women delivers healthy babies.

The incidence of preterm delivery in New Hampshire has declined dramatically thanks to the concentrated efforts of the state's largest health plan. Find out how the plan identifies women who may be at risk for early delivery, keeps tabs on them throughout pregnancy, and keeps newborns safe and out of the hospital after delivery.

Blue Cross Blue Shield Insurance Plans↗
PubMed2002

Methodology to improve data quality from chart review in the managed care setting.

BACKGROUND: Because inherent variability may exist in data collected by multiple reviewers or from potential difficulties with data abstraction tools, we developed a standardized method of evaluating interrater reliability (IRR) for clinical studies, HEDIS effectiveness of care measures, and onsite/medical record reviews. OBJECTIVE: To demonstrate the ability of our standardized methods of data collection and analysis of results to determine the extent of agreement between multiple reviewers; identify areas for improvement in data collection procedures; and improve data reliability. STUDY DESIGN: A prospective chart review with concurrent IRR. METHODS: A subsample of patient records included in the Highmark Blue Cross Blue Shield/Keystone Health Plan West basic medical review for each HEDIS measure was selected for the IRR study. An experienced nurse ("gold standard") conducted a blinded concurrent review of these records. Using the kappa statistic (kappa) we evaluated interobserver agreement between results of the onsite reviewers and the "gold standard" from 1997 through 2000. Revised data collection methods and enhanced reviewer training were incorporated for measures showing areas for rater improvement. RESULTS: Results across years showed excellent IRR for most measures; however, each year 1 or 2 measures showed areas for rater improvement (1997 Papanicolaou kappa = 0.50; 1998 well-child visits 3 to 6 years kappa = 0.37; 1999 comprehensive diabetes kappa = 0.73; high blood pressure kappa = 0.73). After reevaluating these measures, the results of the kappa showed excellent interrater agreement in subsequent years. CONCLUSIONS: Standardized methods of data collection and evaluation of IRR results provides health plans increased confidence in data collection, statistical analyses, and in reaching conclusions and deriving relevant recommendations.

Blue Cross Blue Shield Insurance Plans↗
PubMed1991

A competitive analysis of most favored nations clauses in contracts between health care providers and insurers.

A most favored nations (MFN) clause is a contractual agreement between a buyer and a seller stating that the price paid by the buyer will be at least as low as the price paid by other buyers who purchase the same commodities from the seller. During the past decade the anticompetitive impact of MFN clauses in the health care industry has been challenged under federal antitrust laws. The cases have considered MFN clauses included in contracts between large third-party payers, specifically Blue Cross and Blue Shield (BCBS) plans, and providers of health care. The clauses prohibit providers from selling their medical services to BCBS's competitors at a price lower than the price at which they sell to BCBS. The cases have challenged these clauses on the grounds that they limit selective discounting to the competitors thereby making it difficult for the competitors to attract subscribers from dominant BCBS plans by lowering premiums. In this Article, Professor Celnicker asserts that MFN clauses have significant anticompetitive potential. The Article examines the competitive consequences of MFN clauses used in the health care industry. The Article's analysis draws heavily from the economic criticisms of the Robinson-Patman Act, which prohibits a seller from discriminating in price between customers in certain circumstances. The Article concludes that in certain circumstances, MFN clauses discourage discounting, facilitate oligopolistic pricing, and deter entry or expansion by more efficient distribution systems.

Antitrust Laws↗