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2012 Health Care Quality Improvement Overview

The following information details Quality Improvement Initiatives undertaken by our health plan in 2012.


Quality Improvement Program Summary

Blue Cross Blue Shield of WNY Quality Programs provide health care services to keep our insurance customers healthy and help them to get well when they are ill.


Blue Cross Blue Shield of WNY promotes good, helpful and sensibly priced health care for all ages.  We give our doctors the most up to date information in order to provide the best care.  We work with our doctors to help patients feel well and know how to care for their health.




National Committee for Quality Assurance Accreditation (NCQA)

Blue Cross Blue Shield of WNY is accredited by a national quality agency called the National Committee for Quality Assurance (NCQA).  This agency surveys us to make sure our customers get good treatment, safe care and stay well.  This helps to keep health care costs lower.  In 2012, HealthNow has maintained “Excellent” status for our Commercial, Medicare and Medicaid business by surpassing the minimum threshold of 90% for the excellent category.  This keeps the plan at the highest level awarded by NCQA.  In January 2013, HealthNow will undergo a full NCQA re- accreditation survey to demonstrate continued commitment and attainment of the highest quality standards.


Health care Effectiveness Data and Information Set (HEDIS®) Surveys

This survey measures how well a health insurance plan does in providing quality healthcare services.  Most insurance plans in the nation use this “report card”, which is available to the public, to compare plans to each other.  The yearly HEDIS survey includes measures on preventive health care such as well child visits and adult cancer screening, along with disease specific care including problems with blood sugar and the heart.  HEDIS results are used to develop and evaluate many of the programs found in this report.  In 2012 our NCQA HEDIS score was 37 points out of a possible 43 points which helped earn our grade of “excellent”.


Quality Assurance Reporting Review (QARR)

Quality Assurance Reporting Review or QARR rates health plans for New York State. The measures are the same as HEDIS with New York Sate choosing additional areas to monitor.  All results are reported to the New York State Department of Health.  As with HEDIS, the results are used to show where we can improve our healthcare programs.

Quality Programs

Hospital Quality

Blue Cross Blue Shield of WNY provides hospitals with financial support and incentives to provide good safe care.  Programs promoting good care such as preventing infections, surgical complications and wrong medication are in place at all hospitals.


Blue Distinction Centers for Specialty Care®

Blue Distinction (honor) is awarded to hospitals that are “experts” in providing specialty care.  Hospitals must meet special criteria to be called a “Blue Distinction Center”.  This designation is based on national care standards.  Blue Distinction facilities are recognized for excellent clinical outcomes and processes in the areas of Bariatric Surgery, Cardiac Care and Complex and Rare Cancer treatments, Spinal Surgery and Hip and Knee Replacement.


Doctor Quality

We work with primary care doctors to promote the Patient Centered Medical Home, a nationally recognized way of providing healthcare, which focuses on the total needs of the patient.  This includes using computers to provide information on needed preventive care, patient medication and to communicate with other doctors to provide the best patient care possible.


Culturally and Linguistically Appropriate Services (CLAS)

This program helps promote awareness of the language and cultural needs of individuals seeking health care.  We provide tools and education to health care workers to allow them to be sensitive to the culture, customs and language of each patient.  Language Line Services is available to assist with any language barriers that may exist in order to improve understanding and compliance for all parties.  Annual training of employees is completed to expand and keep current knowledge regarding how culture and language barriers affect our enrollees and how they can help to make the enrollees health care experience a positive one promoting increased compliance and wellness.  Seminars for providers are available on our provider portal.


Continuity and Coordination of Care

Continuity and coordination of care (CCC) between home and the hospital/urgent care/medical facility and between the primary doctor and specialist is very important to ensure safe and appropriate patient care and can prevent unneeded treatments and tests for patients.

This plan monitors how well providers communicate with each other when treating the same patient.  In 2012 surveys were used to assess communication between healthcare providers/settings.  Results identified opportunity for improvement in rate and timeliness of communication between behavioral health providers, specialists, urgent care centers and primary care practitioners.  The orthopedic (bone) and dermatology (skin) specialties showed the greatest need for improved communication with primary care.  Actions to improve provider performance were implemented.  Communication continues to be monitored by medical record review and other quality improvement projects.

In addition other health care programs/projects (i.e. case management, radiation safety awareness, pharmacy, patient centered medical home, etc.) measure and work toward improving coordinated care for our members.


Medical Record Review for Standards

Primary Care medical records are reviewed and scored against proven record standards. We work to assist doctors to improve information and conversations in the following areas: end of life wishes, smoking, alcohol and drug use, adult vaccines, checking weight and cultural needs of patients.


Quality Investigations

Whenever a customer contacts us with a concern about the care they received from one of our providers we look into it.  We review patient medical records to make sure good care was provided and work with doctors and facilities to improve on any concerns we find.


Access to Care Audit

We assure appropriate access to primary care, behavioral health and customer services for our members.  We have an audit and correction system in place to assure primary care and behavioral health offices can be contacted 24 hours per day for urgent or emergency care.


Patient Safety Programs

The Patient Safety Program focuses on ways to improve care and clinical safety for our customers.


Radiation Safety

The waves from x-ray and scan tests are absorbed and stored by the body and can make a person sick when they have a lot of tests over a lifetime.  We are working with our doctors and medical facilities to order x-rays and scans for patients only when needed and to keep track of testing to prevent unnecessary duplication.  The program provides ordering doctors with patient specific information regarding accumulated radiation exposure and promotes coordination of care between the primary care doctor, radiologist and other specialists with the aim to reduce radiation exposure from unneeded tests.


Image Gently Campaign

We encourage provider participation in this national campaign which focuses on reducing radiation exposure particularly for children.  Tracking radiology procedures beginning in early childhood is recommended using a simple tracking tool for parents available on our customer web site.


Medication Safety

Our pharmacy’s vendor, Express Scripts, provides information and tools to doctors to help them prescribe medications safely by informing them of potentially serious drug interactions, excessive dosing or quantity consideration.  We encourage customers to review their medications with healthcare providers on a regular basis.  In 2012 we distributed medication safety bags to members to remind them to take all medications in their original containers to every doctor visit.


Falls Prevention

Interventions included an educational mailing to approximately 3200 Medicare enrollees.  Educational materials consisting of a Falls Risk questionnaire, Medication Reconciliation special purpose bag and an informational brochure were sent.  These materials were designed to assist members in identifying their risks as well as promoting discussion and review with their primary care provider.

Health Management Programs

Blue Cross Blue Shield of WNY promotes improved quality of life for our customers by helping them to better understand their illness and self manage their conditions.  We accomplish this by providing education for our customers and support to our providers to care for these conditions.  Self care is encouraged early in the disease process by nurses, dieticians, social workers and outreach staff who make calls to customers to coach and teach.  Health coaching calls remain well received by our customers who obtain tips and information to care for their conditions.


Asthma (Breathing Problem)

We continue to reach out to asthma customers to help them self manage their illness.  This includes encouraging them to take their medications correctly and to follow a specific action plan when their asthma acts up.


Attention Deficit Hyperactivity Disorder (ADHD)

The Attention Deficit Hyperactivity Disorder (small attention span) management program aims for proper screening, diagnosis, treatment and management of ADHD in children.  We work closely with our pediatric and behavioral health doctors to develop activities and educational materials that encourage parents to get the right help for their children.


Chronic Obstructive Pulmonary Disease (COPD) (Emphysema or Breathing problems)

Our goal is for customers to control their symptoms and maintain an active lifestyle.  An individual’s quality of life can be seriously impacted if COPD is poorly managed.  We give our customers tools to control their symptoms and stay healthier longer.  Spirometry (breathing) testing and medication management rates are measured to determine program success.  The spirometry test to find COPD and assuring members take their medication correctly are areas in which we can improve.


Diabetes (Sugar in the Blood)

The Diabetes Program is designed to promote compliance with diabetic care and raise awareness of the effects of poorly controlled diabetes.  Appropriate and timely screening and treatment can significantly reduce the long-term complications of diabetes.  We continue to educate and encourage members to comply with routine screenings (i.e. blood sugar and cholesterol, eye exams, etc) in the management of their diabetes.


Heart Disease

The Cardiac (heart) Program was developed to address the growing concerns of cardiac care.  Prevention of cardiac disease starts early and in many cases before there is a diagnosis of heart disease.  We focus our efforts on customers with diabetes, hypertension (high blood pressure) and elevated cholesterol (lipids or fats in the blood). A new intervention was implemented this year to encourage customers to continue cholesterol lowering medications as prescribed by their doctor.


Back Care

This program, developed in 2010, is designed to raise awareness and improve outcomes related to the cause, treatment, and management of back related conditions.  While our outcomes demonstrate that our providers are doing a good job in treating and managing low back pain we continue to work on educating customers and providers to further decrease the use of inappropriate imaging studies.


Depression (A condition of feeling sad or hopeless)

The primary focus of the Depression Management Program is to improve the quality of life for our customers with depression by assisting them with getting the right treatment, medications and follow up care.  Our follow up after hospitalization rates have increased with the implementation of calls to customers to encourage them to keep after hospital stay appointments.

Case Management Programs

The Case Management Program assumes responsibility for the coordination of care for customers identified with chronic or high-risk conditions.  This includes chronic kidney disease, and customers awaiting an organ transplant.  The case manager follows the customer through the health care process.


Right Start Prenatal (Maternity Care) and Newborn Care

The Right Start Program is a special program for women expecting a baby which helps them to have a healthy pregnancy and baby.  We help them to get needed doctors care, nutrition services, teaching assistance to quit smoking, information on infant care and much more.  As a result both our timeliness of prenatal care and post partum visit rates continue to improve.


Palliative Care

The Palliative Care Program is designed for customers with end stage illness who are not ready to enter hospice.  This program provides supportive care to customers and their families.   A dedicated case manger works with customers, their families and health care providers to provide needed assistance.



The case management and utilization management team work collaboratively to improve care for transplant candidates.  Targeting providers from Centers of Excellence, for increased interaction, and early identification of potential candidates has resulted in increased member satisfaction and increased cost savings, with quality care.



The HIV/AIDS Case Management Program was developed in 2010.  Adequate and timely care, management of co-morbid conditions, and adherence with medications/treatment plan, as well as addressing high-risk behaviors are key to preventing the spread of infection.

Preventive Health Programs

To keep healthy it is important for people to have routine preventive care.  Examples of preventive care are making sure children receive their vaccinations and cancer checks for older adults.  Routine health screening and immunizations are continuously monitored and action taken to educate customers and healthcare workers of the value and need for preventive care.  Below are some examples of preventive health measures and our rates:



2010 Rate

2011 Rate

2012 Rate

Adolescent Immunization




Pneumonia Vaccine





Adult Preventive Health

The Adult Preventive Health program targets its preventive health message on the adult  enrollee, male and female, 19 years of age and older.  Education of enrollees regarding flu and pneumonia vaccine, colo-rectal screening and health screenings is the main focus.


Women’s Preventive Health

We educate women about the importance of getting checkups for breast and cervical cancer, Chlamydia (sexually transmitted disease - STD) and osteoporosis (weak bones).  Outreach calls to non-compliant women are made regarding breast and cervical cancer screenings.


Child/Adolescent Preventive Health

We educate parents on the importance of making sure their children receive age appropriate well care (recommended health screenings, vaccines).  

Health Promotion Programs

Community Wellness Program

A community network of health educators offer wellness programming to eligible members free of charge.  These educational programs provide members with the information and skills necessary to assist them in making positive lifestyle changes.  Topics include nutrition, fitness, weight management, stress reduction and diabetes education.


Worksite Wellness Program

The Worksite Wellness Program is a comprehensive wellness program centered on the needs of an employer.  This program includes access to a customized wellness web site, access to on-site wellness workshops and lectures, and expert planning, support and advice provided by a health promotion specialist.


Discount Network

Enrollees have access to a comprehensive list of local and national discounts for fitness memberships, and access to health and wellness related services at a discounted rate.  The services are searchable by zip code and or content area.


Tobacco Cessation

This program offers counseling on how to quit using tobacco products.  Service is available by phone, on the internet or face to face.  Overall customer satisfaction with this program remains high at 98%.


Childhood Health and Wellness

Overweight children and adolescence are an important public health issue because of its rapidly increasing prevalence and the associated adverse medical and social consequences.  The dramatic increase, co-morbidities, and associated financial burden warrant a strong preventative approach.  In an effort to address this trend, we will engage the healthcare provider, family and school.


Health Coaching

To educate, motivate and support people with health risks, and guide them to achieve health improvement.  Coaching services can be delivered face-to-face, by telephone or electronically by online communication.  A Health Coach’s role can range from working with a participant to set goals, to establish a treatment plan, and to follow-up on compliance as needed.


Wellness Web Site

My Health is an interactive web-site that promotes enrollee self-management of health. This web site is secure and private.  The Health Assessment is available to give you personal help and information for your health needs and to assist you in keeping track of your health information.  It also provides a multitude of interactive member wellness tools, and hosts our 24 hour ask a nurse functionality with secure messaging.


Collaborative Participation

We’re active in joining with other community groups to work together to improve the health of the community.  We participate in nineteen programs that address special needs and activities for our region.  We also participate in five statewide and three national collaborative groups.  More detail on collaborative participation is available on our website.  Refer to “Summary of Collaborative and Coalition activities 2012”.  Paper copies are available upon request.

Customer Satisfaction Program

Customer Service


In order to improve the accuracy of the information given to customers when they call, we have implemented a Call Monitoring Program on behalf of Customer Service Representatives in 1999.  Since then, we have made frequent modifications to our program to improve the service we offer to our customers.


Customer Satisfaction Monitoring

We have a program that monitors the quality of our customer service department.  This includes making sure that information shared by our staff is accurate and that customers do not have to wait long for a response to their question.  Many times our customers contact us with quality of care complaints.  This allows us to investigate and track issues in order to identify areas for improvement.

We also do customer satisfaction surveys where members are asked questions on how they like our service.   Results from surveys and customer complaints are monitored and data is shared with a team focusing on customer satisfaction.   Although we routinely receive concerns from our customers our data shows that our customer quality of care complaints are within normal ranges.

One of the surveys done is called the Consumer Assessment of Health care Providers and Systems (CAHPS)®.  The same questions are asked to customers across the nation to measure satisfaction with their health plan and doctor.  This survey allows us to compare ourselves with other health plans and to focus on specific areas of improvement.

In 2012, the majority of our lines of business were rated above the national average on the overall satisfaction rating of the health plan.  Members’ satisfaction with customer service also scored positively, with all lines of business scoring at or above the national average.


Pharmacy Benefits Satisfaction

In 2012, HealthNow’s pharmacy benefits manager Express Scripts, formerly known as Medco, met all operations performance standards for the commercial line of business except for the Customer Service average speed of answer (ASA) guarantee.  A number of steps were implemented that resulted in improved performance throughout the contract year.  Corporate Pharmacy Services saw significant savings attributed to the use of RationalMed again this year.  RationalMed alerts for Medicare and Medicaid lines of business were turned on in April 2012.  Significant pharmacy savings are also expected for these lines of business.

If you would like a paper copy of this report or need additional information, contact us at 1-800-677-3086 Option 5 or on our web site via ‘Click and Comment.’ You may also write to us at the following address: Quality Improvement, PO Box 80, Buffalo, New York 14240.