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Patient safety is important to us at Blue Cross and Blue Shield of Missouri. We are continually monitoring available information and evaluating ways to better manage our members' benefits. The structure of our Medical Management Division, along with many of our processes, programs and initiatives, work together to support our mutual goals for patient safety. We believe, however, that recognized accrediting organizations can better monitor certain initiatives, such as CPOE, EHR and ICU physician staffing.

We encourage and support the efforts of accrediting organizations to add patient safety standards to their accrediting criteria. Blue Cross and Blue Shield of Missouri, in turn, requires BlueCHOICE network hospitals to have the appropriate accreditation. Additionally, as plan with Excellent accreditation from NCQA, BlueCHOICE supports and adheres to performance measurements and quality assessments.

Blue Cross and Blue Shield has some effective and innovative initiatives related to patient safety:

Individual case review
The Quality Improvement Peer Review Committee reviews individual cases in which the standard of care received by a member is in question. The review includes comprehensive examination of medical claims data, utilization management data, pharmacy data, physician credentialing profiles and medical records.

Sentinel events review
Unexpected deaths, readmissions and returns to surgery are referred to Clinical Quality Improvement for research and review by the Quality Improvement Peer Review Committee.

Aggregated condition/procedure review
Quality Improvement referrals are trended over time. If an increased number of referrals relating to a particular treatment or procedure is noted, Clinical Quality Improvement focuses its investigation at the network level to determine the prevalence of the issue in question. Such efforts in the past few years have resulted in organizational endorsement and enforcement of physical therapy record-keeping standards and initiation of a facility wide corrective action plan for nosocomial infections within one of our network hospitals. The Quality Improvement Peer Review Committee reviews all findings.

Measurement of network physician compliance with practice guidelines
Annually, Medical Informatics measures network compliance against at least two practice guidelines. Results of the studies, as well as salient points of each treatment guideline, are communicated through focused education interventions (dissemination of guidelines, sponsoring Continuing Medical Education seminars) and have been associated with significant improvements in compliance with asthma and congestive heart failure practice guidelines, and decreases in emergency room and inpatient utilization for those diagnoses.

Monitoring/analysis of antibiotics utilization and intervention
Medical Informatics and QI are working on an intervention to reduce inappropriate antibiotics utilization, which we anticipate should be associated with reduction in adverse reactions from the medication itself or from drug-drug interactions, as well as reduction in the development of antibiotics resistance among organisms.

Pharmacy Programs
Currently, our pharmacy benefits manager, WellPoint Pharmacy Management, processes pharmacy claims at the point of sale. Prescriptions are verified through a drug utilization review process that identifies potential interactions with other medications, duplicate pharmaceuticals within the same drug class, and age and sex related dosage problems. In 2003, we will initiate a program that provides specific member information to providers when a member is using multiple prescriptions within a three-month period. We also have a program that applies quality limits to combination narcotic and analgesic combination products.

Grand Rounds
The Corporate Medical Officer, Medical Director, manager of Healthcare Services and manager of Clinical Quality Improvement meet weekly with telephone nurse reviewers, on-site nurse reviewers and case management nurses to address issues regarding medical necessity and appropriateness of the setting where medical care is received by our members and quality referrals by patients, physicians and other medical staff.

Provider Newsletters
We include articles on patient safely in our quarterly provider newsletter.

Healthcare Advisor site
Members can make informed health care decisions with the Healthcare Advisor - a new online service available through our secure Web site, My Blue Plan. This innovative, easy-to-use service can help members when they are facing an illness or chronic condition by giving them information about health conditions, recommended procedures and how to take care of themselves; possible complications and risks when surgery is recommended and how quickly they can expect to recover; and which hospital in the BlueCHOICE network can best fit their needs. The Healthcare Advisor site is approved by The Leapfrog Group as an evidence-based hospital selection tool. (Subimo owns and operates Healthcare Advisor. Subimo, PO Box 5335, River Forest, IL 60305, is solely responsible for its Web site and is not associated with Blue Cross and Blue Shield of Missouri or its affiliates, other than to arrange for access to the Healthcare Advisor Web site.)

Accreditations
The BlueCHOICE network of doctors and hospitals has received recognition for meeting national standards. The National Committee for Quality Assurance (NCQA) has awarded BlueCHOICE Excellent status through May 2005. The Blue Cross and Blue Shield of Missouri utilization management program is accredited by the American Accreditation Healthcare Commission/URAC, the accrediting body for utilization management organizations.

Credentialing
We have established credentialing policies that require us to select and recredential physicians every three years. Our credentialing standards are modeled after recognized accrediting standards and include requirement such as medical school degree and state licensure, board certification, reviews for history of professional liability claims and valid state and federal narcotics license.

To participate in our networks, hospitals and other health care facilities must be accredited by the Joint Commission on Accreditation of Health Care Organizations or the American Osteopathic Association. If the hospital is not accredited, its site review by the Centers for Medicare and Medicaid Services must show that the hospital meets our quality and certification standards. In addition, hospitals and other health facilities must have state licensure, Medicare certification and minimum malpractice coverage.

Disease Management
Our TakeCharge^® health improvement programs are contributing to improved health outcomes while helping to manage the utilization trends that drive up costs. They feature the newest approach to disease management - a multidisciplinary team of health coaches. The health coach team is headed by a registered nurse and includes respiratory therapists, dietitians, exercise physiologists, licensed social workers and health educators.

TakeCharge Asthma Program: Our goal is to help our members who have asthma manage their disease more successfully. Working with the patient's physician, we provide case management services to severe asthmatics through frequent phone calls, individual care plans, home health visits (as approved by the patient's doctor), durable medical equipment benefits and asthma educational material. A team of health coaches routinely monitors adults and children at high risk. Those at low risk will receive preventive health reminder mailings and asthma educational newsletters regularly.

TakeCharge Diabetes Program: This comprehensive health improvement program is designed to support the health care needs of people with diabetes. Diabetes health coaches periodically contact members with diabetes to discuss their health and ways to manage their diabetes, and to answer any questions. The member's doctor also receives information about the program. This program also provides reminder cards and other important health information to members with diabetes throughout the year.

RightSteps^®: Our RightSteps program is a voluntary program that strives to help mothers-to-be avoid potential problems during pregnancy. Pregnant women who choose to participate are asked to complete a questionnaire. Each month, an obstetrical registered nurse will then contact the members that are at high risk for preterm labor to provide information on pregnancy and childbirth. Low-risk and at-risk members are contacted once a trimester and are also provided information on pregnancy and childbirth. We encourage the member to have early, regular prenatal care and to pay attention to her lifestyle behaviors. Mothers-to-be who participate in the program will also receive a nationally recognized book on pregnancy; childbirth and infant care; up to a $40 reimbursement for the cost of a childbirth or parenting class, and a gift from us after the baby arrives.

Postpartum Depression Screening Program: This behavioral health screening program was launched in November 2001. The purpose of the program is to help members and their physicians in the early identification of postpartum depression so that the member can get appropriate referral and treatment. All female members who receive obstetric services, including those who deliver live infants as well as those who deliver stillborns or miscarry, are eligible for this program.

TakeCharge^® Heart Failure Program: Members with heart failure who enroll in the program will receive information on how to manage their condition. A team of health coaches routinely monitor members at high risk. Those at low risk will receive preventive health reminder mailings and educational newsletters.

Cancer Utilization Management Program: This specialized delegated utilization management program also has a cancer disease management component, including 24-hour-a-day, seven-day-a-week phone access to a team of experienced cancer nurses who provide services such as precertification for cancer related services. Also, the oncology nurses will educate the member about the disease process and coordinate services.