Blue Shield

Patient Safety Initiatives

Patient Safety Officer

Patient Safety Officer: Gifford Boyce-Smith, MD Senior Medical Director, Quality Management reporting to Eric Book, MD, Chief Medical Officer.

Blue Shield of California
Patient Safety Information

In response to the growing national concern over safety, quality health care, and rising hospital inpatient costs, Blue Shield of California has developed effective partnerships with industry collaboratives and its network providers, implementing a variety of programs and informational resources to improve safety and encourage quality-driven, cost effective healthcare decision-making. Blue Shield's goal is to enable health plan members to make more informed decisions about their healthcare.

1. Lifepath Decision Guide

Blue Shield of California evaluated the significant differences in relative cost and relative quality among hospitals and the scarcity and complexity of information publicly available to help consumers make informed decisions. Blue Shield realized the need to provide information that would help its members choose hospitals that participate in programs that address quality, promote patient safety, and enhance the patient experience.

Blue Shield of California implemented a web-based consumer decision support tool called "Lifepath Decision Guide" to help members with hospital selection. A key functionality of this suite of products includes a Hospital Comparison Tool. Members can receive a "side by side" comparison report of various procedures and/or conditions at hospitals based upon mortality, complication rates, volume, cost, and length of stays. Members are able to view quality measures for a hospital, including the results of the Leapfrog survey, California Patient's Evaluation of Performance survey (PEP-C) and the hospital's JCAHO accreditation in a consolidated format. Blue Shield also supplemented its "find-a-provider" website with both relative cost and quality information listed for each hospital.

Blue Shield of California added unique features to its web site. For example, members can also view a graphical representation to indicate the overall relative cost categorized by a price range from inexpensive $ to very expensive $$$$ (i.e., $, $$, $$$, $$$$) for inpatient services, using Blue Shield of California's risk adjusted costs rather than statewide costs.

Also unique to Blue Shield of California's product offering is 24-hour telephonic support provided by a Registered Nurse to answer any questions a member may have specific to the hospital comparison tool.

2. Network Choice

In June 2002, Blue Shield implemented a network choice program incorporating quality, safety, and patient experience. Blue Shield evaluates hospitals every six months to assess participation and compliance by each hospital. Blue Shield makes available reliable, publicly reported quality date and communicated the information in a simple, concise, and impartial manner. Utilizing quality and patient safety measures, including Leapfrog-2 and PEP-C, we display results by hospital on our consumer website mylifepath.com and we have demonstrated increased channeling to low cost higher quality institutions over time. To learn more about Leapfrog and PEP-C, visit https://www.mylifepath.com/bsc/newsroom/pr/NetworkChoice.jhtml.

I. Pharmacy Systems and Programs

Systems in Place for Retrospective and Concurrent Review of Prescription Drug Errors
Blue Shield of California's commitment to quality care and patient safety is exemplified by the systems and programs offered in preventing medical errors and medication side effects. We utilize the sophistication of our online prescription claim systems to promote safe use of prescription medications. Through real time claims processing, our review edits look for: Therapeutic Duplication (taking two medications in the same class), Step Therapy Protocols (promote first-line medications), Maximum Allowable Daily Dose (doses that are higher than FDA-approved or recommended) and drug-drug interactions (evaluates a members entire prescription history for potentially unsafe interactions). Physician feedback is provided, as appropriate.

Drug Prior Authorization for medical necessity occurs when the medication is on the list of "Formulary Drugs Requiring Prior Authorization for Medical Necessity". The Pharmacy and Therapeutics (P&T) Committee is responsible for establishing and overseeing policies and procedures for prior authorization of medically necessary outpatient medications. The P& T Committee may determine that a prior authorization is necessary to promote first line therapy or to reserve the use of certain medications with specialized uses or significant potential for misuse or overuse. Some Drugs may be limited to a maximum quantity for safety reasons and require prior authorization if the limit is exceeded.

The pharmacist receives an on-line message stating that prior authorization is required. The process to obtain prior authorization can be initiated by the physician as well as the pharmacist by contacting Blue shield Pharmacy Staff at (800) 535-9481. Blue Shield has a staff of 22 full time Prior Authorization Technicians and 6 Clinical Pharmacists to assist with the prior authorization process.

Controlled Substance/High Abuse DUR Program identifies, through pharmacy claims data, members with high utilization of controlled substances/high abuse potential. These drugs are often prescribed by different physicians and dispensed by different pharmacies. A letter is sent to the patient's primary care physician explaining the program along with the complete medication profile and the names of the prescribing physicians. Furthermore, recommendations are made to review the medication history with other prescribing physicians and coordinate care, as appropriate.

Our intervention program has worked well. The majority of physicians change therapy within six months of notification. Since 1999,this intervention program has resulted in a 40% to 60 % reduction in the number of controlled substance prescriptions required for these members. Enhanced care coordination between prescribing physicians has been observed.

Chronic Pain Management Program
In October 2003, Blue Shield of California launched a Chronic Pain Management Program to assist physicians, other healthcare workers, and members in managing chronic pain. Patients with chronic intractable pain present with a myriad of diagnoses. For this reason, identification is based first on medication-use. Profiles for these members are created which include medication history and medical claims for easy reference. The program includes both tailored education and nurse case management. Members are stratified to case management based on severity of pain symptoms and the following utilization indicators: a pain-related ER visit in the past year, a pain-related hospitalization in the past year, identification of more than two-quarters in-a-row as high narcotic users through pharmacy high-dose edits. The BSC Pharmacy-based "Pain Case Management Member Profile" and the Chronic Pain Questionnaire completed by the member are used to further stratify members. Members stratified to case management receive a series of telephone support calls along with informational materials from the RN Pain Case Manager. The program has received very positive feedback from members and providers. Data collection is ongoing to assess quality of life, narcotic/polypharmacy use, decrease ER utilization, member and provider satisfaction with outcomes to be measured in 4Q2004.

Potentially Harmful Drug Use in the Elderly DUR Program identifies, through pharmacy claims data, members over 65 taking prescription drugs that could be harmful. The physician receives the member's pharmacy profile and a list of safer alternative drugs. Blue Shield works with the physicians to re-evaluate current medications and encourage them to coordinate care with other prescribing physicians. Since 1998, this intervention has helped improve patient care and coordination by discontinuing potentially harmful drugs in more than 50 percent of the identified elderly members and a reduction in the use of these drugs in other members.

The success of this program has been further enhanced by the geriatric high dose edits that are electronically returned to the pharmacy by Blue Shield's claim processor through point-of-sale technology. When a claim is submitted for a geriatric patient and the prescribed dosage exceeds the FDA recommended safe dosing guidelines, the pharmacist receives an on-line message indicating the requested dosage exceeds the FDA safe dosage guideline. This enables the pharmacist to play an active role in preventing a potentially harmful drug reaction by contacting the physician to verify the dose and recommending a safer daily dosage.

Online Ask the Pharmacist
The Ask the Pharmacist feature was developed to assist members in making wiser health decisions. Members may pose questions to independent and respected pharmacy professors at the University of California at San Francisco. Members will get a personalized confidential response securely online within two business days without ever leaving the privacy of their home. Members may also access helpful online resources regarding drug interactions and formulary information, which account for the overwhelming majority of questions submitted. For more information on Ask the Pharmacist, visit https://www.mylifepath.com/bsc/pharmacy/pharmacy_401.jhtml.

Preventing Medication-related Hospitalization
Blue Shield of California in collaboration with Resolution Health and the Blue Shield of California Foundation is conducting a study to better understand the association between outpatient prescription medication claims and medication-related hospitalizations identified in a commercial managed care administrative database. The prevalence and cost of the associated hospitalizations will be also evaluated. This study attempts to establish, with a greater certainty, the association between outpatient medication uses and hospitalizations deemed as medication-related through ICD-9 coding. This study will develop algorithms around the medication-related hospitalizations that are of highest prevalence and cost. Blue Shield will also evaluate variables or characteristics of subgroup populations that increase the relative risk for a type of medication-related hospitalization. The ultimate study objective is to identify opportunities for interventions that will improve the safety of the healthcare system for Blue Shield of California members and all Californians.

II. Patient Highlight Program-Resolution Health Inc.

Patient Highlights is Blue Shield's strategy to deliver clinical reminder messages about patient-specific gaps in care and potential quality issues to physicians. Blue Shield utilizes sophisticated information technology developed by Resolution Health Inc to evaluate member data for treatment gaps across disease conditions based on evidence -based clinical practice guidelines. Patient safety can be jeopardized by gaps in patient treatment. In some cases, patients use multiple doctors and pharmacists who may not be coordinating the care as well as they could be. If gaps in care are detected, a Patient Highlight reminder message is mailed to the member's physician. This creative use of information technology helps to reduce the incidence of medical errors, improve physician compliance and patient-physician relationships, and provide innovative and potentially life-saving healthcare services to our members. Blue Shield is able to provide members with the highest possible level of quality care. This program was awarded Blue Cross/Blue Shield Associations Best of the Blues award for innovation in System Processes.

Beginning with the program inception, a Randomized Control Trial study evaluates the message effectiveness for improving guideline compliance. Funded by a grant from the California Health Care Foundation, the research team includes experts from U.C. Berkeley Program in Health Management. The final analysis is nearly complete and the preparation of a manuscript for submission to peer-reviewed journal is in progress (expected June 2004).

III. Disease Management Programs

Blue Shield's Reach Your Peak Asthma self-management program assists members identified with asthma from claims or pharmacy data, acute care referrals or members can self-refer into the program. The program is available in English and Spanish and includes both tailored education and nurse case management. Members are stratified to case management based on severity of asthma symptoms and quality of life indicators. All members receive tools to assist in managing asthma, such as an asthma action plan, home environment assessment checklist, and other educational information and complete an Asthma Symptom Survey at baseline, 12 and 24 months. Members stratified to case management receive a series of telephone support calls over a six-month period from an asthma nurse. The nurse reviews several topics with the member including medications, triggers, Asthma Action Plan, smoking cessation, flu immunization, and use of the peak flow meter. The nurse may also direct the member to community resources, speak with the patient's physician as appropriate, answer questions, and explain health plan benefits as necessary. The objective is to encourage member to work with their physician to complete a written asthma action plan. Blue Shield sends a "Patient Progress Note" for both case managed and non-case managed members to the physician with a copy of the member's action plan and symptom survey results at baseline 12 and 24 months. In 2002, Reach Your Peak won the Best Practice in Health Management award from the Blue Cross Blue Shield Association.

Blue Shield's Chart Your Course Diabetes management program assists members identified with diabetes from claims or pharmacy data, acute care referrals, lab data or members can self-refer into the program. The program is available in English and Spanish and includes both tailored education and nurse case management. All members with diabetes can order complimentary educational materials and tools for diabetes self-care, including a blood glucose meter, as well as information on depression in diabetes. Members identified as being at-risk for adverse outcomes are stratified to case management. They complete educational modules with the nurse case manager by telephone for a period of one to six months, depending on the individual needs of the member. Blue Shield also uses medical and pharmacy claims to identify members with diabetes who are not receiving routine tests (retinal eye exams and A1c tests) and sends "treatment alerts" to physicians encouraging them to ensure that the identified members receive recommended care.

Blue Shield's Shield Your Heart cardiovascular risk reduction program assists members with documented cardiovascular disease to delay or prevent future cardiovascular disease progression and related complications including angina, acute myocardial infarction and death. The program includes phone-based training, coaching, and support by cardiovascular nurse specialists. The program emphasizes self-directed, home-based interventions focused on high blood pressure, cholesterol management, smoking cessation, nutrition, exercise and stress management. Members identified as being at-risk for adverse outcomes are stratified to case management. They complete educational modules with the nurse case manager by telephone. Nurses also direct members to community resources, speak with patients' physician as appropriate, answer questions, and explain health plan benefits as necessary. The objective is to encourage member to work with their physician in managing their condition. Blue Shield sends a "Care Plan" for case managed members to the physician. A follow up survey is sent to members at 12 months and 24 months after enrollment to monitor their progress.

VI. Evaluation of New Medical Procedures or Devices

Blue Shield of California has a well-established formal Committee review process to evaluate medical and behavioral health care technologies (procedures and/or devices), promoting safe and appropriate care for its members. The evaluation addresses existing technologies with new applications or new technologies.

Coverage of medical services and technologies is based on the medical necessity for and the safety/efficacy of the procedure/service/technology. Safety and efficacy of new technologies is determined through extensive review and assessment of peer-reviewed scientific data and literature, and clinical studies and trials, utilizing Technology Assessment criteria with input from medical experts.

VII. Other Quality Initiatives

Blue Shield serves as a catalyst for continuing quality improvement and is committed to educating consumers, providers, and employers.

Quality Advisory Board
In 2004, Blue Shield formally developed a Quality Advisory Board comprised of respected and recognized industry leaders. This Board will address critical issues such as the use of quality, patient safety and satisfaction measures in collaboration with consumer advocates, physicians, hospitals and employers to improve the quality of health care. The Board will provide guidance on the use of current and emerging evidence based measures from the Leapfrog Group survey II and the California Patient's Evaluation of Performance survey (PEP C II).

IPA/Medical Group-Pay for Performance
Blue Shield commitment to quality at the provider level as well as help consumers make choices is demonstrated by its active participation in the Pay for Performance initiative, which is driven by physician leadership in key IPA/Medical Groups in California. The overall goal of the Pay for Performance program is to develop a compelling set of provider incentives that will drive breakthrough improvements in clinical quality and patient experience. Blue Shield utilizes six standardized clinical measures involving chronic disease care and preventive care, and the California Cooperative Healthcare Reporting Initiative (Industry group made up of employers, health plans, and large provider groups) Consumer Assessment Survey for patient satisfaction as common metrics to assess physician performance. An additional offering of the program is the development of a public score card, displaying the results. In collaboration with five other major HMOs in the state, we will be paying standardized rewards for physician performance on quality measures to IPA/Medical Groups in 2004.

Report Cards on Blue Shield QI Performance
Blue Shield's QI Program is evaluated in a number of health plan Report Cards. These annual reports compare health plan quality against established standards to aid employers and consumers in choosing a health plan. You can compare Blue Shield to national performance standards by visiting the National Committee for Quality Assurance's (NCQA) web site at www.ncqa.org. To measure Blue Shield against other HMOs in California, visit www.healthscope.org, a web sit sponsored by the Pacific Business Group on Health.

National Quality Forum
Blue Shield of California endorses the work of the National Quality Forum, a membership organization with broad participation representing consumers, purchasers, employers, health care professionals, provider organizations, health plans, accrediting bodies, labor unions and organizations involved in health care research or quality improvement. Blue Shield has participated in an industry collaborative in association with the Pacific Business Group on Health to implement strategies for standardized health care quality measurement and reporting. Furthermore the National Quality Forum established patient safety practices.

VII. Communications

Patient Safety Information in Blue Shield Member Newsletter and web site Mylifepath.com
Patient safety information is communicated to our members through member newsletters, mylifepath.com web site and direct member mailings. The effectiveness of this communication is measured through structured, population based health/disease management program outcome and process measures.

Patient Safety Information in Physician Newsletters and Provider Connection web site
Patient Safety information in the form of Clinical Practice Guidelines and Treatment alerts is communicated to our physician network through the provider group (IPA/MG) leadership, through physician newsletters, the provider connection web site and direct to physician and member mailings. The effectiveness of this communication is measured through structured, population based health/disease management program outcome and process measures.