Highmark Says Quality Blue Program Saves Lives, Dollars

After a decade of documenting, Highmark, one of the nation's largest Blue Cross and Blue Shield affiliates, says physicians and hospitals in its Quality BLUEpay-for-performance initiatives consistently outperform providers who are not part of the program.

In its annual report for fiscal 2011, Highmark says Quality BLUE has used financial incentives to lower healthcare-acquired infection rates—saving hundreds of lives and tens of millions of dollars—and improve screening rates and overall patient safety. The quality measures continue to improve even as the program has grown to include 1.7 million Highmark members, 81 hospitals, and 1,600 practices in 49 counties in central and western Pennsylvania.

Deb Donovan, director of provider performance and strategy at Pittsburgh-based Highmark, told HealthLeaders Media that the secret to the PFP model is simple.

"Frankly, it is skin in the game," Donovan says. "The hospitals place a portion of their contracted reimbursement at risk on performance in the program, and there is enough money at risk for the organization that it gains the C-suite's attention. It quickly galvanizes the organization around aligned goals and helps drive clinical improvements."

Donovan points to several key metrics in 2011 for both hospital and physician PFP programs:

• Well-child visits in the first 15 months of life exceeded the national average by 15% and well visits for children, ages 3-6, exceeded the national average by 13%.
• 76% of women in the program who were between ages 42 and 69 got mammography screenings for breast cancer in the past two years—9% higher than the national average.
• 72% of office-based physicians in Quality BLUE use electronic prescribing compared to only 36% nationally.
• An estimated 351 cases of MRSA with a care cost savings of $9.5 million to $12.2 million were eliminated in the past four years.
• An estimated 1,535 central line associated bloodstream infections with care costs savings of $11.2 million to $44.8 million were eliminated in the last five years, saving potentially 184-384 lives.
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Donovan says the improvements are particularly impressive because Quality BLUE constantly monitors and improves its own standards. "The program is modified each year to increase the rigor. We raise the bar each year and the facilities continue to be challenged and work hard to achieve the outcomes," she says.

Even patients who aren't in the PFP program are enjoying the benefits of the enhanced quality at participating hospitals, Donovan says. "When we operationalize the program, it applies to any patient who crosses the threshold of a facility's door."

"It is Highmark's program that is really creating the infrastructure requirement and changes in the institutions. That change is applicable whether it is a standard Medicare patient or another health insurer. They are receiving the benefit of the changes that the Quality Blue program helps drive within the institution," she says.

Because the program is adjusted annually, providers are required to implement the newest strategies quickly to improve and measure outcomes in a well-defined way. "That way we can look at that consistent measure across all facilities, and then compare ourselves to external benchmarks," Donovan says.

Highmark's next move with Quality Blue will be to take the lessons learned in the PFP program and apply them to other care delivery models, including a newly launched patient-centered medical home pilot serving Pennsylvania and West Virginia. "We are continuing to look at how do we advance value-based models that will improve the care that is being rendered to our members and ultimately bend the cost trend," she says. "If we can't bend the trend, then it is not going to be sustainable in the long term."