Annual Quality Improvement Program Summary

For Our Members

Our mission is to improve the health and well-being of our members and the communities in which they live. We align our efforts around the Institute for Healthcare Improvement’s (IHI’s) Triple Aim framework of improving overall population health, improving the member experience of care, and reducing overall healthcare costs. Improving health and healthcare is a continuous process, and is a goal shared among all involved in the healthcare industry. The fundamentals of our quality improvement program include coordinated efforts, regular measurement of processes and outcomes, specific performance targets, feedback, sharing of best practices, and continued evolution.

Overall, 2019 was a successful year. Significant cross-departmental collaboration and our continued focus on the Capital BlueCross mission and corporate strategy and goals along with IHI’s Triple Aim enabled our success.

Program Goals

  • Improvement in member health and experience of care while providing the best value for the entire population served
  • Measurement, monitoring, and improvement of programs to ensure the safety of our members
  • Improvement in the member experience
  • Focus on population health management that addresses all members’ health needs across the continuum of care
  • Coordination of member programs and services across all levels of care
  • Facilitation of appropriate accessibility and availability of care and services, including the assessment of the availability of high-volume and high-impact providers and web access to health plan services
  • Reduction in unwarranted readmissions through improving continuity and coordination and transition of care and addressing members’ complex health needs
  • Facilitation of improved behavioral health outcomes and experience of care
  • Ensuring compliance with all federal and state regulations, as well as accrediting bodies

Program Scope

  • An organization-wide focus on population health management that addresses member’s health services and needs across various levels of care
  • Integration of all functional areas into decisions that affect the safety and quality of care and services provided to our members
  • Development of policies and procedures to facilitate appropriate utilization of healthcare services
  • Facilitation of a safe and effective network of providers while ensuring accessibility and availability of care and services
  • Assessment of member and provider satisfaction and implementation of effective interventions to address identified needs
  • Providing special considerations for cultural competency needs related to language, ethnicity, gender, age, complexity of health needs, and economic status to assist members in effectively accessing and using covered benefits

Monitoring of Goals and Achievements in 2019

The progress, achievements, and overall effectiveness of Capital’s 2019 Quality Improvement Program included:

  • Continued growth of our value-based provider partnerships

    • Expanded to additional eligible providers
    • Raised performance targets to support improved outcomes for our members
    • Continued partnership with the Leapfrog Group for our hospital performance improvement program, demonstrating increased provider participation and composite score improvement over the prior year
  • Focus on ensuring safe care for our members

    • Point of sale review edits, closing gaps in medication therapy, and maintenance of the formulary system through our pharmaceutical management program
    • Evolution of our opioid strategy in alignment with the Centers for Disease Control and the Blue Cross Blue Shield Association, among others, and through our efforts, demonstrated success in decreasing opioid utilization by our members
  • Focused on ensuring safe care for our members

    • A comprehensive review and update to our quality of care and service review processes
    • Enhanced measurement and tracking of provider-specific quality issues and more direct communication and interventions with providers exceeding thresholds
  • Evolution of the population health management strategy

    • Provided tools and interventions to address our members’ needs across the continuum of care from healthy to catastrophically ill or injured
    • Increased participation in Care Management programs, reducing readmission rates and medical expenses
    • Continued offering of health education and wellness programs to promote and support health maintenance, prevention and self-care
  • Expanded Utilization Management activities

    • Implemented site of service for medical specialty drug review
    • Clinical validation of medical records for high tech imaging services
  • Evolution of our behavioral health strategy

    • Identified key interventions to improve access to quality behavioral health services
    • Worked to more fully integrate medical and behavioral health care and services for our members
  • Evolved our behavioral health strategy

    • Identified key interventions to improve access to quality behavioral health services
    • Integrated medical and behavioral healthcare
  • Enhanced assessment and understanding of member and provider experience

    • Administered surveys with focused review and analysis of results
    • Evaluated the overall provider experience with Capital BlueCross and the adequacy and accessibility of our provider network
  • Achievement of commendable status for all four of our NCQA-accredited commercial products and 4 STAR performance for our two Medicare products