Blue Cross and Blue Shield of Missouri is 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 newer initiatives, work together to support our mutual goals for patient safety. We believe, however, that certain initiatives, such as Computerized Physician Order Entry, Evidence-based Hospital Referral and Intensive Care Unit physician staffing, can be better monitored by recognized accrediting organizations. We have included articles about these initiatives in provider newsletters and have encouraged our network facilities to participate with them.
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 an NCQA-accredited plan, BlueCHOICE supports and adheres to performance measurements and quality assessments.
Listed below are our initiatives as they relate to patient safety:
Individual Case Review
The Quality Improvement Peer Review Committee (QIPRC) 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, of course, medical records.
Sentinel Events Review
Unexpected deaths, readmissions, return to surgery are referred to Clinical QI for research and review by the QIPRC.
Aggregated condition/procedure review
Quality Improvement (QI) referrals are trended over time. If an increased number of referrals relating to a particular treatment or procedure are noted, Clinical QI 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. All findings are reviewed by the QIPRC.
Measurement of network physician compliance with practice guidelines
Annually, Medical Informatics measures network compliance against at least two practice guidelines. We measure compliance for management of depression, diabetes, asthma, and congestive heart failure. 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, diabetes and congestive heart failure practice guidelines and decreases in ER and inpatient utilization for those diagnoses.
Monitoring/analysis of antibiotics utilization and intervention
Medical Informatics and QI are developing 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 interactions, as well as reduction in the development of antibiotics resistance among organisms.
Disease management programs and standards of care
Case managers assist members with patient responsibility for self-care of chronic conditions by reinforcing the physician's treatment plan for each member, reviewing the member's proper administration of medications, and adherence to follow up visit schedules for required maintenance care.
We offer the following disease management programs to our BlueCHOICE members:
- TakeCharge Asthma
- TakeCharge Diabetes
- Baby Connections
- Postpartum Depression Screening
- Co-Existing Depression Screening
- Cancer Utilization Management
- TakeCharge Congestive Heart Failure
- Smoking Cessation
- Obesity
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 related dosage problems.
Member At Risk and Physician Response program:
Our Members At Risk program identifies members utilizing 20 or more prescriptions per quarter, or which at least 15 are for controlled substances. The program is designed to provide medication history to the physician that prescribes the most prescriptions for the identified individual. The objective is to give the prescribing physician information to evaluate the appropriateness of drug therapy, discontinue drug therapy that may no longer be necessary and to detect potential fraudulent prescriptions among his BCBSMo patients. Mailings occur each quarter.
Seniors at Risk Drug Utilization Review program
Identifies members 65 and older utilizing 20 or more prescription claims in a three-month period. The program is designed to provide medication history to the physician that prescribes the most prescriptions for the identified individual. The goals are for the physician to evaluate the appropriateness of drug therapy, discontinue drug therapy that may no longer be necessary and to detect potential drug interactions. Mailings occur twice per year.
Sedative Hypnotics and Anxiolytics Drug Utilization Review program
Identifies members 65 and older utilizing two or more non-barbiturate sedative hypnotic or anxiolytic prescription claims in a three-month period. The program is designed to provide medication history to the physician that prescribes the most prescriptions for the identified individual. It is important for physicians to monitor the use of these medications since these medications may increase the risk of falls in the elderly population. The goals are for the physician to evaluate the appropriateness of drug therapy, discontinue drug therapy that may no longer be necessary and to detect potential drug interactions. Mailings occur twice per year.
Grand Rounds
The Corporate Medical Officer, Medical Director, Manager of Healthcare Services and Manager of Clinical Quality Improvement meet weekly with telephonic 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.
Site visits
Inspection of a primary care practitioner's office, as part of the initial credentialing review, is a monitor for compliance with office safety standards. We are in the process of developing other criteria to help measure patient safety, such as monitoring provider office policies for disposing outdated medications and expired sterilized equipment, and the proper storage of hazardous medication and the disposal of used needles.
Patient Safety Group participation
Our Corporate Medical Director participates in the St. Louis Metropolitan Medical Society patient safety sub-group.
We also participate in a coalition of area businesses, provider groups and health plans convened by the Gateway Purchasers for Health to combine all available data to generate a health status report for metro St. Louis and safety profiles of area hospitals.
HealthCare Advisor website
Members have access to HealthCare Advisor website to enable members to learn more about treatment options and use their interactive tool to make key health care decisions. The HealthCare Advisor is provided by Subimo, which is approved by the Leapfrog group as an evidenced based hospital selection tool. (Subimo owns and operates HealthCare Advisor. Subimo, PO Box 5335, River Forest, IL 60305, is solely responsible for its website 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 website.)