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Improving Outcomes and Lowering Costs

Value Based Care

BCBSNE offers several innovative payment programs designed to improve quality outcomes and control health care costs. Representing a shift from traditional reimbursement methodologies that are based on the number of services performed, these programs focus on quality of care, and are based on improved patient outcomes and cost efficiencies.

Value-based programs are designed to improve the health care system in three key areas: improved patient health, greater patient satisfaction and lower costs — a methodology the Institute for Healthcare Improvement calls the “Triple Aim.” This focus delivers a winning combination for both employers and members.

A Strong Commitment to Primary Care

Blue plans nationwide have developed innovative value-based provider payment programs in their local markets, and continue to expand and enhance these programs. BCBSNE has two market-leading initiatives — the Patient-Centered Medical Home (PCMH) and Accountable Care Organization (ACO).

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Nebraska Value Based Care Initiatives

Patient-Centered Medical Home (PCMH)

BCBSNE is a regional pioneer in the PCMH concept: A medical office or clinic that establishes a team of health care professionals who work together to help improve a patient’s health, increase satisfaction with health care, reduce hospitalizations and emergency room visits, and decrease overall health care costs.

Using pay-for-performance quality incentives, BCBSNE’s PCMH program, Primary Blue, helps improve the quality of care patients receive while reducing overall health care costs. Family and internal medicine providers, as well as pediatricians, participate in Primary Blue.

PCMH Highlights:

  • Over 102,000 attributed members
  • Over 450 participating providers
  • Over 160 clinic locations in more than 70 Nebraska communities
  • Focus on practice transformation
  • Quality is monitored and reported
  • Bonus is achieved by meeting quality targets

Goals of the Primary Blue Program

  • Give members timely access to a personal primary care physician
  • Establish an ongoing relationship between a member and his or her personal primary care physician
  • Meet the majority of members’ health care needs in their personal physician’s office
  • Coordinate and proactively monitor members’ care 
Results of the 2017-2018 PCMH Program Year
Inpatient admissions 3% lower than expected*
ER Utilization 6% lower than expected*
$3 PaMPM (per attributed member per month) total cost of care below expected compared to non-participating PCMH members in Nebraska.

*Results are based on combined PCMH and ACO value-based care arrangements in Nebraska for the period noted.

Accountable Care Organizations (ACOs)

BCBSNE is Nebraska’s leader in developing innovative programs designed to achieve the Triple Aim. We have a strong history of leading the way in promoting value-based care programs locally and collaborating with providers to implement programs that are beneficial to our members.

BCBSNE invests in value-based programs to support practices in making fundamental changes to their care delivery. These changes are needed to provide high quality, patient-focused, whole-person care, which will result in lower total cost of care.

ACO Highlights:

  • Nearly 300,000 attributed members
  • Nearly 2,600 participating providers in more than 425 clinic locations
  • Pay a base per attributed member per month (PaMPM) for care coordination
  • Bonus is achieved by meeting quality targets

BCBSNE’s nine ACOs in Nebraska

  • BluePrint
  • Bryan Health Connect
  • CHI Health Partners
  • Great Plains
  • NHN
  • OneHealth
Results of the 2017-2018 ACO Program Year
Inpatient admissions 3% lower than expected*
ER Utilization 6% lower than expected*
$48 PaMPM total cost of care below expected compared to non-participating ACO members in Nebraska.

*Results are based on combined PCMH and ACO value-based care arrangements in Nebraska for the period noted.

National Value Based Care Initiatives

Blue Distinction® Total Care

In addition to BCBSNE’s local value-based PCMH and ACO contracting arrangements, Blue Cross Blue Shield Plans nationwide have also partnered with hospitals, doctors and nurses on prevention, wellness, disease management and coordinated care programs – all with the goal of better health outcomes to Blue members. Collectively, the Blues’ value-based care programs result in fewer unnecessary emergency room visits, hospital admissions and readmissions, which help save everyone money.

Also known as BlueDistinction Total Care (BDTC), our national value-based care program currently integrates more than 156,000 select ACO and PCMH providers from BCBS Plans across the country (including Nebraska). The BDTC program provides a distinctively local and tailored approach to address the unique needs of each local market – creating a comprehensive national solution for multi-state employers with members who can become attributed to national BDTC value-based providers.

Blue Distinction Total Care
Marked Improvements
  • Lower utilization
    Avoidable hospital admissions, ER visits
  • Better prevention and control of chronic conditions
    Diabetes, asthma, heart disease
  • Increased savings
    $6.71 PaMPM, year over year national aggregate, compared to non-BDTC

1 BCBS 2017 value-based program RFI – Topline National Stats, November 2017.
2 BCBS Provider Data Repository, August 2017.
All other figures, BDTC Evaluation 3.0 - National Aggregate Results, January 2018; Total Care providers compared to non-Total Care providers.

Total Cost of Care Approach

Total Cost of Care (TCC) is a standardized approach to measure the cost of medical care, including inpatient, outpatient, professional, pharmacy and ancillary services. In a TCC model, physicians are rewarded financially if they perform better than projected on patient outcomes, experience and cost, and they share in the financial risk when their patients’ results are less favorable than expected. TCC physicians are supplied with the data and financial resources they need to effectively manage their patients’ care, while helping them understand the costs associated with that care.

BCBSNE works with physicians in the TCC model to provide in-depth and comprehensive data about their patients, including emergency room visits, medications and services received from other providers so that the TCC provider can get a complete picture of their patient’s care. BCBSNE believes the primary care physician plays a critical role in a patient’s health care, and this model is designed to support the physician in efficiently delivering and directing high value health care.

Delivery of quality care is a key component of the TCC model. The TCC model is NOT about restricting care, it’s about delivering quality care in the most efficient and effective way at the right time. Metrics are collected and shared with the physicians in several key areas, such as:

  • How well the physicians educate, immunize and screen their patients to prevent disease
  • How well the physicians minimize the occurrence of potentially preventable hospitalizations and emergency room visits
  • How well the physicians manage the health care needs of members who suffer from chronic conditions
  • How well the physicians manage the use of generic drugs, the use of high value services and avoidance of unnecessary tests for their patients