Question 1 for Chapter 1:

Transcription

1 Taylor C. Veillon Blue Cross and Blue Shield Question 1 for Chapter 1: The Blue Cross and Blue Shield Association (BCBS) is a national federation of 37 independent and locally operated companies, offering a local, need-based approach to healthcare. The association s networks and systems operate together, but independent branches pursue their own information system development as well. An important consideration to keep in mind is the focus on having applicable information at the point of service versus point of sale since the independent bases are service-oriented. For example, the Arkansas Blue Cross and Blue Shield recognized the need for an integrated claims processing, communication transaction, and health care delivery system. To fill the need, the Advanced Health Information Network (AHIN) was created. AHIN enabled hospitals to be connected to their physicians, physicians to be connected to other facility physicians, and physicians to be connected to employers and payers. AHIN works by linking Arkansas BCBS information systems, providing access to eligibility information, remittance advices, claims, claim status, detail reporting capabilities, and fee schedules all at the same time. The functionality includes real-time correction of incorrect claims and electronic claims submission. By using internet-based technology, all programs necessary to access AHIN are present on most personal computers so no purchase or installation of software is needed. With constantly changing regulatory compliance requirements, BCBS affiliates strive for a compliance program designed to build higher brand loyalty, overcome crises, and lower the incidence and impact of risks. MetricStream, a compliance solution provider, was selected to facilitate these system needs. Its capabilities include audit management, regulatory alert tracking, issue management, and policy management. For its audit management needs, the MetricStream solution enables affiliates to be able to ensure compliance with both healthcare regulations and cross-industry mandates such as the Sarbanes-Oxley Act (SOX). The reporting capabilities such as aggregating control assessments and compliance data into reports result in BCBS affiliates that can track compliance patterns, analyze trends, and concentrate their efforts in the areas that need the most attention. In terms of regulatory alert tracking, the software integrates regulatory sources such as the Center for Medicare & Medicaid Services (CMS) and the Health Plan Management System and displays requirement information, national governance, and industry guidance on a central platform. This centralized source of information helps affiliates track updates through the web, , and RSS feeds as well as keeps stakeholders informed of issues to more quickly initiate action plans. The MetricStream policy and procedure management system allows BCBS branches flexibility in creating policies and procedures which has helped them encourage communication and accountability within their compliance teams. Integrated workflow tools are used to access, create, review, and modify documents between branches. The software allows integration of policies with the risk and control framework. For issue management, the MetricStream solution assigns a unique ID to each issue yielding easy tracking through resolution stages. At every stage, company managers can utilize executive dashboards to monitor progress. Because of the need for timely precision in the accreditation process, MetricStream provides BCBS a repository for documentation such as operating procedures and case records. Interfaces with the National Committee for Quality Assurance s Interactive Survey System are provided to facilitate submission of necessary documents to accreditation organizations yielding higher quality metrics for Blue Cross Blue Shield as a whole. Also, self-assessments are triggered to review compliance documentation and audit-readiness, serving as internal selfchecking tools. Blue Cross and Blue Shield of Louisiana teamed up with CareFusion MedMined 1

2 Services with the goal to reduce infection rates in hospitals by using state-of-the-art data mining techniques specifically designed for the task at hand. MedMined provides software that can review billions of patterns of hospital/patient interactions to identify causes of infections, develop preventative measures, and avoid deviation from decided upon best practices. Blue Health Intelligence (BHI) leverages Blue data, the healthcare experience of more than 110 million individuals across the nation, with the goal to improve the delivery of care. BHI uses advanced analytics and applied research studies to reduce medical costs, increase efficiency of operations, support engagement with members, and improve network management. Blue Distinction is a suite of network solutions aimed at designing benefits more tailored to each employer s needs. The suite includes Blue Distinction Specialty Care and Blue Distinction Total Care programs. The specialty care program distinguishes hospitals for their expert and efficient delivery of specialty care. The total care program is directed toward medical homes and accountable care organizations for value-based care. Finally, the latest program launched by Blue Cross and Blue Shield s Louisiana-based affiliate is Quality Blue Value Partnerships. It recognizes the shift from traditional fee-for-service models to value-based and cost effective care. The primary goal of the Quality Blue family of programs is to improve patient health outcomes and keep members costs in line. With this partnership program, BCBS of Louisiana can offer doctors and clinics previously unavailable analytic and data resources. Quality Blue Primary Care, a program in the Quality Blue family, benefits patients with chronic conditions by allowing doctors to share information efficiently and to identify gaps in care provided. With the addition of the partnerships program, larger provider systems can now expand beyond primary care to examine patient experiences within their entire system. To provide the analytical and technical support needed for the program, Blue Cross is paying for access to the online TREO Solutions dashboard for each of its enrolled systems. TREO is allowing administrators to review claims data to identify better uses for resources, conduct better outreach activities, and change practice patterns. Due to the nature of the Blue Cross and Blue Shield Association and its affiliates all operating as separate entities that share some business characteristics but differ in others, the digital nervous system of BCBS, shown in Figure 2, is an idealized version that treats each software and operating program as if they were being used by the same company. AHIN and MetricStream s software solutions serve as part of the technology networks system because AHIN allows important parties to communicate with each other, employers, physicians, and hospitals and is important in processing and tracking transactions at the point of service. MetricStream s intended use is to most effectively provide information to government and regulatory entities on the company s behalf. For the social network systems, AHIN is once again important due to the connection it provides between key players because the integrated information system allows each party to improve business practices by collaborating with the others. Blue Health Intelligence is also a part of the social network operating within BCBS affiliates because its mission is to capture the knowledge that can be found within the 110 million health care experiences and using analytics and applied research efforts to continuously improve services and care. The most prevalent program in the Blue Cross value networks system is the Blue Distinction Program which is broken down into specialty care and total care. The intended result of the program is to use knowledge collected to better design benefit programs for each employer s specific needs. Finally, for the responsive network, the efforts of Blue Cross to team up with MedMined Services to reduce the rising trend in healthcare-associated infections 2

3 as well as its Quality Blue programs which focus on patient health outcomes further demonstrate their focused attention on the health of their members. To relate the architecture displayed in Figure 2 back to Bill Gates original design, shown in Figure 1, for the digital nervous system one must consider the ultimate purpose and end result of each of the four systems : technology networks, social networks, value networks, and responsive networks. For technology, both AHIN and MetricStream s BCBS specific solutions empower parties to devise ways to improve care and yield collaboration to succeed in achieving improved practices. With BCBS s social networks system, AHIN and Blue Health Intelligence practices use repositories of data and industry knowledge to discover more efficient ways of operating. In Blue Cross s value networks system, the Blue Distinction Program aims to most effectively manage knowledge to better serve employers. To respond to identified needs, Blue Cross affiliates deployed high value projects such as a partnership with MedMined to reduce rising infection rates and Quality Blue Programs to refocus attention on patient health outcomes. The projects remind BCBS associates of the importance of their work and cycle back to empower them to continue striving for better business practices and enhanced healthcare delivery. High Business Value Projects Deployment Knowledge Management Business Intelligence/ Data Warehousing Empowerment & Collaboration Figure 1: Adaptation of Bill Gates Digital Nervous System Model 3

4 Responsive Networks MedMined Services & BCBS Louisiana Partnership - 29,000 patients contracted healthcare-associated infections in LA in Partnership intended to resolve trend Quality Blue Value Partnerships - Shift from traditional fee-for-service model - Improving patient health outcome/reducing costs Value Networks Blue Distinction - Network solutions to design benefits tailored to an employer s specific needs Specialty Care Total Care Social Networks Hospitals AHIN -Helps to improve business functions at each level through integrated information system Physicians Employers Blue Health Intelligence - Leveraging health care expertise to improve delivery of care Technology Networks Automated Health Information Network Point of Service System MetricStream Solutions Regulatory/Govt. Entities Figure 2: The Idealized Digital Nervous System of Blue Cross and Blue Shield. 4

5 The information systems, software, and various programs are well integrated and yield beneficial relationships between BCBS affiliates, consumers (hospitals, physicians, members, employers), and government and regulatory entities. AHIN yields connections between BCBS and its consumers as well as connections between the consumers themselves. The day-to-day transactional data and the nature of the healthcare industry result in BCBS needing support to ensure compliance with healthcare and organizational regulations. MetricStream fills that need. Beyond business as usual, BCBS and its consumers are constantly striving for ways to achieve greater efficiency of operations and provide better care. Between BCBS and its physician, hospital, and employer consumers, the use of Blue Health Intelligence, Blue Distinction, and Quality Blue Value Partnerships result in analytics and data-based improvements in operations. Finally, for Blue Cross and its members, partnerships like the one with MedMined services result in better care. At all levels, operations, compliance, and value, Blue Cross information systems and software yield effective connections between the association and its external environment. Blue Cross and Blue Shield has 37 affiliates nationwide that are considered separate companies by most accreditation entities. Therefore, each branch is ranked on its own individual performance. The Utilization Review Accreditation Commission (URAC) holds a Quality Summit Best Practice Awards Program each year, excluding Health plan finalists in the 2013 Best Practices Awards Competition included Aetna, EmblemHealth, Family Health Network, Anthem Blue Cross, and BlueCross BlueShield of Illinois. The International Risk Management Institute published an article about the insurance industry s best practices for benefits integration. With benefits integration, the intended result is reduced cost and increased productivity. The best practices include regular review of system infrastructure capabilities and assurance that employees and vendors are well informed about program policies. The presence of an internal advisory team to manage the integrated program and monitor vendors is advantageous, and enforcement of accountability among internal stakeholders can help minimize mistakes. Another best practice is the effective use of technology with flexibility of design to adapt to each company s specific needs. Blue Cross and Blue Shield companies strive to optimize use of the best practices. To achieve a higher quality of service and greater efficiency, Blue Cross has outlined their own findings and goals regarding best practices in the health care industry. First, they aim to improve care delivery by rewarding doctors who keep patients with chronic conditions well and by focusing on highly customized and coordinated care delivery models such as Patient-Centered Medical Homes and Accountable Care Organizations. Second, BCBS strives to empower consumers with online and mobile applications such as GeoBlue and the Blue National Doctor and Hospital Finder. Blue Cross affiliates also strive to offer higher value services. An example would be the Blue Distinction initiative which identifies excellent specialty care facilities and physicians to help consumers build networks specific to their needs. 5

6 Question 2 for Chapter 2: The Systems Development Environment Blue Cross and Blue Shield affiliates use off the shelf software on a frequent basis, but each independent branch can choose their own provider. A previously unmentioned example is BCBS Florida s use of HP IT Performance Suite software solutions to address two particular challenges with management: responding to issues proactively, versus reactively, and bridging infrastructure silos. These concerns required a business service framework, so they selected HP s Business Service Management (BSM) software which coordinates data and needed applications and then displays the information in operational view. Main considerations when selecting their off-the-shelf software included agility and operations visibility in real-time. A senior manager for Systems Management stated that the company s C-level executives rely on the IT department to enhance value and adjust rapidly for new initiatives. The Florida branch has standardized their use of the HP suite to integrate all aspects of their IT needs. The HP BSM solution was well received in part because of its Run-Time Service Model which integrates existing monitoring tools to display near real-time updates on infrastructure components. Blue Cross affiliates do use integrated enterprise resource planning software. The first example is the relatively widespread use of MetricStream, a compliance solutions software. MetricStream integrated its applications with the PeopleSoft ERP system to extract and synchronize organizational data of the BCBS branches for conflict of interest surveys and related activities. The partnership yielded expandable document storage, secure system access, customizable questionnaires, and query and reporting capabilities. Questionnaires are ed to associates with direct links, a library is maintained, and the software can attach and store related records and retain and archive survey data. BCBS chose MetricStream because it has extensive experience implementing a large variety of governance, risk management, and compliance (GRC) solutions for various large health insurance companies. It also is more user-friendly, secure, and scalable across an enterprise. In another example, ERP software was used by BCBS Nebraska. Due to an enlarged customer base and an increased volume of transactions, the Nebraska affiliate acquired an ERP solution, Microsoft Dynamics GP, and decided to convert it into an enterprise billing system, using integration software known as SmartConnect. Today, Blue Cross and Blue Shield primarily outsource business process support needs, specifically call centers and claims processing. For example, BCBS Michigan outsourced a portion of its customer service calls to Global Response. The North Carolina branch outsourced some of its simpler claims processing work to Accenture. In the past, however, BCBS branches did outsource some of their technological and software requirements. For example, Blue Shield of California contracted out to TriZetto Group, Inc. in order to launch a system-wide technology upgrade. TriZetto used software systems such as Facets, Workflow, extended Integration, ITS interface software, and application management services to improve data systems, claims processing, customer service, and new product development. The multi-year endeavor was a complete overhaul of the technology infrastructure. Blue Cross and Blue Shield has 37 affiliates nationwide that are considered separate companies by most accreditation entities. Therefore, each branch is ranked on its own individual performance. URAC, an accreditation organization, holds a Quality Summit Best Practice Awards Program each year, excluding Health plan finalists in the 2013 Best Practices Awards Competition included Aetna, EmblemHealth, Family Health Network, Anthem Blue Cross, and BlueCross BlueShield of Illinois. PricewaterhouseCoopers (PwC) provides industryfocused consulting and conducts case studies regarding healthcare best practices. Examples include the alignment of incentives between providers and payers to yield better value, utilization 6

7 of digital technologies for electronic medical records, and implementation of personal mobile healthcare technologies to provide new information on delivery of services, clinical outcomes, and patient preferences. The move from a population-based to a precision-based industry is recognized in healthcare as more and more providers facilitate personalized medicine, reducing costs and improving quality. Blue Cross and Blue Shield companies optimize the use of information technology to achieve best practices for their industry. Aligning with PwC s findings of best practices, BCBS exploits the growing popularity of mobile healthcare with its applications such as GeoBlue and Blue National Doctor and Hospital Finder. Another example of their commitment to best practices is the Blue Distinction program which identifies excellent care facilities for members, benefitting members with better healthcare networks and benefitting healthcare providers by showcasing their expertise. Blue Cross and Blue Shield affiliates should continue to develop their technological connection to both physicians and members. With easy-to-use websites and mobile applications, BCBS would likely see an increase in consumer awareness and satisfaction. 7

8 Works Cited "Advanced Health Information Network." AHIN - Arkansas Blue Cross and Blue Shield. Arkansas Blue Cross and Blue Shield, n.d. Web. 6 Sept "Blue Cross Blue Shield Affiliates Adopt an Integrated Approach to Intensify Overall Compliance, Risk and Audit Management." MetricStream. MetricStream, Inc., n.d. Web. 6 Sept "Blue Cross and Blue Shield of Louisiana Launches Quality Blue Value Partnerships to Engage More Providers." Media Center. BlueCross BlueShield of Louisiana, 22 July Web. 4 Sept "Blue Cross and Blue Shield of Louisiana Strongly Supports Federal Efforts to Reduce Harmful Medical Errors." BlueCross BlueShield of Louisiana. BlueCross BlueShield of Louisiana, n.d. Web. 4 Sept "Blue Cross Blue Shield of NB: SmartConnect Turns GP into an Enterprise Billing System." EOne Solutions. EOne Solutions, n.d. Web. 7 Sept "Blue Facts: Healthcare Coverage Designed For Your Community, Accessible Across The Country." Blue Facts of the Blue Cross and Blue Shield Association and Blue System. BlueCross BlueShield Association, n.d. Web. 7 Sept "Blue Shield of California Launches Work on System-Wide Technology Upgrade with TriZetto's Facets Software." Blue Shield of California. Blue Shield of California, 29 Jan Web. 5 Sept Carruthers, Marcia. "Industry Best Practices in Benefits Integration." IRMI: Risk & Insurance. International Risk Management Institute, Inc., May Web. 6 Sept

9 "Global Healthcare Case Studies and Best Practices." PwC. PricewaterhouseCoopers, n.d. Web. 4 Sept Lichtenstein, Marc. "Best Practices for Transforming Healthcare." BlueCross BlueShield Blog. Blue Cross and Blue Shield Association, n.d. Web. 5 Sept Salient Federal Solutions' Sujey Edward to Speak at IBM Innovate 2014 on Agile Techniques Leveraging Existing Off-the-Shelf Software." The Business Journals. American City Business Journals, 2 June Web. 4 Sept "URAC Announces Finalists for Health Plan Best Practices Awards." URAC. Utilization Review Accreditation Commission, 1 Aug Web. 4 Sept Visibility into Business Operations IT Case Study Blue Cross and Blue Shield of Florida HP (n.d.): n. pag. HP. Hewlett-Packard Development Company, L.P., July Web. 6 Sept