Specialty Care Insight

More than ever before, customers are struggling to deal with the soaring costs of healthcare and their personal out-of-pocket medical costs. As such, they are asking for credible information on the cost and quality of healthcare services across Louisiana.

And while many people believe that “more care is better care” and that more expensive care is higher-quality care, we know the opposite is true. Those doctors and practices that produce the best outcomes tend to do so at lower costs.

To address this, Blue Cross is collaborating closely with the providers in our network to drive high-quality healthcare while lowering overall costs.

Blue Cross has access to large amounts of data through our claims, which we are now able to analyze with sophisticated tools to give providers deep insights on the efficiency and effectiveness of care at both a medical condition and full-care episode level.

• The efficiency, or cost, of care is determined not simply by the price and volume of professional services, but also by the cost of diagnostic testing, prescribed medications and facility charges incurred in the management of specific conditions.
• The effectiveness, or quality, of care can be determined by using evidence-based, specialty-specific quality measures and expert consensus on appropriateness.

We have partnered with Cave Consulting Group, Inc. (CCGroup) to share this information with our network providers in certain specialties through our new Specialty Care Insight reports. CCGroup, Inc. is an independent company that provides analytical tools for Blue Cross and Blue Shield of Louisiana and its subsidiaries.

CCGroup has developed an analytics tool that can generate practice-level reports on several important attributes that may help a practice identify overuse of low-value, high-cost services, and reduce these instances to drive use of high-value, cost-effective services. The analytics also help identify underuse of potentially beneficial, high-value services so that practices may review their patterns of care delivery.

SCI Target Specialties
Blue Cross will engage at least four specialties in this program in 2014. The first two specialties that will receive Specialty Care Insight Reports are cardiology and orthopedic groups in the Blue Cross network.

Later in 2014, Blue Cross will select additional specialty groups to include, likely choosing from among gastroenterology, ear/nose/throat, obstetrics/gynecology, urology and/or neurosurgery/spine surgeons. After the initial year, more specialty types may be included.

Blue Cross will conduct training to help the participating specialty groups understand the reports. Live webinars will be offered for eligible providers in each region and specialty selected, to explain the need to create this program, and how providers can glean actionable data from their reports.

Each practice’s Specialty Care Insight Report will:

• Organize medical conditions commonly treated in that specialty, called “market basket” episodes, into Severity of Illness (SOI) categories to profile both quality effectiveness and cost efficiency. The market basket contains only episodes that are commonly treated and represents standard practice for that specialty, with the more complex, outlier cases eliminated from the analytics.
• Provide data that indicates over-utilization of high-cost, low-value diagnostics and/or therapeutics that tend to drive higher costs.
• Indicate quality measures appropriate for the specialty’s market basket episodes that can prevent under-utilization of essential services.

Please see the How to Read Your Specialty Care Insight Report guide for more information.

Practices are strongly advised to view the SCI program videos to gain a better understanding of their reports.

The report’s data is unique in our market, in that the targeted specialties can see their impact relative to their peers across the entire care spectrum for medical conditions most commonly treated by that specialty.

• Cardiology
• Effectiveness Measures Definitions
• Gastroenterology
• General Surgery
• Obstetrics and Gynecology
• Orthopedics
• Otolaryngology
• Specialty Care Insight Regional WebEx
• Urology

Blue Cross intends to meet with the Louisiana professional chapters/societies and groups for participating network physicians in the specialties selected to get their feedback about what are included as market basket episodes and measures for that specialty, and the usefulness of the cost and utilization data the reports provide.

If a medical condition or quality measure is added, altered or deleted based on these discussions, the reports will be modified.

The Specialty Care Insight program held live webinars with providers to describe the program in further detail, discuss how providers can read their Specialty Care Insight reports and use the data included, and address any questions from providers.