October 2018

Innovation Through Teamwork: Value Based Care Programs at BCBSIL

Value based care programs are continuing to emerge and evolve nationally, with an emphasis on shifting from a band-aid approach (treating sickness and symptoms) to a big picture strategy (managing overall health of patient populations). Also known as patient-centered care, value based care “is a healthcare delivery model in which providers, including hospitals and physicians, are paid based on patient health outcomes. Under value based care agreements, providers are rewarded for helping patients improve their health, reduce the effect and incidence of chronic disease, and live healthier lives in an evidence-based way.”¹

In 2015, the Blue Cross and Blue Shield Association launched Blue Distinction Total Care (BDTC). Through BDTC, Blue Cross and Blue Shield companies may bring effective, locally-developed, patient-centered care programs to a national level to better serve national employers and their employees. More than 42 million Blue Cross and Blue Shield members are currently accessing care through these innovative care programs. See below for an overview of value based care programs in place at Blue Cross and Blue Shield of Illinois (BCBSIL).

Accountable Care Organization (ACO)
An ACO is a group of hospital-based or physician group-based health care providers that agree to deliver coordinated care and meet performance benchmarks for quality and affordability to help manage the total cost of care for their patient (member) populations. The ACO model works with health care providers by coordinating care to help ensure that patients – especially those with chronic illnesses – have access to the right care, in the right place and at the right time while avoiding unnecessary hospital admissions, readmissions, emergency room (ER) visits and duplication of services.

BCBSIL is a leader in helping bring commercial ACOs to the market. Currently, we have 24 ACOs, including the first endocrinology ACO in the country, as well as the first pediatric, academic and urgent care ACOs in the state. Our ACO partnerships include 101 hospitals and 4,804 primary care physicians (PCPs), with more than 1.2 million attributed members across all 24 ACOs.

Intensive Medical Home (IMH)
For members with chronic or complex conditions, their specialist functions as their primary care provider. The IMH is designed to deliver hands-on clinical support to high-risk members with chronic or complex conditions. A dedicated nurse care manager, employed by the physician practice, coordinates the member’s care. Each patient is monitored closely and interventions are arranged if needed.

BCBSIL’s first specialty IMH was launched in 2014 with the Illinois Gastroenterology Group (IGG) specializing in conditions of the digestive system. Since then, four additional gastroenterology IMHs have launched with University of Chicago, Rockford Gastroenterology Associates, Illinois Gastroenterology Institute – Peoria (IGI) and Digestive Disease Consultants. In 2015, the first oncology IMH was launched with Illinois Cancer Specialists. In partnership with the University of Chicago Medicine, BCBSIL announced the launch of an additional oncology IMH program in April 2016.

Episodes of Care (EOC)
This model compensates providers based on a negotiated target amount (a variation of a bundled payment) for all services related to a specific episode of care. An episode of care includes the entire set of services surrounding a clinical condition over a pre-defined period. Episodes are identified by BCBSIL once claims are received by BCBSIL; there is nothing additional providers need to do when submitting claims.

This model encourages communication among physicians, specialists and hospitals throughout each episode of care to help maximize efficiencies and eliminate unnecessary care. In addition to peer-to-peer dialogue, provider-patient communication is key to help ensure patients are informed, engaged and committed to participating actively in their own health and wellness along the road to recovery.

Our orthopedic EOC program focused originally on full hip and knee replacements for commercial members. Orthopedic medical groups or health systems already participating in other value based care programs are eligible to participate in episodes of care programs. Our first EOC partnership this year is with Illinois Bone and Joint Institute.

Watch upcoming issues of the Blue Review for additional articles related to value based care programs and initiatives at BCBSIL.

¹ NEJM Catalyst. What is value based healthcare? January 2017. Accessed July 23, 2018, at https://catalyst.nejm.org/what-is-value based-healthcare/

The above material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider. Physicians and other health care providers are encouraged to use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.