Dr. Mark Friedberg,<\/a> Senior Vice President of Performance Measurement and Improvement at BCBSMA, the organization’s success stems from its focus on working closely with provider partners to enhance care quality and ensure access to top-tier healthcare services.<\/p>\r\n\r\n\r\n\r\n“Being a 4.5-star plan for many years is a great accomplishment, but achieving five stars for our PPO plan is a first,” Dr. Friedberg said. “This recognition is the result of a concerted effort by hundreds of individuals across the organization who have worked tirelessly to improve the quality of care we deliver.”<\/p>\r\n\r\n\r\n\r\n
The Alternative Quality Contract (AQC)<\/h2>\r\n\r\n\r\n\r\n
One of the key drivers behind BCBSMA’s high ratings is its innovative Alternative Quality Contract (AQC), launched in 2009. The AQC was designed to incentivize high-quality care while managing overall medical expenses. This initiative laid the groundwork for the development of Accountable Care Organizations (ACOs) before the Affordable Care Act was implemented.<\/p>\r\n\r\n\r\n\r\n
The AQC emphasizes the importance of both clinical quality and patient experience. By integrating quality measures into its incentive structure, BCBSMA encourages its provider partners to focus on delivering affordable, evidence-based care that meets the evolving needs of members. The AQC has continually been updated to adapt to changes in healthcare, most recently incorporating an equity component.<\/p>\r\n\r\n\r\n\r\n
The Role of Equity in Healthcare<\/h2>\r\n\r\n\r\n\r\n
BCBS Massachusetts became the first health plan in the nation to include equity measures in its ACO-type payment model. This significant enhancement reflects the organization’s commitment to addressing disparities in healthcare and promoting equitable access to quality care for all members. By prioritizing equity, BCBSMA sets a new standard for healthcare organizations nationwide.<\/p>\r\n\r\n\r\n\r\n
“Our goal is to ensure that every member receives the same high-quality care, regardless of their background or circumstances,” Dr. Friedberg explained. “Incorporating equity into our payment model is a critical step toward achieving this goal.”<\/p>\r\n\r\n\r\n\r\n
Overcoming Pandemic Challenges<\/h2>\r\n\r\n\r\n\r\n
The COVID-19 pandemic presented unique challenges for healthcare providers and insurers, and Massachusetts was no exception. Many medical services were delayed or postponed due to shutdowns, creating a backlog of necessary care, such as routine screenings and preventive services.<\/p>\r\n\r\n\r\n\r\n
To address this issue, BCBSMA worked closely with its provider network to offer alternative screening options. For example, rather than waiting for delayed colonoscopies, members were offered other methods, such as fecal immunochemical testing and Cologuard. This ensured that members continued to receive timely, evidence-based care despite the pandemic-related disruptions.<\/p>\r\n\r\n\r\n\r\n
“The pandemic has forced us to think creatively about how we deliver care,” Dr. Friedberg said. “We’ve had to find new ways to ensure our members receive the care they need, even in the face of unprecedented challenges.”<\/p>\r\n\r\n\r\n\r\n
Data-Driven Quality Management<\/h2>\r\n\r\n\r\n\r\n
A critical element of BCBSMA’s success in maintaining high-quality care is its rigorous data submission efforts to the NCQA. The organization focuses on two primary areas: technical quality measures and member experience surveys.<\/p>\r\n\r\n\r\n\r\n
Technical Quality Measures<\/h3>\r\n\r\n\r\n\r\n
Technical quality measures involve monitoring the quality of preventive care and chronic disease management. For example, BCBSMA tracks preventive services like mammograms for breast cancer screening and monitors chronic conditions such as hypertension. This data is collected from billing claims and clinical data exchanges with provider partners and submitted to the NCQA for annual audits.<\/p>\r\n\r\n\r\n\r\n
Member Experience Surveys<\/h3>\r\n\r\n\r\n\r\n
Member experience surveys are another essential component of BCBSMA’s quality management program. The Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey, administered by an NCQA-authorized vendor, evaluates various aspects of the member experience, such as access to care, communication with providers, and overall satisfaction.<\/p>\r\n\r\n\r\n\r\n
Payers, including BCBSMA, receive aggregated scores based on the survey results, which helps them identify areas for improvement while maintaining the confidentiality of individual member responses.<\/p>\r\n\r\n\r\n\r\n
Maintaining High Standards<\/h2>\r\n\r\n\r\n\r\n
BCBSMA’s success in achieving and maintaining its five-star rating is the result of a robust internal quality management program and strong relationships with its provider partners. By fostering a culture of collaboration and continuous improvement, BCBSMA ensures that its members receive the highest quality care possible.<\/p>\r\n\r\n\r\n\r\n
“Ultimately, high-quality care requires a dedicated team, strong provider relationships, and a commitment to supporting our members,” Dr. Friedberg said. “It’s about more than just meeting metrics\u2014it’s about delivering care that truly makes a difference in our members’ lives.”<\/p>\r\n\r\n\r\n\r\n
Conclusion<\/h2>\r\n\r\n\r\n\r\n
Blue Cross Blue Shield of Massachusetts has set a new standard for healthcare plans with its five-star rating from the NCQA. Through innovative programs like the Alternative Quality Contract and a focus on equity, BCBSMA continues to lead the way in providing high-quality, affordable healthcare to its members. By embracing data-driven quality management and overcoming challenges posed by the pandemic, BCBSMA demonstrates its unwavering commitment to delivering exceptional care.<\/p>\r\n\r\n\r\n\r\n
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