POINTS TO PONDER
Issue 02-11
From your Federation President
NARFE Members of California:
NEW BCBS PROGRAM: For your information, Blue Cross/Blue Shield is
starting a new program in California that will provide information from a variety of sources
on BCBS enrollees to their physicians when there appears to be adverse or at-risk
circumstances for enrollees.
In such cases, only the enrollee's doctors will be contacted. No enrollees will be
contacted by BCBS or its agent.
This is a quality health improvement plan that has been encouraged by OPM to
improve health care for FEHBP enrollees and help keep costs down.
The following is the "Patient Highlight Program" as presented by Blue Shield of
California. Any questions or clarifications on the following would have to be directed to
your BSC agent.
BLUE SHIELD OF CALIFORNIA (BSC) - PATIENT HIGHLIGHT PROGRAM
Statement of Purpose:
The BSC Patient Highlight Program uses claims and encounter data from BSC systems
to create tools that assist physicians with managing member care. On an ongoing basis,
BSC member data is analyzed and compared to well-accepted clinical guidelines.
Discrepancies between the care each health plan member is receiving and generally
accepted clinical practice guidelines are communicated to the physician with a Patient
Highlight message.
This project was identified as a strategic priority by the BSC executive team in 2001.
This project supports the BSC Mission and Objectives through focus on Quality of Service
and Quality of Care. In addition to compliance with well-accepted clinical practice guidelines,
the Patient Highlight Program seek to:
1. Deliver improved patient safety, and improved HEDIS rates (for BSC HMO products).
2. Reduce errors of omission and avoidance of costs associated with avoidable adverse
clinical events.
3. Provide a population wide, yet patient-specific approach to improving clinical practice
guideline compliance.
4. Allow an efficient, routine method to communicate with 50,000 physicians that care
for 2 million members.
5. Measurable results.
6. A cost-effective mechanism for communication, potential to utilize a secure web-based
application.
7. Evaluates the program effectiveness with a randomized control trial (RCT) designed
by UC Berkeley.
Resolution Health, Inc.
Resolution Health, Inc. (RHI) provides the technical expertise and the infrastructure to
perform adequate safety checks that would give an accurate depiction of a clinical review
process. RHI identifies potential opportunities to reduce safety issues while generating
meaningful performance reports. RHI integrates data from various data streams (i.e., claims,
pharmacy and labs), to provide a more complete picture of the member's medical history.
RHI analyzes all available claims data against a set of sophisticated clinical algorithms
that will help identify members who are potentially at-risk for an adverse outcome. The
identification of a patient at-risk can be triggered by a variety of data sources that include
diagnosis, procedures, symptoms, current therapies and/or possible drug interaction. In turn,
the treating physician will be contacted with specific member information outlining a course
of action to remedy the potential risk.
Till Next Time ....
Lea D. Zajac, Your California Federation President
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