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2021 BCBSILQUALITY IMPROVEMENTPROGRAM EVALUATIONHealth Care Service CorporationPROPRIETARY & CONFIDENTIALDate approved:BCBSIL Quality Improvement Committee04/06/2022Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association
2021 BCBSIL QI Program Evaluation2021 BCBSIL QI PROGRAM EVALUATIONEvaluation and Overall Effectiveness .4Executive Summary . 4Challenges and Accomplishments . 4BCBSIL Quality Core Measures . 4Summary of 2021 Health Equity Initiatives . 5Evaluation of 2021 Work Plan. 7Adequacy of QI Program Resources . 7QI Committee Structure . 7Leadership Involvement and Practitioner Participation. 8Quality Improvement Resources.8Quality and Safety of Clinical Care .9Accreditation Matrix . 10Quality Improvement Projects . 10Improving Timeliness of Notification of Denial Determinations . 10Clinician Outreach to Support Member Safety . 11Quality of Service .13HMO Service Project Initiatives . 13Wellness and Prevention .13Clinical Practice Guidelines . 13Member Messages. 14BCBSIL Quality Core Measures . 14Credentialing and Recredentialing .16Pharmacy .16Delegation Oversight .21Group and Retail HMO . 21Credentialing Delegation Oversight . 21Complaints and Appeals .22Retail Exchange Affected Markets (REAM), On and Off Complaints . 23Quality of Care Complaints/Adverse Events . 24Plan Access .24PCP and Behavioral Health Practitioner Site Visit Results . 24Behavioral Health Care Practitioners . 24Primary Care Physician . 25FHP/ICP/MLTSS/MMAI . 25Availability of Providers . 25HMO Member Survey . 25ConfidentialPage 2 of 33
2021 BCBSIL QI Program EvaluationCommercial Member Satisfaction/Continuous Tracking Program Results . 25HMO Asthma and Diabetes Condition Management Population Health Management Surveys . 27Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey . 272020 QHP Enrollee Experience Survey (PPO and HMO) and Commercial CAHPS (HMO) Member Summary 28HMO PCP Survey . 29HMO Contract Entity Survey . 31Continuity and Coordination of Care .31Continuity and Coordination of Medical Care . 31Continuity and Coordination of Care between PCP and Behavioral Health Practitioner. 32Continuity and Coordination of Care between PCP and Behavioral Health Practitioner- Group and/or Retail . 32Plan Acknowledgement and Approval .33Conclusion . 33ConfidentialPage 3 of 33
2021 BCBSIL QI Program EvaluationEvaluation and Overall EffectivenessExecutive SummaryAn evaluation of the Blue Cross and Blue Shield of Illinois (BCBSIL) 2021 Quality Improvement (QI) program hasbeen conducted. This evaluation included review of trended results for QI measures over time, comparisonagainst performance objectives, quantitative and qualitative analyses for completed and ongoing QI activities.Overall, improvements were achieved in planned QI initiatives, both clinical and service. In addition, programsthat address patient safety were implemented.The BCBSIL Quality Improvement Committee (QIC) and the Governance and Nominating Committee reviewedand approved the 2021 QI Program Description. The 2021 QI Work Plan was implemented in accordance with theplan. The indicators measured cover a broad spectrum, including quality of clinical care, quality of service andsafe clinical practices. The QI initiatives are relevant to the needs of the membership of the BCBSIL Commercialand Retail HMO and PPO products. Corporate structure and resources are adequate and supportive of the QIprocess.Challenges and AccomplishmentsThe COVID-19 pandemic stretched into its second year and continued to impact operations in 2021, but overallservices have stabilized and there is evidence of ongoing recovery. Key accomplishments are as follows: Year over year improvements in Healthcare Effectiveness Data and Information Set (HEDIS ) ratesacross product lines for BCBSIL. The subsequent results show Core Measures exceeding the QualityCompass National Average for Commercial HMO, 3 out of 24, Marketplace HMO, 3 out of 24, for PPOCommercial, 3 out of 24 and for PPO Marketplace, 6 out of 24.QI Best Practice provider educational tools addressing evidence-based methods to achieve highperformance were authorized and released to Network Providers. These tools align with HCSC’sCommon Measure Set including Breast, Cervical and Colorectal Cancer Screenings, Asthma,Immunizations, and Well Child Care Indicators.Design of the Collaborative Quality Improvement Coaching (CQuIC) program to provide coaching toproviders performing below average in terms of quality related performance in measures identified in theHMO Quality Fund. This collaborative effort replaces a prior intervention that was more contractual andpunitive in nature. The goal of this new program is to recognize that a punitive approach is insensitive tothe varied needs of different providers in our network. Based on their size, resources, and sophistication,a more tailored approach to working with low performing providers is better suited to respond to theirvaried circumstances.Enhancing our abilities to receive electronic health record (EHR) data from our providers. Through anarrangement with Epic, one of the largest EHR vendors, we have the ability for providers to share theirHER data directly with us. This capability will be further enhanced and more fully implemented into 2022and beyond. Furthermore, we have improved our ability to receive Supplemental Data for determinationof quality measures in HEDIS for both our HMO and ACO providers. This new collection channel shouldenhance our ability to do better quality and care gap reporting that are essential to effective qualityimprovement effortsBCBSIL Quality Core MeasuresThe BCBSIL Quality Core Measures are utilized to focus enterprise quality efforts across all five state plans.Reporting Year 2021 (MY 2020) Benchmarking to Quality CompassConfidentialPage 4 of 33
2021 BCBSIL QI Program Evaluation*Product not formally accredited. Hybrid measures not reported.** 2021 Quality Compass (Measurement Year 2020) All LOBs BenchmarkSummary of 2021 Health Equity InitiativesEquity of care has been established as a core component of the QI program at HCSC. As such, initiativesdesigned to address health equity are reported to the Quality Improvement Committee as requested.BCBSIL has taken the following actions to address health equity for its members:Health Equity Steering Committee 2021 Goals: To expand the enterprise-wide business imperative to addresshealth equity, the Health Equity Steering Committee revised and launched the strategic vision for 2021.These goalsfacilitated enterprise wide and health plan level multidisciplinary actions to implement strategies, programs and newservice delivery models. Due to the pandemic and numerous organizational staffing changes many of theworkstreams were paused in 2021. n 2021, the Eliminate Healthcare Disparities workstream continued to prioritizeimplementing strategies which identify, monitor, and eliminate health disparities (gender / racial / ethnic / language/ economic) through clinical and provider interventions. Provider Education: As aligned with the Health Equity Steering Committee’s Enhance Health CareWorkforce Workstream, BCBSIL continued to offer and require CME cultural competency and implicit biastrainings to our provider network via our IL ACO relationships with providers after previously offering thisservice in our HMO in 2019. In 2021, BCBSIL concluded a grant program offered in conjunction with theAmerican Hospital Association’s Equity Roadmap partnership program with 13 hospitals in Illinois. Thegrant program provided mentorship from the American Hospital Association to developing hospital capacityConfidentialPage 5 of 33
2021 BCBSIL QI Program Evaluationto evaluate healthcare disparities within their organization and implement interventions to reduce observeddisparities. The program also offered cultural competency and implicit bias training for providers. BCBSILlaunched a three-year Hospital Health Equity Quality Incentive Program in partnership with sevencommunity and academic hospital systems and the American College of Graduate Medical Education(ACGME) in 2021. The program encompasses both member and provider efforts to reduce healthcaredisparities. Member efforts include focused evaluation under the tutoring of the ACGME’s Equity Mattersprogram to identify healthcare disparities in their organization and make focused improvements to reducehealthcare disparities. Provider efforts focus on recruiting and retaining underrepresented minorities inmedicine throughout the training and practice spectrum, from medical students to residents to residents,fellows, and attendings across specialty disciplines to improve the representation of underrepresentedminorities in medicine practicing within Illinois. Pilot Programs with Blue Cross Blue Shield Association:RideQ (AT&T “Trek World” Transportation Pilot) launched Q.4 2019: HCSC, in coordination withthe Blue Cross Association and Ride Q, the program coordinates transportation for AT&T memberswho may not have reliable transportation to and from medical appointments. Trek World is a fullservice, digital platform specializing in transportation and delivery for senior citizens, persons withdisabilities, and others. Boeing: participated in the Ride Q (Trek World) pilot. Pilot results deemedthe transportation initiative a success. With success noted, Ride Q (Trek World) services werescaled to meet Boeing membership transportation needs. AT&T: ready to implement Ride Q (TrekWorld) for AT&TA. HCSC AT&T staff have completed Ride Q (Trek World) training. AT&T pushedimplementation to 2022 Q2. Sandi Skinner, HCSC Sales and Account Executive, working with ATTfor sign off and implementation timeframe. HEDIS Disparities Maps: In partnership with BCBSIL Data & Analytics team, a tableau tool was created tomap and analyze HEDIS compliance rates by gender, race and ethnicity. Analyzed measures include:o AAB: Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis;o BCS: Breast Cancer Screening;o COL: Colorectal Cancer Screening;o CDC-HbA1c: Comprehensive Diabetes Care - HbA1c testing;o CCS: Cervical Cancer Screening;o CIS (Com 3); Childhood Immunization Status;o MMA: Medication Management for People with Asthma (Looking at % of members who remainedon asthma controller medication for at least 75% of their treatment periodo W15 ( 6 visits); Well-Child Visits in the first 15 months of Life BCBSIL Physician Diversity and Health Equity summit launched in Q. 1 2019: In partnership withAssociation of American Medical Colleges, BCBSIL convened key academic medical school and hospitalleaders for a day-long conference focused on health equity, and the imperative to increase the number ofunderrepresented minority students in medicine and the physician workforce in IL. In 2020, the 2nd AnnualPhysician Diversity and Health Equity Summit was canceled due to COVID-19. In Q1 2021 the Institute forPhysician Diversity Roundtable is scheduled to reconvene, BCBSIL will lead a state-wide call to action toencourage innovations to diversify the physician workforce state-wide, including strategic partnerships withmedical schools in the state. HCSC Health Equity Summit: Completed in partnership with Blue University’s Development Weekprogram, “Achieving Health Equity: Moving from Awareness to Action” and concluded in Q.4 2020.TheAmerican Hospital Association’s Equity Roadmap Program is expected to launch in Q.1 2020: BCBSILseeks to continue in expanding the number of hospitals engaged in American Hospital Association’sEquity Roadmap Program. This program provides operational and strategic direction for hospitals toimplement health equity strategies, programs, and services to reduce racial and ethnic disparities. Centering Healthcare Institute’s CenteringPregnancy program launched in Q.1 2020: This programcontinued to implement a group prenatal care model in 30 HCSC-approved Federally QualifiedConfidentialPage 6 of 33
2021 BCBSIL QI Program EvaluationHealthcare and Indian Health Services sites throughout the enterprise, with at least 10 sites in IL(including rural facilities).Evaluation of 2021 Work PlanThe following is an assessment of progress made in meeting identified QI goals and an evaluation of the overalleffectiveness of the QI Program.HMO Group/CommercialOf the 78 indicators listed in the 2021 Work Plan with goals assigned:o 49 indicators met the goal 8 indicators partially met the goalo 17 indicators did not meet the goalHMO Marketplace/ExchangeOf the 69 indicators listed in the 2021 Work Plan with goals assigned:o 41 indicators met the goal 11 indicators partially met the goalo 13 indicators did not meet the goalPPO Group/CommercialOf the 45 indicators listed in the 2021 Work Plan with goals assigned:o 29 indicators met the goal 7 indicators partially met the goalo 4 indicators did not meet the goalPPO Marketplace/ExchangeOf the 49 indicators listed in the 2021 Work Plan with goals assigned:o 33 indicators met the goal 8 indicators partially met the goalo 7 indicators did not meet the goalAdequacy of QI Program ResourcesAs part of BCBSIL’s QI Program development, resource evaluation is ongoing throughout the year. In 2020,staffing resources were adequate for implementation of the BCBSIL QI Program. Staff included BCBSIL VicePresident and Chief Medical Officer (CMO), Medical Directors, Senior Director, Analytics Director, SeniorManagers and the clinical and analytic staff reporting to them.Additional HCSC staff performing QI functions include: BCBSIL Network Management, HCSC Behavioral Health,Credentialing, Delegation Oversight, Medical Management, Enterprise Health Care Management and EnterpriseQuality and Accreditation. These individuals supported physician credentialing, utilization management, casemanagement, condition management, delegation oversight, implementation of the behavioral health program andhealth plan accreditation.QI Committee StructureUltimate accountability for the management and improvement of the quality of clinical care and service providedto HCSC members rests with the Board of Directors of HCSC. The Governance and Nominating Committee of theBoard of Directors of HCSC is a committee of the HCSC Board responsible for assisting the Board in fulfilling itsoversight functions related to the QI Program for HCSC members. The Governance and Nominating Committeedelegates certain responsibilities for management and oversight of the QI Program to individual Plan QICs.The BCBSIL QIC is responsible for providing oversight and direction to the BCBSIL QI Program. The QIC ischaired by the Medical Director. The QIC brings multidivisional staff together with network providers including abehavioral healthcare practitioner.ConfidentialPage 7 of 33
2021 BCBSIL QI Program EvaluationThe BCBSIL QIC and the Enterprise Quality Improvement Oversight Committee of review and approve the annualBCBSIL QI Program Description. The BCBSIL QIC also reviews and approves the annual BCBSIL QI Work Planand the annual QI Program Evaluation.Leadership Involvement and Practitioner ParticipationBCBSIL physician leadership is responsible for the QI Program. A dedicated BCBSIL Medical Director providesdirection and oversight for the BCBSIL Clinical Quality Program and chairs the BCBSIL QIC. The BCBSIL QICmet 12 times virtually in 2021, included consistent medical and behavioral health practitioner representation andinvolvement at each meeting.The BCBSIL QIC thoughtfully reviewed and analyzed QI project results, identified needed actions, recommendedpolicy decisions and followed up on open issues. In addition to the QIC, BCBSIL sponsors several providerforums including the Value Based Care Medical Director Round Table, and Administrative Forums. Theseconferences and meetings offer an opportunity to review quality data, share best practices and collaborate acrossorganizations.Quality Improvement ResourcesHCSC has sufficient resources to meet the QI Program objectives, carry out the scope of activities to beconducted and complete annual and ongoing activities.Staffing and resources supporting the QI Program include but are not limited to: Blue Care Connection / Wellnesso Condition Management and Lifestyle Managemento Enterprise Wellness Programs Clinical Pharmacy Programs Credentialing (Network Operations & Solution Delivery) Communications (Marketing, Positioning and Targeted, and Public Affairs) Customer Service Delegation Oversight Programs Medical Directors HEDIS, Quality and Accreditation Program staff (including nurses and analytic staff) Reporting (EHCM Care Management Tools and Technology, EHCM Clinical Operations Performance,Systems and Reporting and Analytics and Information Management) Claims, Membership, Medical Management and other systems/platforms as needed Utilization Management/Case Management/Wellness Condition Management (Medical Management) Special Beginnings HCSC Behavioral Health Unit Market Research: Continuous Tracking Survey, Consumer Assessment of Healthcare Providers andSystems (CAHPS), and Qualified Health Plan Enrollee Experience Survey (EES) Network Management including but not limited to, Value Based Care Models, such as Intensive MedicalHome (IMH); and Accountable Care Organization (ACO))Quality Improvement CommitteeUltimate accountability for the management and improvement of the quality of clinical care and service providedto HCSC members rests with the Board of Directors of HCSC. The Governance and Nominating Committee of theBoard of Directors of HCSC is a committee of the HCSC Board responsible for assisting the Board in fulfilling itsoversight functions related to the QI Program for HCSC members. The Governance and Nominating Committeedelegates certain responsibilities for management and oversight of the QI Program to individual Plan QICs. TheBCBSIL QIC is responsible for providing oversight and direction to the BCBSIL QI Program. The QIC is chairedby a dedicated Medical Director. The QIC brings multidivisional staff together with network providers including abehavioral healthcare practitioner.ConfidentialPage 8 of 33
2021 BCBSIL QI Program EvaluationThe BCBSIL QIC and the Governance and Nominating Committee of the HCSC Board of Directors review andapprove the annual BCBSIL QI Program Description. The BCBSIL QIC also reviews and approves the annualBCBSIL QI Work Plan and the annual QI Program Evaluation.The BCBSIL QIC is responsible for providing oversight and direction to the QI Program. The QIC is chaired by adedicated Medical Director. The QI Committee brings multidivisional staff together with employers, providers andmembers for the purpose of reflecting customer values. An HCSC Medical Director is responsible for ensuringthe Governance and Nominating Committee receives the reports from the QI Committee.Responsibilities of the QI Committee include: Review and approval of the annual HCSC QI Program including the Illinois Appendix Review and approval of the annual BCBSIL QI Work Plan Review and approval of the preventive care and clinical practice guidelines Monitoring and analysis of reports on QI activities from subcommittees Oversight of delegated activities Review and approval of annual BCBSIL QI Program Evaluations Review and approval of the Case Management/Utilization Management QI Projects Recommendation of policy decisions Analysis and evaluation of the results of QI activities Review of analysis of significant health care disparities in clinical areas Review of analysis of information, training and tools to staff and practitioners to support culturallycompetent communication Review of analysis of onsite audit results Review of analysis and evaluation of member complaints Review and analysis of member and provider appeals Review of analysis and evaluation of populations with complex health needs Ensuring practitioner participation in the QI program through project planning, design, implementationand/or review Institution of needed actions Ensuring follow-up, as appropriate Maintain signed and dated meeting minutesThe BCBSIL QIC meets a minimum of (10) times per year. Its membership includes: Practitioners from BCBSILNetworks (with at least 1 behavioral health specialist), BCBSIL Vice President and CMO IL, Quality MedicalDirector (Chair) and additional departmental leadership including representatives from Clinical Operations,Network Programs, Quality, Accreditation, Quality Administration, Provider Affairs Operations, RegulatoryCompliance, Leadership Oversight, Enterprise Medical Director, Account Management, and additional staffsupport as needed may include Marketing, Credentialing, Service Delivery Operations, Legal Department, andIllinois Medical Directors (Medical Management, Quality Improvement and Health Equity).Quality and Safety of Clinical CareThe HCSC QI Program is designed to meet all applicable state and federal requirements (e.g. HIPAA etc.). Planstaff, in cooperation with the HCSC Compliance and Legal Departments, monitor state and federal laws andregulations related to quality improvement and review program activities to assure compliance. In addition, if thePlan achieves external accreditation/certification, maintenance of such accreditation/certification is monitoredthrough the QI program. There were two (2) Accreditation Organizations used at HCSC, the National Committeefor Quality Assurance (NCQA) and Utilization Review Accreditation Commission (URAC). The selection of theAccreditation Organization is based upon a combination of state and federal requirements, and plan-specificpreference.ConfidentialPage 9 of 33
2021 BCBSIL QI Program EvaluationAccreditation MatrixHCSC maintains accreditation for the products identified from the listed accrediting bodies:URAC HealthNCQAURAC UMPlanBCBSILHMOYesNoNoPPONoYesNoExchange HMOYesNoNoExchange PPOYesNoNoQuality Improvement ProjectsBCBSIL’s HMO plans are unique in that the clinical care is delegated to physician groups (Medical Groups, IPAs,PHOs). In this arrangement, BCBSIL maintains responsibility for quality and provides delegation oversight toassure compliance. Foundational to the delegated model is an alternative payment model (APM) that includesshared risk and a quality improvement fund that is designed to align incentives. This model has resulted inimproved quality and lower cost for our members.Due to the COVID pandemic impact the QI fund projects were suspended. In response, BCBSIL agreed to reviewthe better of 2020 performance results in accordance with the 2021 contract performance and paymentincrements. Currently analytics is working on the final 2021results, this information will be updated in April.Improving Timeliness of Notification of Denial Determinations2021 Illinois Commercial PPO: a random sample of 90 denial files per quarter are reviewed using the 733 SmartUtilization Management (SUM) Reports and the Tableau Turn-around Time (TAT) Summary Report. Samples ofrandom denial files are selected by reviewing cases that meets audit/ review parameters. Approved auditparameters include: IL Plan Code, funding type, treatment setting and reason for denial.The review tool calculates which department (Intake, HC, Nurse, MD, Denials Team) held the request the longestand had the request when the TAT expired.The TAT goal is to achieve and maintain a compliance score of 90% for the Notification of the Denial. The QIPwill be closed once the compliance score has been maintained 90% for 3 consecutive quarters. The results arebelow:2021 Q1IL Commercial PPO:Indicators URAC HUM 19, 20, 21: Timeliness of Decision and Notification URAC HUM 24 (a): Principal Reason for the Determination URAC HUM 24 (b): Clinical Rationale in Easy-to-Understand LanguageIllinois: overall (TAT) was 100%, (90/90 files met TAT) 90% goal metNo Barriers Identified.2021 Q2Illinois: overall (TAT) was 92%, (83/90 files met TAT) 90% goal met.ConfidentialPage 10 of 33
2021 BCBSIL QI Program EvaluationThe data results of 92% for the 2nd Quarter 2021 indicates that the hold times within the clinical area resulted inan eight (8) percentage point decrease from the 1st Quarter 2021 results of 100%.Barriers 3 FTE positions remain open, currently interviewing Number of employees allowed to take PTO has been increased to support the PTO incentivized programwithin the company High volume of DenialsInterventions High volume of Denials, additional staff required Interviews are in progress2021 Q 3Illinois: overall (TAT) was 90%, (81/90 files met TAT) 90% goal met.The data results of 90% for the 3rd Quarter 2021 indicates that nine (9) out of the ninety (90) cases reviewedmissed the required turn-a round time and resulted in a two (2) percentage point decrease from the 2nd Quarter2021 results of 92%.Barriers Training and precepting of newly hired staff for weekend coverage is in progressIntervention
Executive Summary An evaluation of the Blue Cross and Blue Shield of Illinois (BCBSIL) 2021 Quality Improvement (QI) program has been conducted. This evaluation included review of trended results for QI measures over time, comparison against performance objectives, quantitative and qualitative analyses for completed and ongoing QI activities.
