Understanding Health Care Costs and Quality


Most health insurance plans offer you resources, tools and even savings on retail items. For example, as a member, you may get perks to help you save time and money, lose weight, quit smoking and even get discounts at retail stores. Here you'll find some helpful tips for making your health insurance plan work for you.

Making the Most of Your Medical Benefits

Medical benefits are most likely the number one reason you chose to get health insurance. Here are a few simple things you can do to get the most out of your benefits.

  • Stay in the network. Most health plans have negotiated discounts with doctors, hospitals and other health care experts who are in their network. That often means lower out-of-pocket costs to you.
  • Use the ER for emergencies only. Real emergencies call for a trip to the closest Emergency Room (ER). But you can usually save money on your copayment by going to your primary care doctor for colds, minor sprains and other less serious health issues.
  • Follow your doctor's orders. Be sure to take any medications, treatments or therapies your doctor suggests. That way you can get better quickly and avoid extra costs.
  • Use generic drugs. Generic drugs cost less than brand name drugs and offer you the lowest available copay. Generic drugs have the same ingredients and work the same as their brand-name equivalents.
  • Use freestanding medical service facilities. You can usually lower medical costs by scheduling lab work, imaging and other outpatient services at freestanding medical service facilities instead of a full-service or general acute care hospital.
  • Know your coverage. Make sure services or treatments are covered before you plan your next doctor's visit. Knowing this ahead of time can save you money.
  • Do an "annual check-up" of your health insurance plan. Make sure your plan still meets your needs. This is even more important if you had any major life-changing events in the past year, such as marriage, the birth of a child or the removal of a dependent from your health insurance policy.

Use Your Member Perks

Most health insurance plans offer useful tools and conveniences to their members. To get the most out your plan, take full advantage of these perks:

  • Get online. We offer a secure website (Blue Access for MembersSM) where you can check the status of claims, view benefits information, find a doctor and much more.
  • Take advantage of programs. If your plan has free health screenings or wellness programs, use them to better your health. For example, some have programs to help you lose weight and quit smoking with no extra cost to members.
  • Learn how to be healthy. We have information to help keep you and your family healthy. Sign up for newsletters, read articles online, or have health and wellness tips.

Use Blue Access for Members

Blue Access for Members is the best way to get the most from your plan. With this secure members-only website, you can:

  • Manage your account online
  • Take a health assessment to get personalized wellness tips
  • Check the status of claims and set-up email alerts
  • Order a new ID card and print a temporary card
  • Look into our special members-only discounts and offers from health and wellness companies

Log in to Blue Access for Members

Understanding Provider Quality

We offer performance and quality information on doctors, hospitals and other health care facilities to help you make health care choices for you and your family. Be sure to follow your doctor's suggestions about getting care and check whether your benefits cover those services and treatments.

If there is no performance information for a certain doctor or provider that does not mean that the standards of care were not followed. This information might not be there because there is no way to measure it yet, or because there isn't enough data to come up with performance scores.

Physician Quality Bridges to Excellence Programs

Bridges to Excellence programs recognize and reward top-performing doctors, nurse practitioners and physician assistants who give excellent patient care. These programs, designed and carried out by the Health Care Incentives Improvement Institute, are based on nationally accepted quality measures that are most predictive of improved patient health. Clinicians who follow these quality measures often outperform others on process measures of quality. They also have lower average costs per patient and per health episode. Clinicians who continually improve their practices are rewarded through incentives.

Those recognized by a Bridges to Excellence program:

  • Offer a higher measured quality of care than non-recognized physicians
  • Have fewer episodes per patient and lower resource use per episode
  • Have lower average costs per patient and per episode

Bridges to Excellence programs recognize all major chronic conditions and office systems including:

  • Asthma
  • Cardiac care
  • Congestive heart failure
  • Cardiology practice
  • Chronic obstructive pulmonary disease (COPD)
  • Coronary artery disease
  • Depression
  • Diabetes
  • Hypertension
  • Physician office systems
  • Spine care
  • Medical home

To learn more, visit the Health Care Incentives Improvement Institute website external link.

Hospital Quality Measures Process of Care Measures and Outcome of Care Measures

The Centers for Medicare and Medicaid Services (CMS) follows a standard set of performance measures for recommended hospital care for these 5 conditions:

  • Heart attack
  • Heart failure
  • Pneumonia
  • Surgical care improvement and infection prevention
  • Pediatric asthma

Hospitals are encouraged to report their quality of care information for these medical conditions. Reporting is voluntary, but it is linked to the payments hospitals get for treating Medicare patients.

Each hospital is given an overall score and detailed benchmark scores for each of the quality measures. The detailed benchmark scores include the national average hospital compliance and the top hospitals' compliance for each of the measures. (The top hospitals are the top 10% of hospitals nationwide.)

Process of care measures include quality measure sets for each of the conditions listed above.

Outcome of care measures are the 30-day mortality (death) and readmission rates for each of these categories:

  • Heart attack
  • Heart failure
  • Pneumonia

Blue Distinction Centers

Blue Distinction is a designation awarded by the Blue Cross and Blue Shield companies to medical facilities that have shown expertise in delivering quality health care. The designation is based on rigorous, evidence-based selection criteria formed by leading medical specialists and professional organizations.

To earn this designation, a facility's overall experience and total data must meet criteria formed by expert clinicians and leading professional organizations.

Blue Distinction Centers+SM are hospitals recognized for their expertise and efficiency in delivering specialty care. Quality remains key: to qualify as a Blue Distinction Center+, a facility must first meet all of the quality requirements for a Blue Distinction Center before cost will be evaluated.

HCAHPS

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a national, standardized survey sent to a random sample of hospital patients 18 years and older within 48 hours to 6 weeks after being released from the hospital. The survey includes 10 questions about a patients' view on important measures of care. The HCAHPS results can help you compare patients' experiences among different hospitals and against state and national benchmarks.

The survey includes information about these hospital patient experiences:

  • Communications with nurses and doctors
  • Responsiveness of hospital staff
  • Pain management
  • Communication about medicines
  • Discharge information

The survey also includes questions about:

  • Cleanliness of the hospital environment
  • Quietness of the hospital environment
  • Overall rating of the hospital
  • Their willingness to recommend the hospital

More information is available on the HCAHPS website external link.