1. Nearly six years after the launch of Blue Shield’s first ACO, what do you see that sets our model apart from other ACO models across the country?
Because Blue Shield’s ACO model was the first of its kind nationally, we have the advantage of longevity and experience, and have earned our reputation as the pioneer and innovator in this marketplace. We’re always working to continue building on the success of our program by offering innovative options for our providers, brokers, employer groups and members.
As part of deepening our provider relationships, leadership engagement, transparency and information sharing, a number of projects and programs are up and running, including:
- Continuing to work even closer with providers by integrating care delivery processes, systems and data to improve patient care
- Leveraging Cal INDEX to build an integrated data platform across our ACOs. Cal INDEX is a Health Information Exchange (HIE) that improves patient care and analytics by providing comprehensive data about patients to providers
- Applying clinical best practices
- Sharing metrics, reporting and analytic tools
- Expanding our aligned incentive/risk-share methodologies (e.g. to account for specialty drugs, risk-based capitation)
- Building networks and products centered around our ACO providers
Our ACO model is predicated on a unique framework for deep integration with our ACO providers. This alignment, and the collaborative working relationship it yields, enables us to introduce innovative new care delivery models with our providers that can transform the way they deliver healthcare services, leading to better cost containment, quality improvement and increased member satisfaction.
2. What are the key components of establishing a successful ACO collaboration?
The value of provider engagement is paramount. We rely on provider expertise and the trusted relationships they forge with our members. Their collaboration with us to deliver this program is incredibly powerful, promoting member confidence in the health care they receive from their doctors and health plan.
Transparency is another critical element of our successful ACO program. We have built our model on a foundation of sharing cost and utilization data with our providers, as well as giving them insight into the financial risk-share and pricing practices. Collectively, we are building a better patient experience while also controlling costs through new product and network offerings.
Since the inception of the program, Blue Shield has contributed significant resources – including program management, data analytics, clinical resources, pharmacy program management, and more.
3. The last few years have been arguably some of the most transformative for the health care system. How do you see the system as having improved for patients?
Our ACOs have streamlined the patient experience in the way services are provided. Once a fragmented system with inconsistent communication between the inpatient and outpatient world, ACOs offer a coordinated and cohesive process where all parties involved in a member’s care are connected. Members have seamless access to care through referrals, optimization of site of care and an integrated delivery system.
We are bolstering and improving services our members receive across the continuum of care. By ensuring members have access to healthcare coaching, education and shared decision-making, they are empowered to make the healthcare decisions that are best for them.
While ACOs have done much in the way of integrating processes and improving care coordination, continuing the transformation requires integrated data and system. An integrated, longitudinal patient record is required to provide best-in-class care. This is an important step forward for patients all across California.
4. What are some of the existing challenges in a post-Affordable Care Act (ACA) climate?
Cost will always be a challenge in health care. There are so many external factors at play (pharmaceuticals, deviation in costs of services, etc.) making it extremely difficult to forecast and achieve consistency year to year. Access to care can be a challenge in those markets where physicians are retiring and not being replaced immediately, especially with the influx of newly insured members.
Another challenge is for health plans to create value for the younger, healthier population that will encourage them to continue coverage. It is critical these members still receive a benefit from their healthcare dollars, even if they are not accessing care regularly.
5. Your role at Blue Shield is vice president of ACO Strategic Partnerships. How does the vision of ACO collaborations impact the health care delivery system as a whole? What kind of vision is necessary to ensure that members have access to affordable health care?
At Blue Shield, we believe we have a historic opportunity to transform a dysfunctional health care system. It is no secret our healthcare system is broken. While the ACA has helped to usher in long-overdue access and reform, challenges abound. Medical costs and pharmaceutical prices continue to rise at unsustainable rates. Millions of Californians still lack basic coverage. Programs for the poor are underfunded. Many consumers have trouble paying their deductibles. Pricing is opaque. Health information sharing is only slowly entering the digital age. The list goes on.
I believe that ACOs must be the dominant delivery model for healthcare. And those of us leading the direction of healthcare have a responsibility to create a system that is sustainably affordable while offering quality care worthy of our family and friends. It’s an ambitious goal, and one we are uniquely positioned to achieve.
6. As we wrap-up 2016, how are you looking back at the year that was, and looking forward to 2017?
We have made great strides in 2016 towards growing our membership, bringing us further into the digital age through our new website and mobile app, and improving both customer service and clinical performance. While we face new uncertainty with the incoming presidential administration and changing policy perspective on the healthcare frontier, our position remains the same – improving care delivery quality while controlling costs.
For 2017, we are focused on continued membership growth. Significant efforts are in place to increase participation in Cal INDEX, the integrated data platform that collects healthcare data for all Californians. Provider participation in this data exchange will be instrumental in achieving consistency and quality of care for our ACO members. We will continue to support our ACO providers and members through our focus on clinical performance while managing the cost of healthcare. Ultimately, in collaboration with our providers, we will persevere in our search for innovative ways to improve and optimize our members’ health and healthcare experience.
Susan Hallett is vice president of strategic partnerships and innovation at Blue Shield of California