Local, State, Federal

HCSC Turns to IT Framework to Improve Outcomes and Reduce Costs
The Bill Box
AHRA 2007 Audio Web Conferences

HCSC Turns to IT Framework to Improve Outcomes and Reduce Costs

For 2 years now, the Health Care Service Corp (HCSC), Chicago, which operates the Blue Cross and Blue Shield plans in Illinois, Texas, Oklahoma, and New Mexico, has been developing its Blue Care Connection health IT framework—a significant investment in leveraging member health information into actionable, usable data, with the aim of lowering costs while addressing gaps in care. Axis Imaging News spoke with William Gerardi, MD, clinical advisor of managed health care delivery at HCSC, about the initiative, which is currently in the implementation stage.

IE:  What is Blue Care Connection?

William Gerardi, MD

Gerardi: Over the past couple of years, we have completely redesigned our medical management activities so that all four plans are doing the same thing, and now we’re in the final stages of implanting the platform to support those activities so that it’s consistent for all of our 11.5 million members. Everything’s integrated—the precertification process, prenotification, utilization management, case management, and disease management. In addition, we have deployed a very robust solution, a predictive modeling tool, through which we analyze our entire population. We know something about everyone.

IE:  Where does the term “predictive” come in—what is being predicted?

Gerardi: The term “predictive modeling” is used in a couple of ways. The purest definition is analyzing the population to determine who’s at the greatest future risk of developing a severe condition and generating high-dollar claims. The way the term is more broadly used across the industry is to stratify members, identify treatment opportunities, and then target those members with appropriate outreach activities. One of the things we’re doing that’s unique is presenting the output from that predictive modeling to three different stakeholders. The first stakeholder is the provider, and that could be a physician or the facility. We provide a summary that includes the patient’s demographic information, which physicians they’ve seen, and which facilities they’ve visited; tracks services, like labs and x-rays; and shows what medications they’re on, what treatment opportunities we’ve identified, their chronic conditions, and the severity levels for those members. Then, we present that information to our clinical staff at HCSC—the nurses who are doing case management and disease management—so that they see the same information as the physician. The third stakeholder is obviously the member, who is able to access their information on our member portal. When the member goes through Blue Access to get to their personal health record, they have their patient clinical summary there as well.

IE:  Obviously, this is going to create a number of efficiencies, but I know an important goal is to reduce costs. How will it reduce costs on a larger scale?

Gerardi: We want to provide useful, actionable information to the provider at the point of care. I’m an internist by training, and patients aren’t always the best historians. A patient might forget to say that he visited an emergency department [ED] when he was on vacation in Florida, or that he saw this particular doctor who prescribed a certain medication. Providing that snapshot to a physician or to an ED is incredibly useful. It also provides a record of any diagnostic procedures that have been performed.

IE:  Was HCSC following the model of any other plans with this framework?

Gerardi: We actually did a lot of the work internally. We pulled together experts from our Blues plans; over a year, they created a plan for where we wanted to be. From that, we created a set of business requirements that informed the selection of the technology platforms that we needed to support these endeavors. Now we’re in the final stages of implementation. In talking with policy makers in Washington and other health industry folks, it appears that this is going to become a model for the way medical management can take place, using health IT to drive this information and make it usable. Plenty of information is certainly out there, but it’s not yet being harnessed and delivered in a way that people can make use of it. It actually will improve quality and reduce costs simultaneously. We’re hopeful that this will become a model for the industry.

IE:  And all of this is free?

Gerardi: Yes, it is no cost to [the stakeholders]. It’s an investment that we are making because we feel that getting this information to the point of care is so important to the growth of the entire health care system.

IE:  How much has HCSC invested in it?

Gerardi: A lot. It’s not an insignificant amount. We’re the largest noninvestor-owned health plan in the country. We’re successful, and we believe in investing in our future.

The Bill Box

By Cat Vasko

CARE Bill Introduced in Senate

The 2007 Consistency, Accuracy, Responsibility and Excellence in Medical Imaging and Radiation Therapy (CARE) bill was introduced into the Senate on March 30 by US Senators Michael Enzi (R-Wyo) and Ted Kennedy (D-Mass). A previous incarnation of the bill, the Consumer Assurance of Radiologic Excellence bill, was passed in December 2006, but Congress adjourned before voting on the House version of the bill—which was introduced to the House in its 2007 form on January 19.

The bill would establish federal education and credentialing standards for clinicians performing medical imaging and radiation therapy procedures who wish to participate in federal health programs like Medicare and Medicaid. Currently, training standards are voluntary in some states, meaning individuals can perform medical-imaging procedures without formal education or credentialing.

Christine Lung, director of government relations at the American Society of Radiologic Technologists (ASRT), Albuquerque, NM, said, “ASRT members have worked diligently at the grass-roots level and through programs like the RT in DC lobbying event to educate their senators and congressmen on the need for education and credentialing standards in medical imaging and radiation therapy. It will be exciting to see the long-term efforts of so many dedicated radiologic technologists come to realization when the CARE legislation is enacted.”

Colorado Passes Managed Care Contract Bill

On March 30, Colorado became the first state to require health insurers to use a standard managed care contract when negotiating with medical care providers. SB 79, which was sponsored by State Senator Steve Johnson (R-Fort Collins), requires insurers to disclose terms of payment in plain language and to notify providers of any changes to the contract; it also prohibits insurers from requiring physicians to accept patients with a different type of plan.

Supporters of the bill—like the Colorado Medical Society (CMS), which lobbied for similar legislation in 2006, only to have it vetoed by Governor Bill Owens (R)—claim it will save providers money, especially those who are small-business owners. The Medical Group Management Association (MGMA), Englewood, Colo, which issued a statement supporting the bill, recently found that the average 10-physician practice spends as much as $247,500 per year dealing with administrative tasks related to insurance contracts. The study also found that a practice can spend as much as $33,800 per year negotiating with an average of 15 health plans.

“Administrative complexity is a major concern for our members—the medical practice professionals typically charged with managing these colossal and confusing contracts,” said William F. Jessee, MD, president and CEO of the MGMA. “The burden of administrative complexity comes from a variety of sources. However, standardizing basic contract terms to make them easier for the groups to understand, and making the contracting process more equitable, is low-hanging fruit.”

Opponents of the measure, primarily insurers, claim that it will increase costs by requiring health plans to send out more notices to providers; however, the Colorado Association of Health Plans, Denver, said the major concerns of the insurers that it represents are addressed in this version of the bill.

Jessee added, “We congratulate the health care community in Colorado for its hard work and urge other local governments to consider similar legislation.”

Stark Introduces Universal Health Care Bill

On March 29, Pete Stark (D-Calif), chair of the House Ways and Means Health Subcommittee, reintroduced his AmeriCare bill, which would provide universal health care based on Medicare and employment-based coverage. The introduction of the AmeriCare Health Act of 2007 came in the wake of an independent report released March 19 that says at least two of the health care proposals being presented to Congress, including Stark’s, would cover all Americans lacking health insurance while decreasing spending—more effectively than any proposals made by President George W. Bush.

The study—released by the nonprofit Commonwealth Fund, New York City, which studies health care issues—analyzed 10 health care plans introduced into Congress during 2006 and 2007, as well as the President’s proposals. It found that AmeriCare could save families with low and moderate incomes a total of $142.6 billion and would cover an additional 47.8 million Americans.

AmeriCare would work by using the existing Medicare infrastructure to provide health insurance to those not covered by their employers; for people with incomes lower than 300% of the poverty level, all costs would be subsidized. It would be financed through contributions from employers, individuals, and states—”all of whom pay into our current health care system,” Stark’s summary notes. “Unlike today’s system, however, AmeriCare will save billions of dollars by utilizing Medicare’s highly efficient administrative infrastructure that operates on a 2% margin. Requiring the Secretary to negotiate with the pharmaceutical industry for reasonable prices and expanding the use of health information technology in the clinical setting will achieve additional savings.”

Cat Vasko is associate editor of  Axis Imaging News. For more information, contact .

AHRA 2007 Audio Web Conferences

A series of upcoming audio Web conferences sponsored by the American Healthcare Radiology Administrators (AHRA), Sudbury, Mass, offers an economical and convenient way to learn more about critical issues affecting the radiology industry. Beginning in April and concluding in November, the series touches on such topics as PACS, coding, reimbursement, and workforce development. Registration is $99 per session for AHRA members or $109 for nonmembers, with CE credit available. Upcoming conferences include:

  • Critical Factors in Workforce Devel-opment: May 17, 2007; 1–2 pm EST. Speaker: June Cowen, BS Ed, MSM, Senior Project Specialist, Massachusetts General Hospital
  • Why PACS Does Not Always Deliver Promised Productivity … And How to Make It Happen: June 21, 2007; 1–2 pm EST. Speaker: Nathan Hurle, BS, National Delivery Manager, Kodak Business Diagnostics
  • Can You Justify a Dedicated Radiology Coding/Reimbursement Specialist for Your Organization?: August 16, 2007; 1–2:30 pm EST. Speaker: Melody W. Mulaik, MSHS, CPC, RCC, President and Co-founder of Coding Strategies Inc
  • Real World Recognition: October 18, 2007; 1–2 pm EST. Speakers: Peggy Wagner, CRA; and Lori Wise, RN, CodeRyte Inc
  • Ready, Set, Go … Getting Prepared for 2008: November 29, 2007; 1–2:30 pm EST. Speaker: Melody W. Mulaik, MSHS, CPC, RCC, President and Co-founder of Coding Strategies Inc

To learn more or register, contact the AHRA at (800) 334-AHRA or .