Originally published in The Tennessean, December 2023
When I was a practicing emergency medicine physician, I thought I could change the world one person at a time. And I did so for more than 20 years. But by joining the BlueCross Medicare team for what I jokingly call “a desk job,” I’ve been part of a movement where we affect change not just for individuals or communities, but the entire state.
In my days in the ER, I thought of health insurers as just the ones who paid the bills. But in recent years, the provider/insurer relationship has evolved into more of a partnership with quality care at its center.
Quality care starts with preventive care
I support the care coordination efforts for our Medicare Advantage members, but members with other types of BlueCross coverage have access to this type of support, as well. That means we engage with all our members using a variety of touchpoints — calls, texts, emails, in-person visits — and encouraging them to see their doctors more often and spend more time with them going over recommended screenings, their medications, or whatever concerns they may have.
As insurers, one of our roles is helping make sure the care our members receive meets high standards and follows evidence-based best practices.
We define quality not just from the benefits we offer but the resulting outcomes. We have regular meetings with physician practices to understand their pain points and ensure the best possible outcomes for those we serve.
A story that stuck with me involved a Medicare Advantage member who uses an automated blood pressure cuff. To help support our provider networks, we’d formed an internal team to stay connected with such members. One of our case managers called this member to check in and learned they were homeless and living in their car. In working to close one gap in care, our team identified a crucial need and was able to connect the member with the right resources.
This story illustrates our concierge approach and how we’ve helped take some of the procedural burden off physicians. We ask them about their needs and their barriers to administering effective treatment.
We’ve developed case management teams, clinical teams and population health teams that work with providers and hospitals on everything from discharge coordination to office documentation and paperwork.
Through our health navigator program, we reach out directly to patients upon discharge and ask them a series of questions — do you understand why you were in the hospital, do you understand your next steps, can you afford the medications, etc. — and offer ourselves as a resource if they struggle to answer any of these. Insurers and providers alike don’t want these patients to end up right back in the hospital.
Because of this personal approach, the Centers for Medicare & Medicaid Services (CMS) awarded our Medicare Advantage plan a 4.5 Star quality rating, which means members received timely preventive screenings and health care and overall are extremely satisfied with our plans.
Looking ahead to 2024, we plan to bring our members into this process more directly by creating workgroups to hear how we can more effectively support them on their health journey.
We recognize that while our CMS rating is a testament to the quality of service we deliver, there are so many situations that our members and their families experience where we can learn and better support them.
We want to identify and resolve those pain points before they happen for anyone else.
Affecting change on a statewide level is meaningful. But the heart of that change lies with the people we serve. And as a service to them, as well as to the communities in which we live, we’re looking at every opportunity to reduce red tape and improve the quality of care they receive.