Health Care Quality Improvement Overview

The following information details Quality Improvement Initiatives undertaken by our health plan

BlueCross BlueShield of WNY programs provide health care services to keep our insurance customers healthy and help them to get well when they are ill.

BlueCross BlueShield of WNY promotes good, helpful and sensibly priced health care for all ages. We give our doctors the most up to date information in order to provide the best care. We work with our doctors to help patients feel well and know how to care for their health.


National Committee for Quality Assurance Accreditation (NCQA)

Blue Cross Blue Shield of WNY is accredited by a national quality agency called the National Committee for Quality Assurance (NCQA). This agency surveys us to make sure our customers get good treatment, safe care and stay well. This helps to keep health care costs lower. HealthNow underwent a re-accreditation survey in January through March 2016 to demonstrate continued commitment and attainment of the highest quality standards.


Healthcare Effectiveness Data and Information Set (HEDIS®)

The Healthcare Effectiveness Data and Information Set (HEDIS) is a standardized measurement tool used by more than 90 percent of America's health plans to measure performance on important dimensions of care and service. HEDIS was developed and is maintained by the National Committee for Quality Assurance (NCQA). Altogether, HEDIS consists of 91 measures across 7 domains of care. 

  • Effectiveness of Care
  • Access/Availability of Care
  • Experience of Care
  • Utilization and Risk Adjusted Utilization
  • Relative Resource Use
  • Health Plan Descriptive Information
  • Measures Collected Using Electronic Clinical Data Systems
Because so many plans collect HEDIS data, and because the measures are so specifically defined, HEDIS makes it possible to compare the performance of health plans on an 'apples-to-apples' basis. 
HEDIS results are collected and reported separately for populations covered by Commercial, Medicaid, Medicare and Qualified Health Plan (Marketplace) products. The Commercial submission is a combination of HMO, POS, EPO and FEP lines of business. HEDIS results are used to identify opportunities for improvement in the healthcare provided to our members. In addition to being used to evaluate the effectiveness of existing quality programs. 
In 2016, HEDIS clinical measures, along with customer satisfaction survey results, contributed to the "Commendable" NCQA Health Plan Accreditation status for our Commercial, Medicare HMO and PPO products. 
Quality Assurance Reporting Requirements (QARR)
The Quality Assurance Reporting Review or QARR are reported to the New York State Department of Health and consist of measures from the National Committee for Quality Assurance's (NCQA) HEDIS and New York State-specific measures (Adolescent Preventive Care, HIV/AIDS Comprehensive Care and Colorectal and Lead Screening measures). In 2016, QARR was publically reported for our Commercial, Medicaid and Marketplace products. QARR performance results assist our members and enrollees in choosing a health plan. These results are also used to identify opportunities for improvement of services for evaluating existing and potential quality programs. 


Hospital Quality

BlueCross BlueShield of WNY works with our hospitals to provide quality and safe care.  Programs promoting good care such as preventing infections, surgical complications and wrong medication are in place at all hospitals. 

Blue Distinction Centers for Specialty Care®

Blue Distinction (honor) is awarded to hospitals that are “experts” in providing specialty care. Hospitals must meet special criteria to be called a “Blue Distinction Center”. This designation is based on national care standards. Blue Distinction facilities are recognized for excellent clinical outcomes and processes in the areas of Bariatric Surgery, Transplants, Cardiac Care, Maternity, Complex and Rare Cancer treatments, Spinal Surgery and Hip and Knee Replacement.

Doctor  Quality

We work with primary care doctors utilizing programs that focus on quality improvement for our Primary Care network, including ‘BestPractice’ a new Center for Excellence program to be implemented on January 1, 2017.


Culturally and Linguistically Appropriate Services (CLAS)

This program is designed to enhance the enrollee/provider/health plan relationship from a cultural and linguistic perspective.  Language Line Services are used to assist with any language barriers that may exist in order to improve understanding and compliance for all parties and to ultimately improve the health and health care of our enrollees.  Educational programs are provided to promote culturally competent care, and programs are planned to decrease ethnic disparities in care. Annual training of employees is completed to expand and keep current knowledge regarding how culture and language barriers affect our enrollees and how they can help to make the enrollees health care experience a positive one promoting increased compliance and wellness.  Seminars for providers are available on our provider portal.


Continuity and Coordination of Care

Continuity and coordination of care (CCC) between the hospital/urgent care/specialist and the primary doctor is very important to ensure safe and appropriate patient care and can prevent unneeded treatments and tests for patients.

This plan monitors how well providers communicate with each other when treating the same patient. In 2016, surveys were used to assess communication between healthcare providers/settings. Results identified opportunity for improvement in rate and timeliness of communication between behavioral health providers, specialists, urgent care centers and primary care practitioners. Actions to improve provider performance were implemented. Communication continues to be monitored by medical record review and other quality improvement projects.

In addition other health care programs/projects (i.e. case management, radiation safety awareness, pharmacy, etc.) measure and work toward improving coordinated care for our members.


Medical Record Review for Standards

Primary Care medical records are reviewed and scored against proven record standards. We work to assist doctors to improve information and conversations in the following areas: end of life wishes, smoking, alcohol and drug use, adult vaccines, checking weight and cultural needs of patients.


Quality Investigations

Whenever a customer contacts us with a concern about the care they received from one of our providers we look into it. We review patient medical records to make sure good care was provided and work with doctors and facilities to improve on any concerns we find.

After Hours Access to Care Audit

Our plan assures the provision and maintenance of appropriate access to Primary Care services, Behavioral Health services and Member Services for BlueCross BlueShield members. All providers being credentialed or those who notify BlueCross BlueShield of a new location go through an on-site review and are expected to be in 100% compliance with the plan's access to care standards. 

Health Care Quality Improvement (HCQI) works in collaboration with Credentialing and Provider Relations to audit Primary Care/Pediatric and Behavioral Health offices to assure 24-hour access to care. If there is a provider office who does not meet our Access to Care criteria, the case is forwarded on to HCQI for a further investigation. Corrective action is required on 100% of offices not meeting this standard. In 2016, there were 5 Access to Care phone audits sent to HCQI for further quality investigations. All of the Provider offices that failed the audits received a letter from the HCQI department outlining their inadequacies in addition to the BlueCross BlueShield Access to Care Policy. They were all required to send a written response and Corrective Action Plan (CAP) back to BlueCross BlueShield. All CAP's were reviewed and approved by the HCQI and Provider Relations Department. 

Patient Safety Program

The Patient Safety Program focuses on ways to improve care and clinical safety for our customers.

Radiation Safety

We are working with our doctors and medical facilities to order x-rays and scans for patients only when needed and to keep track of testing to prevent unnecessary duplication. The program provides ordering doctors with patient specific information regarding accumulated radiation exposure and promotes coordination of care between the primary care doctor, radiologist and other specialists with the aim to reduce radiation exposure from unneeded tests.

Image Gently Campaign

We encourage provider participation in this national campaign which focuses on reducing radiation exposure particularly for children. Tracking radiology procedures beginning in early childhood is recommended using a simple tracking tool for parents available on our customer web site.

Medication Safety

Our pharmacy’s vendor, Express Scripts, provides information and tools to doctors to help them prescribe medications safely by informing them of potentially serious drug interactions, excessive dosing or quantity consideration. We encourage customers to review their medications with healthcare providers on a regular basis. Some medications may place members at risk for falls. 

Falls Prevention

Educational materials have been developed consisting of a Falls Risk patient survey and recommendations for fall prevention. These materials have been designed to assist members in identifying their risks as well as promoting discussion and review with their primary care provider (PCP). It is important to let your PCP know if you have had a fall or are worried about falling. Your doctor may have recommendations to assist you in preventing a fall. 

The health plan promotes improved quality of life for our customers by helping them to better understand their illness and self manage their conditions. We accomplish this by providing education for our customers and support to our providers to care for these conditions. Self care is encouraged early in the disease process by nurses, dieticians, social workers and outreach staff who make calls to customers to coach and teach. Health coaching calls remain well received by our customers who obtain tips and information to care for their conditions.


The goal of the Asthma Management Program is to improve the health status for members using a multi-disciplinary, population-based approach and to manage health care costs by promoting evidence-based treatment while assisting members to achieve optimal control of their disease.  Interventions are individualized and targeted to specific enrollee needs based upon the enrollee’s level of self- management.

The results of HEDIS Medication Management for People with Asthma – 75% compliance rate: showed a 1 % decrease for the Commercial HMO/POS/PPO lines of business – combined age range from last measurement year.

 The results of HEDIS Medication Management for People with Asthma – 75% compliance rate: showed a 1 % increase  for the Medicaid line of business – combined age range from last measurement year.  Rates are above the NYS and national averages.

Flu shot results for those enrolled in an Asthma management program have improved for all lines of business from last measurement year.

Attention Deficit Hyperactivity Disorder (ADHD)

The Attention Deficit Hyperactivity Disorder (small attention span) management program aims for proper screening, diagnosis, treatment and management of ADHD in children. We work closely with our pediatric and behavioral health doctors to develop activities and educational materials that encourage parents to get the right help for their children.


Chronic Obstructive Pulmonary Disease (COPD) 

The goal of the program is for members to control their symptoms and maintain an active lifestyle. An individual’s quality of life can be seriously impacted if COPD is poorly managed and we provide tools to assist in controlling symptoms and stay healthier longer. Spirometry testing and medication management rates are measured to determine program success.

The results of HEDIS Use of Spirometry Testing for COPD measure increased 2% for the Commercial and Medicare PPO line of business from last measurement year. 

The results of The Pharmacotherapy Management of COPD exacerbations measure have remained relatively the same from last measurement year for Systemic Corticosteroid for all lines of business and has increased 2.7% from last measurement year for the Commercial population for the bronchodilator measure.

Flu shot rates have improved for those members enrolled in a COPD program for all lines of business from last measurement year. 

Depression (A condition of feeling sad or hopeless)

The primary focus of the Depression Management Program is to improve the quality of life for our customers with depression by assisting them with getting the right treatment, medications and follow up care. Assuring our enrollees receive appropriate office follow-up after an antidepressant medication has been prescribed and following hospitalization are major objectives of this program.


Diabetes (Sugar in the Blood)

The Diabetes Program is designed to promote compliance with diabetic care and raise awareness of the effects of poorly controlled diabetes. Appropriate and timely screening and treatment can significantly reduce the long-term complications of diabetes. We continue to educate and encourage members to participate in routine screenings (i.e. blood sugar and cholesterol, eye exams, etc) in the management of their diabetes.

Heart Disease

The Cardiac Management Program was developed in 2005 to address the growing concerns regarding cardiac disease. Prevention of cardiac disease starts early and in many cases before there is a diagnosis of heart disease. Efforts are focused on enrollees with diabetes, hypertension and elevated cholesterol. With the exception of Medicare PPO, results for controlling blood pressure have seen an increase from last measurement year. All LOB results for controlling BP and for beta blocker use after MI were significantly better than statewide and national averages. Program focus includes messaging from the Million Hearts Campaign.

Spine Program

The program goal is to raise awareness and improve outcomes related to the cause, treatment, and management of back related conditions with both our physicians and members.  We utilize the HEDIS measure for Use of Imaging Studies for low back pain (LBP) to monitor the care our enrollees receive.  The HEDIS results for Use of Imaging for people with low back pain measure for Commercial HMO/POS/PPO lines of business remained the same from last measurement year, but still above the state and national averages.

The HEDIS results for Use of Imaging for people with low back pain measure for Medicaid decreased 1.5% from last measurement year.

The annual wellness visit rate for those engaged in the spine program increased about 4.5% from last measurement year and is well above the NYS average.

The case management program assumes responsibility for the coordination of all aspects of care for enrollees identified with chronic or high-risk conditions.  This includes high risk maternity, palliative, cancer, chronic kidney disease, behavioral health, and enrollees awaiting a transplant.  The case manager follows the enrollee through the health care continuum.  The role of the case manager is to promote quality care and meet the enrollee’s needs while maximizing benefits and assuring proper use of services in the most appropriate setting.  A stable workforce of clinical staff with flexible work schedules result in improved efforts for early identification and engagement of appropriate members to best meet member needs.

Right Start Prenatal (Maternity Care) and Newborn Care

The Prenatal Case management program (Right Start) continued as a priority focus. The emphasis of the program is to promote full term births among program participants.

The Right Start program assumes responsibility for the coordination of all aspects of care for pregnant enrollees identified as high-risk.  The case manager follows the enrollee throughout the pregnancy.  The role of the case manager is to promote quality care and meet the enrollee’s needs while maximizing benefits and assuring proper use of services in the most appropriate setting. The program utilizes the NYS Department of Health Medicaid Prenatal guidelines in an effort to standardize and improve prenatal care.

The results of HEDIS Timeliness of prenatal care measure stayed relatively the same for the Commercial line of business from last measurement year

The results of HEDIS postpartum care measure increased 3.9% from last measurement year for the Commercial line of business.

Palliative Care

The Palliative Care Program is designed for customers with end stage illness who are not ready to enter hospice. The program has a dedicated case manager to interact with enrollees, their families and their health care providers to assist members in achieving goals during a difficult time.


The case management and utilization management team work collaboratively to improve care for transplant candidates. Targeting providers from Centers of Excellence, for increased interaction, and early identification of potential candidates has resulted in increased member satisfaction and increased cost savings, with quality care.


Our HIV/AIDS Case Management program goal is to promote adequate and timely care, management of comorbid conditions, and adherence with medications/treatment plan, as well as addressing high-risk behaviors to prevent the spread of infection. Linkage with proper care, support services and home care promote improved outcomes. Analysis of annual QARR measures for Medicaid comprehensive care include: 

  • Engaged in care, viral load monitoring and Syphilis screening
  • Engaged in care rate increased 4.5% from last measurement year
  • Syphilis rate increased 6.9% from last measurement year
  • Both the engaged in care rate, as well as viral load monitoring are above the state averages

Obstructive Sleep Apnea

Sleep apnea is a chronic condition that requires long-term management. Lifestyle changes such as weight loss and elimination of alcohol before bedtime may decrease the severity of the apnea, other treatments such as oral appliances, surgery, and breathing devices (CPAP, BiPAP etc.) may be required to effectively manage the disorder. Positive Airway Pressure (PAP) Therapy often is the best treatment for moderate to severe obstructive sleep apnea.

The Sleep Apnea Health Management Program is designed to address ‘new starts’ for Members beginning CPAP as a recommendation from their Provider in collaboration with a Durable Medical Equipment vendor.  This program provides telephonic outreach by Respiratory Therapists (RT) to assist patients with adapting to their therapy while achieving the maximum therapeutic benefits of the prescribed treatment.

Preventive health is a key component to keeping our members healthy. Recommended screenings, immunizations and other assessments are outlined in the Preventive Health Guidelines posted on the provider and member websites.  Members and providers are also educated on preventive health requirements through various methods such as newsletters, websites, fax, phone calls and mailings. Below are a couple examples or preventive health measures and rates. 

Measure 2013 Rate 2014 Rate 2015 Rate 2015 NYS Average 2016 Rate
Adolescent Immunization (Medicaid) 62.03% 65.94% 66.76% 69.24% 70.89%
Cervical Cancer Screening (Commercial) 78% 82.24% 80.8% 79.01%  
Breast Cancer Screening (Medicare HMO) 73.01% 74.12% 74.48% 66.37%  
Well Child Visits (3 to 6 years) Commercial 86.1% 88.2% 89.28% 84.37%  
Chlamydia Screening in Women (Commercial)    59.84% 57.35%   58.15%


Adult Preventive Health

The Adult Preventive Health program targets its preventive health message on the adult enrollee, male and female, 19 years of age and older. Education of enrollees regarding flu and pneumonia vaccine, colo-rectal screening and health screenings is the main focus.

Women’s Preventive Health

We educate women about the importance of getting recommended screenings for breast and cervical cancer, sexually transmitted diseases such as chlamydia and bone mineral density testing to evaluate risk for osteoporosis. 

Child/Adolescent Preventive Health

We educate parents on the importance of making sure their children receive doctor visits for age appropriate well care to include recommended well child and adolescent visits, screenings and vaccinations. 

Community Wellness Program

A community network of health educators offer wellness programming to eligible members free of charge. These educational programs provide members with the information and skills necessary to assist them in making positive lifestyle changes. Topics include nutrition, fitness, weight management, stress reduction, and diabetes education.

Worksite Wellness Program

The Worksite Wellness Program is a comprehensive wellness program centered on the needs of an employer. This program includes access to a customized wellness web site, access to on-site wellness workshops and lectures, interactive campaigns and challenges as well as expert planning, support and advice provided by a Health Promotion Specialist.

Discount Network

Enrollees have access to a comprehensive list of local and national fitness facilities offered at the lowest price guaranteed. Benefits include flexible memberships and travel privileges, as well as transfer and freeze options. Members also have the ability of purchase fitness and nutrition services at a discounted rate. Services are searchable by zip code.

Tobacco Cessation

The Roswellness InhaleLife Program is a scientifically based program that has helped members quit tobacco successfully for over 10 years through telephonic counseling. Roswellness InhaleLife uses a comprehensive approach to effectively address all three aspects of tobacco dependence: physical, psychological and behavioral. Quit Coaches work with the member to develop a customized quit plan that is tailored to their needs. Overall customer satisfaction with this program remains high at 97%.  The Roswellness InhaleLife Program includes up to four scheduled phone-based treatment sessions in English or Spanish with a professional quit coach as well as fulfillment of nicotine replacement therapy for eligible members.

Break the Habit is a tobacco cessation program offered at the employer group level.  This 4-week program is aimed at helping participants succeed at leading a tobacco free lifestyle by providing education and motivation along the way.  

Childhood Health and Wellness

Overweight children and adolescence are an important public health issue because of its rapidly increasing prevalence and the associated adverse medical and social consequences.  The dramatic increase, co-morbidities, and associated financial burden warrant a strong preventative approach. Practitioners are provided with the tools and resources necessary to help educate and manage their patient population through the  Good Health Club obesity prevention toolkit.  

Health Coaching

Our health coaches work with members to help identify their wellness needs, provide them with the tools and resources needed to succeed, and motivate them to make long-term health or lifestyle changes. A health coach can actively support, encourage, and educate members in the areas of:

• Weight management

• Exercise

• Nutrition

• Stress management

• Tobacco cessation 

A Health Coach’s role can range from working with a participant to set goals, to establish a treatment plan, and to follow-up on compliance as needed. Health Coaching is provided over the phone.

Wellness Web Site

MyHealth, our digital health management tool, engages employees by leveraging health plan data to populate an individualized Personal Health Itinerary®—a unique health optimization plan created specifically for employees to improve their health. This web site is secure and private. MyHealth provides a multitude of interactive  wellness tools, including:

  • Self-paced wellness programs
  • Ask an Expert functionality
  • Online video coaching
  • Integration with hundreds of wearable devices
  • Comprehensive Health Assessment 

All content is available through mobile devices.

Collaborative Participation

We’re active in joining with other organizations to improve the health and well-being of the local community.  Our health experts participated in many programs throughout the year with the goal of engaging as many members as possible.  More detail on collaborative participation is available on the Annual Evaluation document.

In order to improve the accuracy of the information given to customers when they call Customer Service, a Call Monitoring Program is in place. Frequent modifications are made to our program to improve the service we offer to our customers. The Call Monitoring Program includes an evaluation of eight call behavior strategies that have been taught to all of our customer service representatives. This behavior strategy program, called the Ulysses Learning Program, was implemented to improve and provide excellent customer service to our members, providers, and partners.

Customer Satisfaction Monitoring

We have a program that monitors the quality of our customer service department. This includes making sure that information given by our staff is accurate and that customers do not have to wait long for a response to their question. Many times our customers contact us with quality of care complaints. This allows us to investigate and track issues in order to identify areas for improvement.

We also do customer satisfaction surveys where members are asked questions on how they like our service. Results from surveys and customer complaints are monitored and data is shared with a team focusing on customer satisfaction. Although we routinely receive concerns from our customers our data shows that our customer quality of care complaints are within normal ranges.

One of the surveys done is called the Consumer Assessment of Health care Providers and Systems (CAHPS)®. The same questions are asked to customers across the nation to measure satisfaction with their health plan and doctor. This survey allows us to compare ourselves with other health plans and to focus on specific areas of improvement.

In 2016, the majority of our lines of business were rated above the national average on the overall satisfaction rating of the health plan. Members’ satisfaction with customer service also scored positively, with all lines of business scoring at or above the national average.

Pharmacy Benefits Satisfaction

In 2016, BlueCross BlueShield of WNY’s Pharmacy Benefits Manager (PBM), Express Scripts, strived to meet all operations performance standards for all lines of business and implemented process improvement for any that did not.

If you would like a paper copy of this report or need additional information, contact us at 1-877-878-8785 Option 3. You may also write to us at the following address: Quality Improvement, PO Box 80, Buffalo, New York 14240.

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