Health Care Quality Improvement Overview

The following information details quality improvement initiatives undertaken by our health plan.


1 All measures in this category exceed the 2017 national average in one or more lines of business.

2 All measures in this category exceed the 2017 NYS average in one or more lines of business.


BlueCross BlueShield of Western New York programs provide health care services to keep our members healthy and help them to get well when they are ill.

BlueCross BlueShield of Western New York 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 understand how to care for their health.



National Committee for Quality Assurance Accreditation (NCQA)

BlueCross BlueShield of Western New York is accredited by a national quality agency called the National Committee for Quality Assurance (NCQA). This agency surveys us to make sure our members get good treatment and safe care to stay well. This helps keep health care costs lower.

Our 2017 NCQA accreditation status was “Excellent” for our Commercial and Medicare PPO products and “Commendable” for our Medicare HMO and Medicaid products.


Healthcare Effectiveness Data and Information Set (HEDIS®)

The Healthcare Effectiveness Data and Information Set (HEDIS®), developed and maintained by the NCQA, is a standardized measurement tool used by more than 90% of America’s health plans to measure performance on important dimensions of care and service:

  • 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 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 Marketplace lines of business. HEDIS results are used to identify opportunities for improvement in the health care provided to our members, in addition to being used to evaluate the effectiveness of existing quality programs.


Quality Assurance Reporting Requirements (QARR)

Quality Assurance Reporting Requirements (QARR) are reported to the New York State Department of Health and consist of measures from the NCQA, HEDIS, and New York State (adolescent preventive care, HIV/AIDS comprehensive care, and colorectal and lead screening).


In 2017, QARR was publically reported for our Commercial, Medicaid, and Marketplace lines of business. QARR performance results assist our members and prospective members in choosing a health plan. These results are also used to identify service-improvement opportunities for evaluating existing and potential quality programs.



Hospital Quality

BlueCross BlueShield of Western New York works with our hospitals to improve quality and provide safe care. Programs promoting good care such as prevention of infections, surgical complications, and incorrect medications are in place at all participating hospitals.

Blue Distinction Centers for Specialty Care®

Blue Distinction honor is awarded to hospitals that are considered experts in providing specialty care. Hospitals must meet special criteria to be called a Blue Distinction Center (BDC). This designation is based on national care standards. BDCs are recognized for excellent clinical outcomes and processes in the areas of bariatric (weight-loss) surgery, transplants, cardiac care, maternity care, cancer care, spine surgery, and knee and hip replacement.


Doctor  Quality

We recognize the importance of the member/provider relationship and its significance in delivering high-quality care. We work with primary care doctors who use innovative programs that focus on quality-based health care.


Culturally and Linguistically Appropriate Services (CLAS)

Culturally and Linguistically Appropriate Services (CLAS) Standards are designed to enhance the member/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 care of our members.

Educational programs designed to decrease ethnic disparities are provided to promote culturally competent care. Health plan employees complete annual training on how culture and language barriers affect our members and how they can help to make the member health care experience a positive one, while promoting increased compliance and wellness.


Continuity and Coordination of Care

Continuity and coordination of care between the hospital/urgent care/specialist and the primary care doctor ensures safe and appropriate care and can prevent unnecessary treatments and tests for members. Through an annual survey, we monitor how well our providers communicate with each other when treating the same member and identify areas of opportunity. In addition, other health care programs and projects (e.g., case management, radiation safety awareness, etc.) measure and work toward improving coordinated care for our members.

Medical Record Review for Standards

Primary care provider medical records are reviewed and scored against proven record standards. We work to assist doctors to improve information and conversations in the following areas: body mass index (BMI), health care proxy, cultural needs of patients, assessment of depression in an adolescent record, adult vaccines, and substance-use disorders.


Quality Investigations

Whenever a member contacts us with a concern about the care they received from one of our providers, we look into it. We review member 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 ensures the provision and maintenance of appropriate access to primary care services, member services, and some specialty services (behavioral health and OB-GYN) for BlueCross BlueShield of Western New York members. All credentialed providers and those providers who notify us of a new office location go through an on-site review and are expected to be 100% compliant with the plan’s access-to-care standards.

We audit our primary care offices (including pediatricians) and behavioral health offices to make sure our members have 24-hour access to care. We follow up with any office not meeting the standards, review our access-to-care policy with them, and require them to submit written documentation on how they are going to meet the standard.


The patient safety program fosters a supportive environment to promote clinical safety for our members through collaborative efforts with internal departments as well as our practitioners, providers, and community organizations. The patient safety program includes fall prevention in older adults, radiation safety awareness, and medication safety.


Fall prevention in older adults is a population-based, goal- and outcome-oriented initiative that aligns the member, health care delivery system, and planned interventions to decrease the incidence of falls among community members age 65 and older.


We work with our doctors and medical facilities to order X-rays and scans for members only when needed and to keep track of testing to prevent unnecessary duplication. The program provides ordering doctors with member-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.


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 or improper dosing. We encourage members to review their medications with health care providers on a regular basis. Improved medication safety can help reduce hospitalizations and falls in older adults, and can result in increased overall quality of care for our members.


The health plan promotes improved quality of life for our members by helping them to better understand their illness and self-manage their conditions.  We accomplish this by providing education for our members 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 members to coach and teach. Health coaching calls remain well received by our members who obtain tips and information to care for their conditions.


Asthma 1, 2

The goal of the asthma management program is to improve the health status for members using a multidisciplinary, population-based approach and to manage health care costs by promoting evidence-based treatment while assisting members to achieve optimal control of their illness. Interventions are individualized and targeted to specific member needs based on the member’s level of self-management.


Attention Deficit Hyperactivity Disorder (ADHD) 1

The attention deficit hyperactivity disorder (ADHD) 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) 1

The goal of the chronic obstructive pulmonary disease (COPD) program is for members to control their symptoms and maintain an active lifestyle. An individual’s quality of life can be seriously affected if COPD is poorly managed — we provide tools to assist in controlling symptoms and staying healthier longer. Spirometry testing and medication management (corticosteroids and bronchodilator) rates are measured to determine program success.


The primary focus of the depression management program is to improve the quality of life for our members with depression by assisting them in getting the right treatment, medications, and follow-up care. Ensuring our members receive appropriate office follow-up after an antidepressant medication has been prescribed or following hospitalization is a major objective of this program.


Diabetes (Sugar in the Blood)

The diabetes program is designed to promote compliance with diabetic care and to 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 recommended tests (e.g., blood sugar and cholesterol, eye exams, etc.) to monitor their diabetes.

Cardiac Program

The cardiovascular health program was developed to address growing concerns about cardiac disease. The program addresses those members at higher risk for complications associated with cardiovascular diagnosis.

Hip & Knee 2

This is a new program developed in July 2017 designed to raise awareness and improve outcomes related to the cause, treatment, and management of osteoarthritis of hip and knee, with both our physicians and members.

Patient self-care education starts as soon as possible after osteoarthritis diagnosis of the hip or knee to prevent life-changing complications. An integral part of this process is one-on-one health coaching offered by health coaches who are specifically trained in telephonic health coaching. As part of this member-centered approach, the health coach actively listens and works collaboratively to achieve desired health goals and enhance the overall quality of life for every member served. Identified members are encouraged to participate in preventive visits with providers. Education is focused on conservative treatment options and lifestyle techniques for improved health including exercise, smoking cessation, and weight loss, as needed.


Spine Program 1

The program goal is to raise awareness and improve outcomes related to the cause, treatment, and management of back-related conditions with both our providers and members.


Substance Use Disorder (SUD)

A new program in 2017, the substance-use disorder (SUD) care management program includes strategies to treat existing dependency among members and the prevention of future addiction. The comprehensive care management approach includes prevention, treatment, recovery, and specialized services. Substance-use treatment can be characterized as a continuum, dependent on things such as magnitude of the substance-use problem, level of care (inpatient, residential, intermediate, or outpatient), or the intensity of the services. The continuum ranges from case finding and pretreatment to primary treatment and aftercare.

The case management program assumes responsibility for the coordination of all aspects of care for members identified with chronic or high-risk conditions. This includes high-risk maternity, palliative, cancer, chronic kidney disease, behavioral health, and members awaiting a transplant. The role of the case manager is to promote quality care and meet the member’s needs while maximizing benefits and assuring proper use of services in the most appropriate setting.

Chronic Kidney Disease

The target audience for this program includes members with chronic kidney disease. The goal of this program is to assist members in slowing the progression of their illness through member education and coordination with a nephrologist. Targeted interventions are offered for different stages of chronic kidney disease, and care managers work with primary care physicians to encourage nephrologist referrals for appropriate members.

Right Start Prenatal (Maternity Care) and Newborn Care 1

The Right Start prenatal case management program continues 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 members identified as high-risk.


The case manager follows the member throughout the pregnancy. The role of the case manager is to promote quality care and meet members’ needs while maximizing benefits and assuring proper use of services in the most appropriate setting. The program uses New York State Department of Health Medicaid prenatal guidelines in an effort to standardize and improve prenatal care.


Palliative Care

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


The case management and utilization management teams 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 quality care.



Our HIV/AIDS case management program goal is to promote adequate and timely care, management of comorbid conditions, and adherence with medications and treatment plans, 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.


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. Positive airway pressure (PAP) therapy often is the best treatment for moderate to severe obstructive sleep apnea. Other treatments such as oral appliances, surgery, and breathing devices (CPAP, BiPAP, etc.) may be required to effectively manage the disorder.

This program provides telephonic outreach by respiratory therapists to assist members in 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 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.

Adult Preventive Health 1

The adult preventive health program educates adult members 21 years of age and older on the importance of preventive health visits and receiving recommended health screenings (such as a colorectal cancer screening) and important vaccinations (including flu and pneumonia).


Women’s Preventive Health

The women’s preventive health program educates women on the importance of receiving recommended preventive health visits and screenings for breast and cervical cancer, osteoporosis, and chlamydia (a sexually transmitted disease).


Child/Adolescent Preventive Health 1, 2

The child and adolescent preventive health program educates parents on the importance of making sure their children receive age-appropriate well care, including recommended well child and adolescent visits, screenings, and vaccinations.

Community Wellness Program

A community network of health educators offers 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 website, on-site wellness workshops and lectures, and interactive campaigns and challenges, as well as expert planning, support, and advice provided by a health promotion specialist.

Discount Network

Members have access to a comprehensive list of local and national fitness facilities. 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 through telephonic counseling for more than 10 years. 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 member 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 four-week program is aimed at helping participants succeed at leading a tobacco-free lifestyle by providing education and motivation along the way.

Health Coaching

Our health coaches work with members to help identify their wellness needs, provide them with the tools and resources 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 include working with a participant to set goals, establishing a treatment plan, and following 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 website is secure and private. MyHealth provides a multitude of interactive wellness tools, and all content is available through mobile devices.


Collaborative Participation

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


In order to improve the accuracy of the information given to members 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 members. 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 information given by our staff is accurate and that members do not have to wait long for a response to their question. Many times our members 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 member satisfaction surveys where members are asked questions on how they like our service. Results from surveys and member complaints are monitored and data are shared with a team that focuses on member satisfaction.

One of the surveys is called the Consumer Assessment of Healthcare Providers and Systems (CAHPS®). The same questions are asked to members 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 2017, 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 above the New York State average.


Pharmacy Benefits Satisfaction

In 2017, BlueCross BlueShield’s pharmacy benefits manager (PBM), Express Scripts, strived to meet all operations performance standards and implemented process improvement for any that were not met.


All measures in this category exceed the 2017 national average in one or more lines of business.

All measures in this category exceed the 2017 NYS average in one or more lines of business.


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.


BlueCross BlueShield of Western New York is a Medicare Advantage plan with a Medicare contract and enrollment depends on contract renewal. A division of HealthNow New York Inc., an independent licensee of the BlueCross BlueShield Association.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits may change on January 1 of each year. The pharmacy network and/ or provider network may change at any time. You will receive notice when necessary.

The value-added services described are neither offered nor guaranteed under our contract with the Medicare program. In addition, they are not subject to the Medicare appeals process. Any disputes regarding these products and services may be subject to the BlueCross BlueShield grievance process.

BlueCross BlueShield of Western New York complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

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