11
CASE STUDY: BLUE CROSS BLUE SHIELD OF NORTH CAROLINA

Interviewees: Robert Emerson, PhD, VP and Head of Strategic Data Management; and Bradley Donovan, Director of Divisional Strategy

ABSTRACT

Blue Cross Blue Shield of North Carolina (Blue Cross NC) is the largest health insurer in the state of North Carolina, with more than four million covered lives as of 2020. With sizable market share, Blue Cross NC has led a statewide shift toward value-based care (VBC) in an innovative partnership with five health systems. This initiative, called Blue Premier, aims to align incentives for improving quality of care, and create a data infrastructure for standardized reporting of data to support clinical improvements and manage total cost of care. Initiated in 2019, the program has grown from five initial health system partners to eight, and has reported both quality improvements and cost savings. In developing Blue Premier, program leaders began with a single-site pilot to navigate the operational, legal, and technical barriers of data sharing, and used insights from this pilot to create a broader playbook to support data exchange and anticipate challenges as new systems were brought into the program.

BACKGROUND

Value-based care has been a cornerstone of the shift in health care payment reform over the last decade. Under this arrangement a physician, clinic, or health system contracts with an insurer (payer) to be accountable for a defined population of patients. Predefined benchmarks for cost and quality are often established as part of the contract, and those who deliver health care are thus incentivized to provide the highest quality care at a lower cost. Many VBC arrangements are “shared risk” in that doctors and hospitals share in the cost savings—receiving performance payments if targets are met, and share the losses if targets are missed.

In North Carolina, a collaboration called Blue Premier was initiated in 2019 between five health systems and a single payer, Blue Cross Blue Shield of North Carolina (Blue Cross NC). Blue Premier is a significant effort to apply VBC on a very large scale. For it to succeed, the health systems also needed to agree to share health data to support population health management. For independent physicians, this data-sharing and analytics capability is managed by a related partnership with Aledade, a private company that supports the creation and maintenance of accountable care organizations (McClellan et al., 2019; Reese, 2020).

Data shared between systems in the Blue Premier program and Blue Cross NC (as the payer) include encounter-level structured and unstructured clinical notes, and the structured data are typically formatted to Health Level 7 (HL7) standards, which is an international set of standards that guides the transfer of clinical and administrative data between software applications. Early efforts to pilot test the health data sharing focused on the use case of Admit, Discharge, and Transfer (ADT) data, as this is a core piece of administration and patient management, and the Continuity of Care Document, which helps systems exchange essential patient information (e.g., demographics, allergies, medications, lab results) in a seamless and standardized way. In the pilot, Blue Premier leaders identified important considerations when moving data from clinicians to payers, including the extent to which certain data may be filtered out before it is shared with the payer, such as any private-pay arrangements, or certain sensitive clinical information. A key lesson from the pilot was to identify a use case that had value for both the system and Blue Cross NC. The workflow for exchanging ADT data was comparatively straightforward, and the value proposition of reducing redundancies and administrative burden was compelling as a pilot.

DESCRIPTION

With respect to governance and leadership, again, the VBC arrangement drove the parameters for sharing data. Negotiations and agreements were developed at the level of the chief medical

officers and other C-suite leaders, such as chief data officers, chief data analytics officers, and chief financial officers. The leadership of the participating organizations understood that there was a positive return on investment netted by creating a more efficient infrastructure for sharing data, particularly as federal regulations from the Centers for Medicare & Medicaid Services and the Office of the National Coordinator for Health Information Technology move in the direction of mandatory health data sharing.

As Blue Premier moved from a pilot to a larger initiative, new and different challenges were encountered. Addressing concerns from legal and privacy departments was cited as an early learning, in that the legal contracts needed to include mutually agreeable language related to data use and business associate agreements, as well as a priori agreements about how to handle out of network claims data, which requires upfront patient consent in order to be shared. An additional challenge was that the philosophies and processes at the health system level were highly variable. Some systems were more comfortable than others with the data release procedures, including the cadence of data release, and types of data to be shared. It was also the case that data were usually, but not always, harmonized to the established HL7 standards, which necessitated additional data extraction and standardization.

The level of comfort with data sharing also varied by medical subspecialty within a system, an important insight for other health care delivery organizations, since improving quality is a linchpin of this initiative as it is for other accountable care organizations structured around VBC agreements. Many medical specialties have specific performance measures designed to measure quality of care. When system partners come together to create accountable care organizations and craft attendant data-sharing agreements, the Blue Cross NC interviewee encouraged that the partners take these specialty-specific performance measures into account rather than developing new or separate quality measures. This will facilitate data exchange and reporting and will also yield administrative efficiencies and accelerate support from frontline clinicians. Moreover, many specialties, such as oncology, have many interdependencies with other clinical disciplines (e.g., radiology, surgery, primary care), and measuring quality must take these relationships into account.

Overall, Blue Premier’s ability to overcome these challenges was facilitated by the VBC arrangement itself, and the fact that VBC conferred benefits to participating systems. In short, meaningfully improving quality and reducing costs was predicated on data sharing. An unanticipated but beneficial opportunity to leverage their early work on standardizing data for sharing came about when the COVID-19 pandemic hit, as Blue Premier collaborators were able to use their standardized lab data to guide plans for virtual care and telehealth, including finding capacity in their systems for different patient care modalities.

FUTURE DIRECTIONS

Reflecting on the early success of Blue Premier, the case study interviewees recognized two important contributing factors: Blue Cross NC’s unique position in the market and the fact that it insures half the population of North Carolina. The state also has a significant proportion of health systems that are academic/research institutions, creating an environment that is open to innovation and offers technological acumen. Some of these factors are configurable in other states or regions, even as other factors are unique. The interviewees further emphasized the fundamental importance of understanding the incentives driving each partner and then aligning the incentives across all collaborators. In their case, the desire for more fluid data that could be applied for multiple synergistic needs, coupled with the shared imperative to take on VBC contracts helped to drive collaboration and a desire to build “the infrastructure of the future.”

Notwithstanding the success of Blue Premier, the case study interviewees believed that, in spite of the important work the partners did to standardize data across their systems, the better way forward would be for all health data to be in a pre-standardized to a pre-specified format, to avert the need for back-end harmonization by each individual health system or data compiler (such as a health information exchange). A second recommendation they encouraged was the development of a national governance structure to oversee the (re)use of data by third parties that are not covered by the Health Insurance Portability and Accountability Act. Ulti-

mately, the initiation of a comprehensive shift to VBC offered an opportunity to improve the care while improving the data infrastructure.