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CareFirst BlueCross BlueShield (CareFirst) recognizes that Patient Safety (PI) is critical to all aspects of clinical care and services, including behavioral health. Our ability to control medical errors is limited because we do not actually provide the medical services. However, we fully support an environment to help practitioners and providers improve the safety of their clinical practice. We do so by:

• Reviewing continuity and coordination between behavioral health care and medical care services;

• Reviewing continuity and coordination of care between medical practices, specialists, and providers;

• PCP site visit reviews that occur prior to initial credentialing;

• Tracking and trending adverse events and customer complaints

Our goals are to:

• Promote, implement, and maintain effective quality improvement processes throughout the organization;

• Maintain a high quality network of credentialed health care practitioners and providers through a systematic selection and evaluation process;

• Use data to identify opportunities for improving the quality and safety of clinical care, including behavioral health care, and the quality of service;

• Establish standards for care and service and monitor and evaluate performance against standards, including recognized public health goals;

• Monitor and promote the use of preventive health services and implement interventions for improvement;

• Collaborate in the development of programs to promote the effective management of chronic conditions (disease management programs);

• Promote excellence in practitioner medical record documentation that chronicles effective patient care and permits quality review;

We have established an annual Quality Improvement (QI) work plan that provides a framework of activities planned throughout the year. These activities include member surveys, physician accreditation and compliance efforts, and the review, revision, and distribution of clinical practice guidelines. The QI work plan is designed to assist in evaluating the overall effectiveness of our patient safety program.

No. However, our QI Medical Director is responsible for implementing our QI programs.

We use an on-line drug utilization review (DUR) program to help reduce potential prescription drug errors. This tool provides a high level screening for various indicators that might identify possible problems. The pharmacist will receive a message when a problem is detected, thus allowing them to use their professional judgement to determine if the prescription is appropriate.

Retrospectively, we focus a majority of our efforts towards the prescribing physician. Drug safety alerts are sent to notify the physician of their patients whom have received prescriptions for medications that have been recalled from the market for safety reasons, medications that have been issued a black box warning by the FDA, or any necessary notification required based upon manufacture indication. Furthermore, we notify physicians of their patients who are concurrently taking medications that interact with each other. Such notification includes a provision to allow the physician to review the entire medication history of the patient.

Disease Management (DM) is a comprehensive, integrated, and targeted approach to care for members with selected chronic or life-threatening diseases in the areas of asthma, diabetes, cardiovascular disease, and cancer. Our DM programs are designed to help you manage these diseases and improve your quality of life by offering educational information, personal support, and coordination of care with your physicians. Components of the DM programs range from disease-specific quarterly newsletters and community based health education classes to telephonic case management and/or home health programs depending on your level of need. The DM programs also serve to strengthen your relationship with your doctor by making it easier for your physician to monitor your care through the utilization of self-management tools. Your doctor will receive the clinical practice guidelines associated with each DM program as well as receive “patient profiles” that include prescription drug usage and the use of other services (e.g. diabetic retinal eye exam, ER visits, etc.). Eligible members and providers are informed about the DM programs through targeted mailings. Your participation in the DM programs is voluntary. You can learn more about the DM programs at the CareFirst Web site www.CareFirst.com.

Yes, we develop clinical guidelines through our Quality Improvement program. These guidelines are based upon national medical association and health organization recommendations.

Yes. Our provider newsletters contain patient safety information on topics such as practice guidelines, new technology evaluations, and online medical policy.

Yes. We have two physician recognition programs - the Primary Care Physician Recognition Program (PCPRP) and the Specialist Variable Reimbursement Program. We believe that these programs will enhance your health and satisfaction and will also act as an incentive for other medical practices to improve.

The purpose of PCPRP is to acknowledge value-added services not reimbursable to PCPs under our usual fee-for-service arrangements and then reward those practices that are doing a better job of providing these services. Qualifying practices are assessed on 11 measures. These measure include input from our customers and network PCPs and are based on information gathered through the application and credentialing process, patient satisfaction surveys, claims paid, and other sources. Each measure carries a specified number of points. After totaling the number and share of possible points for each practice, all qualifying practices are arrayed in a distribution to determine what incentive they will receive.

The purpose of the Specialist Program is to identify, encourage and recognize practitioners in selected specialties, who have achieved a high-level of training, credentials, experience and use resources efficiently. Under this program a specialist will receive variable reimbursements ranging from 90% to 110% of our fee schedule based on a composite score of the program measures.