Accountable Care Organizations (ACOs) and Patient-Centered Medical Homes (PCMHs) partnering with Blue Cross and Blue Shield of Nebraska (BCBSNE) in the company’s Total Care program drove improved patient health outcomes while lowering the cost of care during the 2019-2020 program year, achieving savings of approximately $82.8 million.

Total Care value-based programs are intended to help ensure patients see primary care providers who know their entire medical history, understand their preferences and effectively coordinate optimal care in collaboration with specialized practitioners. BCBSNE members connected (or “attributed”) to a Total Care physician are more likely to be engaged with their doctors, avoid inpatient hospital stays or emergency room visits, get preventive care and effectively manage chronic conditions.

“The interaction between physicians and patients in the Total Care program is the key to mitigating escalating health care costs,” said Dr. Debra Esser, BCBSNE’s chief medical officer. “Our ACO and PCMH partners want to provide this kind of team-based care for their patients because it is improving health outcomes. For example, when you focus on prevention, there are more opportunities to find cancer in its early stages when it’s less expensive to treat; likewise, when a diabetic patient is controlling his or her blood sugars, there are fewer complications.”

Appreciating the impact these incremental outcomes have on population health, Total Care providers are incentivized by BCBSNE for the quality of care they deliver rather than the volume of services they perform. The savings achieved by such things as avoiding unnecessary services, expensive facilities, duplicative care or treatment that could have been prevented is shared between the ACO providers and BCBSNE or its self-funded employer groups. Last year, Total Care savings totaled $82.8 million – up 26% over the previous program year.

The annual health care costs for BCBSNE members attributed to ACO providers were $720 lower on average than those of members who were not in a Total Care arrangement last year (more than $60 in savings per month).

“These encouraging results demonstrate what is possible when payers, providers and employers work together to improve the system,” said Michael Nelson, BCBSNE’s executive vice president of sales and account management. “The strong relationships we have with these key stakeholders—providers and employers—enable us to make a real difference in the health of our members.”

“Care coordination has been a huge success,” said Andrea Eaton, executive director of Great Plains Health Innovation Network, one of BCBSNE’s partner ACOs. “Patients enjoy working with our Care Coordination Team who help educate the patient, develop an action plan and encourage and motivate them to manage their chronic conditions. We’ve seen fewer emergency room visits and reductions in unnecessary testing, procedures and medication for patients in [the Total Care] program. These patients end up leading much healthier lives. During the COVID-19 pandemic, when many people are nervous to leave their homes and feel isolated, the patients in the program have appreciated, more than ever, having a care coordinator checking in with them on a regular basis.”

The Total Care quality criteria ACOs are required to meet is established by Health Effectiveness Data and Information Set (HEDIS®) and measured against national benchmarks provided by the National Committee for Quality Assurance (NCQA). Metrics address hospital readmissions, ambulatory care, cancer screenings, immunizations, diabetic care, antibiotic avoidance, medication monitoring and more.

From July 2019 through June 2020, diabetic members in the Total Care program were 42% more likely to have their blood glucose levels under control than non-attributed members. Attributed children were 23% more likely, and adolescents were 13% more likely, to be up to date on recommended immunizations than those not seeing a Total Care physician. Screenings for cervical and colorectal cancers were 17% and 26% better, respectively, for Total Care members.

“Unfortunately, the onset of the COVID-19 in Spring 2020 led many patients to delay non-urgent visits for preventive care or chronic condition management,” Dr. Esser explained. “Had they remained on track from March through June, we would likely have seen even greater quality improvements. We hope to help all providers and patients return to pre-pandemic levels of preventive care and continue to exceed quality expectations in the coming years.”