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Quality Improvement Program Summary

BlueShield of Northeastern New York programs provide health care services to help our members get and stay healthy.

We promote quality, affordable health care for all ages. We give our providers the most up-to-date information and patient resources so they can provide the best care.

Participation in National Proven Quality Programs

 

National Committee for Quality Assurance (NCQA) Accreditation 

We are accredited by the NCQA, a national agency that evaluates us for quality and safety. This helps keep health care costs lower.

Our 2018 NCQA accreditation status was “Commendable” for our Commercial, Medicare PPO, and Medicare HMO products.

Healthcare Effectiveness Data and Information Set (HEDIS®)

Developed and maintained by the NCQA, HEDIS is a standardized tool used by more than 90% of America’s health plans to measure performance on important areas of care and service:

  • Effectiveness of care
  • Access and 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

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, and used to evaluate the effectiveness of existing quality programs.

Because many plans collect HEDIS data and the measures are so specifically defined, HEDIS makes it possible to do an “apples-to-apples” comparison of health plan performance.

Quality Assurance Reporting Requirements (QARR)

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

In 2018, 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 and identify service-improvement opportunities for evaluating existing and potential quality programs.

Medicare Star

The Centers for Medicare and Medicaid Services (CMS) created the Part C and Part D star ratings to measure how well Medicare Advantage and prescription drug plans (PDPs) perform. Star ratings range from one to five stars, with five being the highest score and one being the lowest. 

This five-star rating system provides Medicare beneficiaries and their families a way to compare plan performance and quality. Star ratings are calculated each year and published in the fall. They’re also used to determine the plan’s quality bonus payment.    

Star ratings are consistent with CMS’ quality strategy of optimizing health outcomes by improving quality and transforming the health care system. The CMS quality strategy goals reflect the six priorities set out in the National Quality Strategy. These priorities include safety, person- and caregiver-centered experience and outcomes, care coordination, clinical care, population/community health, and efficiency and cost reduction.