My previous employer, Highmark BCBS, is the largest integrated healthcare system created by an insurer rather than a provider network. The affiliated companies serve almost 50 million people nationwide.

To address the paradigm shift where managing chronic disease becomes a primary need and high costs driven by transactional and fee-for-service models are no longer sustainable, Highmark identified the need to evolve from volume-based models to value-based models; from treating people only when they are sick to supporting the whole person throughout his or her life; and from organization-centered processes and priorities to a patient-centric coordinated care experience that aligns each organization serving that patient. To that end, putting patients first means giving members access to high-quality care.

A good example of creating value for its members is the Highmark Cancer Collaborative, which brought together Highmark Blue Cross Blue Shield, Allegheny Health Network, and the Johns Hopkins Kimmel Cancer Center. The goals of this collaboration include:

  • Improving patient safety, patient experience, and clinical outcomes
  • Enhancing quality by increasing the use of evidence-based treatment and reducing unwarranted variations
  • Lowering total costs of care
  • Expanding patient access to high-value care

To promote use of evidence-based treatment pathways, Allegheny Health Network clinicians and the Highmark health plan team reviewed and chose a web-based, decision-support tool powered by the National Comprehensive Cancer Network. They designed a Medical Oncology Pathways Program that gives clinicians free access to that tool and rewards 80% or higher use of recommended pathways by removing requirements for prior authorization. The platform provides access to evidence-based treatment pathways and can be integrated with electronic medical records and other data. It also includes cost information, allowing the medical oncologist and patient to have real-time conversations about treatment costs, where appropriate.

In year 1 of this program:

  • 28 physician practices across Highmark’s 3-state insurance service area joined Allegheny Health Network in using the decision-support tool to aid more than 2,000 decisions
  • Based on initial success, the program has been expanded to cover more than 96% of cancers faced by Highmark health plan members
  • On average, participating medical oncologists used the platform’s treatment guidelines 83% of the time during the first 7 quarters, exceeding the target goal of 80%

With patient-centric care, quality and total costs of care, as well as outcomes, are key value drivers for an integrated healthcare system. Creating and demonstrating value to members ensures retention and long-term growth for a healthcare system. Manufacturers need to continue to establish the clinical and economic value of their products to secure optimal access and utilization.