Managed Care BCBS

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University of Massachusetts, Boston *

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334

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Health Science

Date

Oct 30, 2023

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pptx

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Uploaded by DeanHerringMaster134

Professional Managed Care Roles for RNs in the Payer Environment Presented by : Kathie Sliney, RN, BSN Clinical Training Specialist , BCBSMA Kathy Gardner, RN, MBA Vice President Clinical Operations, BCBSMA

2 Blue Cross Blue Shield of Massachusetts Objectives • Describe the responsibility of a health plan (payer) to achieve the goals of the Triple Aim • Identify 3 roles held by the professional nurse in the payer setting • Explain how the professional nurse can translate clinical skills to impact a member’s care and improve outcomes

3 Blue Cross Blue Shield of Massachusetts What is the Triple Aim? Source: Institute for Healthcare Improvement • Improving the individual experience of care • Improving the health of populations • Reducing the per capita costs of care for populations

4 Blue Cross Blue Shield of Massachusetts How to improve the individual care experience  Reduce fragmentation of care – assist with care coordination, collaborate and communicate with providers  Assure our policies are evidence-based and align with principles of health equity and “Parity”  Integrate Behavioral Health, Complex Case Management, Disease Management, Prevention and Wellness  Primary Nurse Care Management model

5 Blue Cross Blue Shield of Massachusetts Populations • Groups of individuals defined by geography, condition or other attributes can be considered a population if data are available to track them over time. • Social determinants of health: health literacy, education level, geography, access to care and socioeconomic status can have an adverse impact on health outcomes Population Health Management Data • Health Effectiveness Data Information Set (HEDIS) • Predictive Modeling • Provider Quality (Measuring outcomes of our provider partners) Source: David Nash, MD, MBA, Dean, Jefferson College of Population Health

6 Blue Cross Blue Shield of Massachusetts Reducing per capita cost of care  Value-based contracts and provider partnerships  Focus on preventing avoidable readmissions  Proper utilization through reduction of overutilization and underutilization  “The right care, in the right setting, for the right duration”

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