Download Spine Surgery/ Knee and Hip Replacement

Blue Distinction Centers+
Spine Surgery/ Knee and Hip Replacement
Elevator Speech
Blue Distinction® is awarded by Blue Cross and Blue Shield companies to recognize specialty medical
facilities that deliver the highest quality health care. The Blue Distinction program has recently been
updated to focus on two criterions: quality and cost of care. The medical facilities that meet the total
value criteria will be recognized as Blue Distinction Centers+ (BDC+).
Due to increased pressure to rein in medical costs in the U.S. and customer requests, the Blue Cross and
Blue Shield Association added cost criteria to the Blue Distinction program. The new criteria prompts
specialty care providers to hold down costs, while still offering superior care.
The addition of the cost criteria will likely cause a number of Blue Distinction centers to lose their status,
so the Blue Cross and Blue Shield Association established the quality-only designation to support the
delivery of high quality care.
Current Blue Distinction Centers for Spine Surgery® and Blue Distinction Centers for Knee and Hip
Replacement® have been evaluated on quality and cost. Those who meet the total-value (BDC+) and
quality-only (BDC) criteria will be recognized with a national announcement from the Association in
February 2013.
Blue Cross and Blue Shield of North Carolina will recognize those facilities that have met the total-value
(BDC+) designation only. In support of our commitment to help reduce costs BCBSNC will not recognize
facilities who have met the quality only (BDC) requirements.
Key Messages
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The Blue Cross and Blue Shield Association recently announced changes to the evaluation
process for Blue Distinction Centers for Specialty Care® to include cost-of-care criteria.
The Blue Distinction Center+ program now recognizes facilities with the highest quality of care
at the most competitive price.
The addition of cost-of-care criteria to the Blue Distinction evaluation process will help
consumers be more cost-conscious by bringing attention to medical facilities that offer more
affordable, high quality care. Facilities that meet the criteria will be recognized as Blue
Distinction Centers+.
Some current Blue Distinction Centers may not meet the Blue Distinction Center+ criteria and
therefore will not be recognized as a BDC+.
Blue Distinction Centers for Spine Surgery® and Blue Distinction Centers for Knee and Hip
Replacement® will be impacted at this time by the addition of cost-of-care criteria. Facilities in
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these groups that meet total value-based (BDC+) or quality-only (BDC) requirements will be
announced by the Blue Cross Blue Shield Association in February 2013.
Spine Surgery, and Knee and Hip Replacement will be the first treatment categories impacted by
the addition of the cost criteria. Four other programs – Cardiac Care, Transplants, Bariatric
Surgery, and Complex and Rare Cancers – will add the cost criteria in 2013.
BCBSNC is committed to helping reduce the cost of health care without compromising quality.
This change is an example of how BCBSNC is working to help rein in health care costs for its
customers.
In support of our commitment to help reduce costs BCBSNC has elected to only recognize totalvalue (BDC+) facilities in NC and will not recognize facilities who have met the quality only (BDC)
requirements.
National Accounts
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BCBSNC will recognize total-value (BDC+) designations only; however, other Blue Cross and Blue
Shield Plans may accept both the Blue Distinction Center and the Blue Distinction Center+
designations.
Some facilities may not meet the Blue Distinction Center+ criteria which include the new costof-care criteria, and in the Blue Cross and Blue Shield of North Carolina these facilities will lose
their designation as a Blue Distinction Center, because North Carolina does not recognize quality
only (BDC).
Facilities that meet total value-based (BDC+) or quality-only (BDC) requirements will be
announced by the Blue Cross and Blue Shield Association in February 2013.
Nationally, more than 460 facilities are being recognized as Blue Distinction Centers+ for their
expertise and cost efficiency in delivering specialty care.
Q&A
What is Blue Distinction?
Blue Distinction is a national designation program, set by the Blue Cross and Blue Shield Association,
that recognizes facilities that demonstrate expertise in delivering quality specialty care safely, efficiently
and cost effectively. There are currently six Blue Distinction designations: Spine Surgery, Knee and Hip
Replacement, Cardiac Care, Transplants, Bariatric Surgery, and Complex and Rare Cancers.
The Blue Cross and Blue Shield Association created the Blue Distinction program with two goals:
 To encourage facilities and physicians to improve the overall quality and delivery of health care
at the best price, resulting in better outcomes for patients.
 To support consumers as they identify high quality and cost-effective medical facilities that best
meet their specialty medical needs.
How is Blue Distinction evolving?
Blue Distinction now includes a value-based designation awarded to facilities that meet stringent quality
measures, as well as cost-of-care criteria. This is known as the Blue Distinction Center+ (BDC+)
designation. In addition, the Blue Cross and Blue Shield Association has created a quality-only
designation to recognize facilities that offer superior quality care, but do not meet the cost-of-care
criteria. This is known as the Blue Distinction Center (BDC) designation, which is not recognized by
BCBSNC.
These new Blue Distinction Centers+ designations will help consumers find quality and affordability in
their search for specialty-care doctors who practice at these facilities. They will also encourage health
care professionals to improve the overall quality and delivery of care, while holding down costs.
What changes are being made?
New cost criteria have been added to the Blue Distinction program to address market demand and
customer request for more affordable health care. Only facilities that meet Blue Distinction’s quality
criteria will be considered under the newly added cost criteria. The addition of the cost criteria has
caused some Blue Distinction centers to lose their designation. In response to this, the Blue Cross and
Blue Shield Association created a quality-only designation (BDC) that allows medical facilities to continue
to be recognized for offering superior quality medical care. Blue Cross and Blue Shield of Carolina and
Blue Cross and Blue Shield of Mississippi do not recognize the quality only (Blue Distinction Center)
designation. Only the Blue Distinction Center+ is recognized by BCBSNC.
These changes in criteria will help customers make more informed health care decisions by helping them
find facilities that provide the highest quality and most cost-effective care options.
Why are these changes being made?
Due to increased pressure to rein in medical costs in the U.S., the Blue Cross and Blue Shield Association
added the cost criteria to the Blue Distinction program. With the new criteria, the Blue Cross and Blue
Shield Association is prompting specialty care facilities and physicians to hold down costs, while still
offering superior care.
However, a number of Blue Distinction centers participating in the previous quality-based program do
not meet the higher quality standards or the new cost criteria. Thus, the Blue Cross and Blue Shield
Association created an additional quality only designation that uses the higher quality standards for the
designation. This additional quality-only designation will include a broader list of facilities that meet the
same selection criteria of quality status as the value-based designation, but did not meet the cost-ofcare selection criteria. These designations of Blue Distinction Center+ and Blue Distinction Centers will
help BCBSNC customers be more informed when looking for specialty care. Eligible North Carolina
quality-only facilities were notified in November 2012 that BCBSNC will not be participating in the
quality only designation. The Blue Distinction Centers+ will be announced in mid-February 2013.
BCBSNC is committed to helping its customers make more informed choices when seeking specialty
medical treatment. Supporting the new Blue Distinction Center+ designation will make it easier for
customers to find more affordable, high quality care in North Carolina.
What centers will be affected by these changes?
The new total-value (BDC+) and quality-only designations (BDC) will be phased in across all six Blue
Distinction programs during 2012 and 2013, beginning with Blue Distinction Centers for Spine Surgery
and Blue Distinction Centers for Knee and Hip Replacement. BCBSNC will continue to only recognize the
BDC+ designation.
When will the changes be announced?
Spine surgery, and knee and hip replacement facilities that meet the new Blue Distinction Centers +
designation criteria will be announced in February 2013.
Similar designation processes for Blue Distinction’s four other programs – Cardiac Care, Transplants,
Bariatric Surgery, and Complex and Rare Cancers – will follow in 2013.
What is the timeline for this rollout?
BCBSNC invited eligible Spine Surgery, and Knee and Hip Replacement facilities to apply for these two
Blue Distinction designations in December 2011. Facilities completed the Request for Information (RFI)
by Feb. 14, 2012. Once evaluated using both the quality and cost-of-care criteria, new Blue Distinction
Centers+ for Specialty Care will be announced in February 2013.
Will this lead to fewer Blue Distinction Centers for Specialty Care?
Yes. With more robust quality selection criteria and the addition of cost criteria, not all of the existing
Blue Distinction Centers for Spine Surgery and the Blue Distinction Centers for Knee and Hip
Replacement will be re-designated with the total-value (BDC+) designation. However, we do not
anticipate a dramatic reduction in Blue Distinction centers with every future evaluation.
While the new total-value (BDC+) designation will lead to fewer Blue Distinction Centers for Spine
Surgery® and Blue Distinction Centers for Knee and Hip Replacement®, specialty-care providers can still
participate in the Blue Distinction program if their facility offers high quality care through a new qualityonly designation, however these Blue Distinction Center designations will not be accepted by North
Carolina and Mississippi. Created by the Blue Cross and Blue Shield Association, this additional
designation will represent a broader list of facilities that meet the same selection criteria for quality as
the total-value designation, but these facilities did not meet the cost-of-care criteria.
The new Blue Distinction Centers+ and the Blue Distinction Center designations will better inform health
care consumers about facilities that deliver quality specialty care safely, efficiently and cost effectively.
If facilities lose their Blue Distinction designation, can they file an appeal?
If specialty-care facilities would like to appeal, they can submit a written appeal request within 30 days
of the date that BCBSNC sends the Eligibility Notification Packet to their facility. Specialty care facilities
should refer to the Appeal and Reconsideration Procedures document available on the BD Link Bulletin
Board for more details.
Facilities should look for an upcoming request for information (RFIs) on other Blue Distinction Center+
designations, including Cardiac Care, Transplant, Bariatric Surgery, and Complex and Rare Cancers in
2013. BCBSNC will notify facilities when these dates are announced.
Could a facility keep its Blue Distinction designation in one specialty area, but lose its designation in
another specialty area (e.g., under the total-value criteria, could a hospital keep its designation as a
Blue Distinction Center for Spine Surgery, but lose its designation as a Blue Distinction Center for Knee
and Hip Replacement)?
Yes. Each Blue Distinction designation has its own specific selection criteria, so a facility must apply
separately and meet the selection criteria for each Blue Distinction program during each designation
cycle.
What if a facility met the quality, but not the cost criteria? What options does the facility have?
Since the Blue Cross and Blue Shield Association began the value-based designation process, it added
another quality-only designation. The additional designation will represent a broader list of national
facilities that meet the same selection criteria for quality status as the total value-based designation, but
did not meet the cost criteria. BCBSNC will not recognize the quality only Blue Distinction Center (BDC)
designation. Eligible quality-only facilities were notified by BCBSNC and the Association in November
2012 that BCBSNC will not be recognizing quality only facilities. The total-value and quality-only
designations will be announced in February 2013. Please note: quality-only designations (BDC) will not
be announced for North Carolina.
Has Blue Distinction moved from being a more inclusive to a more selective designation?
Employers are asking for more options to help their employees find more affordable, high quality health
care, especially for expensive specialty care. Blue Distinction seeks to identify and recognize facilities
that deliver quality care safely, efficiently and more cost effectively.
We’ve responded to consumer and employer demands for greater emphasis on increased quality and
affordability in specialty care, which has resulted in fewer Blue Distinction Center+ designations for
Specialty Care.
Consumer and employer groups are always looking for ways to address rising health care costs. Did
this influence the addition of the cost-of-care criteria in Blue Distinction designations?
Strong market demand from both consumers and employer groups called for an evolution to the valuebased designation. The Blue Cross and Blue Shield Association met these demands by enhancing Blue
Distinction program to create a new designation, Blue Distinction Center+, that recognizes specialty care
facilities for providing high quality care at a more affordable price.
In addition, the Blue Cross and Blue Shield Association has also created a quality-only designation to
continue to support and recognize facilities that provide medical care of superior quality, however the
Blue Distinction Center (BDC) designation of quality-only criteria will not be recognized in North
Carolina.
Who determined these changes? Are there additional criteria being set by BCBSNC?
The Blue Cross and Blue Shield Association sets the guidelines and criteria for the Blue Distinction
Centers for specialty care. The Blue Cross and Blue Shield Association changed to program to include the
total-value (BDC+) and the quality-only (BDC) designations. Additional criteria from BCBSNC require that
all hospital-based physicians employed by the hospital are under contract with BCBSNC. The qualityonly designation of Blue Distinction Center is not recognized in North Carolina.
What is the cost impact of this change to BCBSNC?
This change can help reduce the overall cost of health care for spine surgery, and knee and hip
replacements by making consumers more aware of their health care spending.
If facilities do not meet the cost-of-care requirements but are still interested in achieving the Blue
Distinction Center+ status, they may choose to restructure their costs, or make cost reductions and
submit for reconsideration of their Blue Distinction status. This may reduce what a patient pays at a
facility.
Will these changes limit the choices for patients?
Certain employers offer health plans that require participating employees to pay a significantly higher
cost share if they do not use Blue Distinction centers for their spine surgeries, and hip and knee
replacements. Since BCBSNC does not recognize a quality-only Blue Distinction Center in North Carolina,
these individuals must use a Blue Distinction Center+ to have a lower cost share for these surgeries.
Individuals enrolled in these plans may have fewer Blue Distinction Center+ facilities located near them
once the new cost criteria are in effect. These patients may need to travel further to a Blue Distinction
Center+ facility for their surgery, or they may opt to pay more for a surgery at a nearby facility that is
not a Blue Distinction Center+.
Will the addition of the cost-of-care criteria affect the quality received in Blue Distinction Centers?
No, quality will continue to be the most important factor for determining which specialty care facilities
receive Blue Distinction Center+ designation. The quality criteria is continually updated and increased on
a prescribed basis. If Blue Distinction Centers+ for specialty care do not continue to improve quality
while holding down costs, they can lose their BDC+ designation. If a facility does not pass the quality
metrics, they are not passed on to the cost-criteria determination stage of the evaluation process.
To further emphasize the Blue Cross and Blue Shield Association’s focus on high quality health care, it
has created the quality-only (BDC) designation. This additional designation will allow the Blue Cross and
Blue Shield Association to continue supporting and recognizing facilities that provide medical care of
superior quality. Blue Cross and Blue Shield of North Carolina will not recognize the Blue Distinction
Center designation. Only the Blue Distinction Center+ designation will be recognized in North Carolina
and Mississippi.
Will this impact what a patient pays at a Blue Distinction Center?
Possibly. If a Blue Distinction Center for Specialty Care meets the newly added cost criteria to receive
the Blue Distinction Center + designation, their costs probably won’t change. If a facility is in a contract
negotiation when they receive their Blue Distinction Center recognition, its rates could change and
patients could pay different prices for specialty care.
If a facility loses its Blue Distinction Center recognition because of the added cost-of-care component,
the facility may choose to restructure their costs to offer more affordable care, and reapply for their
Blue Distinction Center+ status. This would reduce what a patient pays at a facility.
How many Blue Distinction Centers+ for Specialty Care do we have now in North Carolina, and how
many will be impacted by this?
Blue Distinction Centers+ for Spine Surgery® and Blue Distinction Centers+ for Knee and Hip
Replacement® participation agreements are not complete yet. They will be finalized and announced in
February 2013 by the Association.
How will I know if my plan is impacted by these changes?
Requirements for customers seeking speciality care vary on a plan-by-plan basis. If you have any
questions about Blue Distinction Center+ requirements based on your plan, and how these changes may
affect you, please call the Customer Service number listed on the back of your BCBSNC member ID card.
A Customer Service representative will speak with you about specific policy requirements.
What is the number of hospitals in North Carolina that specialize in spine, knee and hip? What is the
number of facilities that applied and the number that were designated?
There were 34 facilities that applied for spine, knee, and hip Blue Distinction Center+ designation in
2011- 2012 cycle, and currently 10 facilities are designated as BDC+ (quality and cost). For the most
updated list, please visit the BCBSNC provider directory at www.bcbsnc.com and on the bcbs.com
national website at http://www.bcbs.com/why-bcbs/blue-distinction/. A total of 32 facilities applied in
the 2009 and 2010 RFI cycles and 26 that were designated as BDC (quality) facilities. This is a decrease
in the number of Blue Distinction Center+ facilities in North Carolina for Spine Surgery and Knee and Hip
Replacement designation.
What percentage of all facilities is designated in NC and nationally?
This is pending right now until all BDC+ agreements are signed nationally. I have requested this % from
the Association.
What specific criteria are required for consideration, including the volume of procedures, etc.?
To be eligible for Blue Distinction Center +, a facility must meet the minimum thresholds for that
specialty area, in all of the following evaluation components:
Quality Decision – based on information provided by a facility in the RFI Survey
Business Decision – based on information provided by local Blue Plans
o The Facility and Physician Participation Status, in the local Blue Plan’s BlueCard PPO
Network
o Local Blue Plan Criteria
o Cost of Care, based on healthcare claims information using NCCT methodology
The local plan criteria are that all hospital-based physicians must be in network. BCBSNC is only offering
BDC+ (cost and quality). Specific quality criteria can be found at http://www.bcbs.com/why-bcbs/bluedistinction/.
When will the next re-contracting take place?
The next Spine Surgery, Knee and Hip Replacement Blue Distinction Center+ RFI cycle has not been
announced. The facilities that passed quality and didn’t meet cost have until the next Spine, Knee and
Hip cycle to submit for reconsideration to their plan regarding their cost. The local plan then submits
the reconsideration to the Association.
The Blue Distinction Center+ cycles for cardiac care are occurring now and should be complete by early
summer of 2013. The Blue Distinction Center+ cycles for Bariatric Surgery, Complex and Rare Cancer,
and Transplant are expected to be finished during 2013.
Can an employer build a benefit designed to steer members to a BDC+ facility?
Yes, they can. Several employer groups offer lower out of pocket costs to the member if the care is
provided at a BDC+ facility.
What percentage of members has access to a designated facility within 100 miles?
Depends on the employer group. Geo access would need to be done.
Could two Blue plans consider a facility differently?
No, the facility is scored by the BCBS Association. The facility is designated as a BDC, BDC+ or not
designated. The only time two plans would be looking at a facility is if the facility is on the border of two
states. The Association makes sure that border facilities are always scored the same way for both Blue
Cross and Blue Shield Plans.
What is the effective date?
BDC + programs for Spine Surgery and for Knee and Hip Replacement are effective 01/01/2013.
How will members identify the designated facilities?
Facilities are identified through the BCBSNC provider directory at www.bcbsnc.com and on the bcbs.com
national website at http://www.bcbs.com/why-bcbs/blue-distinction/.
What savings can a client considering BDC+ steerage expect?
This depends on the facility. No specific information has been provided as of yet.
Where can I go for more information?
Visit http://www.bcbs.com/why-bcbs/blue-distinction/ for more information.