From emergency department (ED) doc to Medical Director and VP of Network Services at Blue Cross and Blue Shield of Alabama (BCBSAL), Dr. Darrel Weaver has seen it all – from the hustle of the ED, to administrative hospital roles to being among a small group of physicians nationally impacting the future of value-based care within the health plan environment. HPI connected with Dr. Weaver as part of a public television interview in early March 2020 and follows up here noting the dramatic turn the healthcare landscape in the weeks following to see how BCBSAL was continuing to meet the needs of their physicians and patients during this time.
The value of a healthier patient
While it seems the world around us will never be what it was before, whether pre-COVID or today, the value of a healthier patient remains the same. When they’re healthier, patients feel better and ultimately cost the healthcare system less. Sometimes it costs the system more up front to promote better health in the long-term, an investment which not only results in lowering costs but more importantly, making patients healthier contributes to happier families, and happier employees who are more productive at work and more involved in activities of life. When you create health, it’s a win for everybody. BCBSAL clearly strives to build this truth into the foundation of the work they do today, a focus Dr. Weaver connects to two evolving practices: telehealth and data integration.
The value of telehealth
Dr. Weaver reflects back to “when COVID hit” and he quickly realized that patients were going to stay away from doctor’s offices, stop going to emergency rooms and hospitals, and a lot of that was for care that really still needed to happen.
People were not going to the emergency room for heart attacks and they didn’t go get checked after. People were not having their diabetes followed up. We quickly opened the door to telehealth. We only had a small presence in telehealth before because we were under the impression that we had to have special equipment with audio and video capabilities, as well as the ability to transmit x-rays, EKGs and other medical functions.
Dr. Weaver expands, noting that physicians were obviously not going to be doing elective procedures, but a surgeon could do a follow up visit or talk to a patient needing some type of surgery in the future by telehealth. An eye doctor could help a patient with a piece of sand in their eye the same way. Restorative dentistry could not be done but acute issues could be handled by calling in antibiotics or pain medicine. Video could be used by physical therapists to check mobility and audio could be used for continued speech and occupational therapy sessions.
Additionally, we told our specialists when they were rounding on COVID patients, if you don’t really have to go into the room to treat that patient, you can do it telephonically and by reviewing records and tests. You can call in and talk to the patient, preventing the physician from getting exposed to a COVID patient. This also really cut back on the use of PPE because they were supposed to put on a brand new, fresh set of personal protective equipment prior to entering a patient’s room that had to be thrown out after seeing that patient – room after room. Being able to conduct a lot of those visits by telehealth (in the hospital) made a huge difference for both continuity of care and conserving PPE resources.
BCBSAL immediately began working on programs to make telehealth a payment parity option to further support this as a valuable alternative to continue care during this stage of the pandemic. Dr. Weaver candidly recognizes that an assumption existed around tele-health being substandard care and thus should be paid lower as well. During COVID however, most non-serious illnesses could be handled telephonically. Physicians said it was very helpful to deliver care by telephone and as that care appeared to be good quality, BCBSAL began paying at parity with traditional care. If a physician was taking care of a problem that would have been a level three billing in the office, we told them to bill us a level three and we’ll pay for it – same for level four. The exception was level fives, as these are really sick patients that require a thorough physical exam.
Pre-COVID, with the traditional version of telehealth, BCBSAL received about 2000 telehealth claims a week for payment. The first week that they expanded telehealth reimbursement during COVID-19, those numbers rose to 14,000. The following week, 30,000 and by April, they had jumped up to nearly 80,000 claims a week.
This new approach to telehealth has become one of the biggest innovations at BCBSAL. We’ve learned during this COVID crisis that there’s a lot of care that can be done without having high technology. We’re a rural state and we have hospitals that are in danger, like plenty of other states around the country. There are people who are homebound, and they can’t get out to the doctor’s office easily regardless of the current healthcare crisis. Prior to COVID, we would hear all the time that offices had to have broadband in order to deliver care through telehealth in rural areas. This was proven not to be the case as the vast majority of services can be done with cell phones or landlines. While broadband does provide the ability to do some high-tech things, we’re going to expand the use of telehealth using current technology in small towns.
Alabama began to open back up early in May, including elective procedures. Patients could get out of their houses so telehealth visits began to decline. Telehealth numbers rose dramatically when that was the only source of care but when people had the option; most went back to traditional forms of care. Subsequently, submitted telehealth cases per week declined from the peak of 80,000 to near 20,000 a week in early June and have stayed there. While the current wide-open form of telemedicine was created rapidly for speed to market purposes, BCBSAL considers this new use of telehealth here to stay. We are considering what a post COVID telehealth platform could look like and when carefully planned and considering lessons learned, should be of even more benefit to the providers and patients, we serve.
The value of data
Dr. Weaver has always believed data tells a story – specifically in medicine. Whether in a busy ED or leading a hospital or health plan, data is a source of truth all can rally around. In his role leading physician networks at BCBSAL, Dr. Weaver believes data is the key to better outcomes.
If you can’t measure something, you cannot improve it. Data empowers physicians, patients, and health plans to work together to build better outcomes. If you measure what’s going on and provide data as close to real time as possible, decisions can be made and acted upon.
BCBSAL currently has a number of platforms for measurement. The largest being a patient management tool that uses claims data and other supplemental resources, providing an overall picture of an individual’s health, illustrating what kind of problems they have, what kind of medications they’re on and if they are taking the medications as prescribed.
As a health plan, you can then aggregate all the people that make up an individual practice, attribute that toward a doctor and provide them actionable data. For example: “You’re doing really good on controlling blood pressure, you’re doing fairly well on controlling diabetes, you’re not doing well on getting colonoscopies scheduled”. Additionally: “Here are your 61 people who are due for a colonoscopy but not scheduled yet. Here’s another group of people who have not been filling their diabetic medicine”.
BCBSAL is also aggregating data to review a physician specific patient group, sharing with the group so they can make changes. We believe in reimbursing the physicians who are doing a better job. One of the ways we do that is through our value-based system for primary care doctors. This group can make up to 30% more than standard pay in this program. We currently have about 2000 doctors in the state on this Program with most increasing their pay from 5-30%. The activities performed by these physicians that earn them additional pay are also the activities that contribute to better health for each patient.
Another tool BCBSAL developed from data is a patient health snapshot. When somebody walks in the door, hands their card in and signs in to be seen, we automatically print off a patient health snapshot for the physician and patient. When the physician walks in the room, they have the chart in their hand, and they have a piece of paper that tells them: This is Mrs. Jones. Mrs. Jones has diabetes and hypertension. Here are the medicines that she should be taking. She’s not really taking the ones for diabetes, she did get her A1C done twice in the past a year, but she has not had her mammogram done. It’s a roadmap handed straight to the physician to clearly identify what needs to be addressed with the patient while they’re in the office. It’s also been extremely successful.
BCBSAL hasn’t stopped there – they have a similar dashboard for opiates. Alabama leads the country in per capita, opiate prescriptions. This dashboard specifically highlights what drugs the patient is taking, highlighting if they are taking opiates, or something they shouldn’t be on. The physician is also provided a profile of their opiate prescribing habits. It helps them understand where they fall. Even if they’re a great doctor and have the best of intentions, it helps them know what their opiate prescribing is like. You could be the best doctor in the world and of the thousand people you see this month, 995 of them were just perfect, but there could be five that got lost in what you’re doing. Those people may be on a combination of drugs that don’t need to be there. And a few of those could be sneaking around seeing other doctors getting opiate prescriptions as well. Or, it could be a patient doing exactly what they should be, but one doctor gave them a benzodiazepine prescription and one doctor gave them an opiate prescription. These together are not a good combination. This kind of data is working very well to help keep people safe from inappropriate opiate use as well. Like Dr. Weaver said: If you can’t measure it, you can’t improve it.
Value-based care at BCBSAL is clearly patient centered. The health plan focuses on supporting healthy patients, the physicians use their resources to best take care for their patients, and they collectively deliver improvements in quality. Whether before, during, or after the pandemic, this approach delivers better patient outcomes. Period.