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Blue Cross and Blue Shield Plans across the country have created a suite of initiatives to offer a standardized, consistent approach to engaging members in health care decision making. These initiatives are categorized in the areas of patient experience with providers, and channels for BCBS members to access information on provider cost and quality.

There are two main types of quality measures that can help members choose quality health care: consumer ratings and clinical performance.

Consumer ratings or “consumer satisfaction” information look at health care from the consumer’s point of view. For example, do doctors in the Blue Plan communicate well? Do members get the health services they need?

Clinical performance measures, sometimes called “technical quality” measures, look at how well a health care organization, provider, group, or clinic prevents and treats illness.

The consumer transparency initiatives developed by the Blue Plans address the consumer satisfaction needs when purchasing health care services. In addition, they address the consumer’s need to know he/she is purchasing health care from a provider who demonstrates a practice philosophy of prevention and treatment of illness that is cost-effective and of high quality as defined in the transparency initiatives.

These initiatives have been or will be integrated with the National Doctor and Hospital Finder. Please note that some of features, such as the Patient Review of Physicians (PRP) require BCBSKS members to verify their insurance ID number, before proceeding.

Quality Initiatives include:

  • Accountable Care Organization (ACO) - ACOs are comprised of groups of doctors, hospitals, and other health care providers and suppliers who come together to provide coordinated, high-quality care at lower costs to patients. ACOs are patient-centered organizations where the patient and providers are true partners in care decisions.  The goal of care coordination is to ensure patients, especially those with chronic conditions, get the right care at the right time while avoiding medical errors and unnecessary duplication of services. Patients have better control over their health care, and providers will have better information about their patients' medical history and better relationships wiht their patients' and other providers.  When an ACO succeeds in demonstrating improvements in clinical quality, patient satisfaction and cost metrics, the ACO is offered incentive payments.
  • Blue Distinction - Blue Cross and Blue Shield companies work with more than 90 percent of all doctors and hospitals in the U.S. and serve nearly 105 million members (that's one in three Americans). As a result, the companies have a unique perspective on doctors and hospitals that are effective in improving patient care and health. This perspective is the foundation of Blue Distinction, Blue Cross and Blue Shield companies' national doctor and hospital recognition program.

    These recognized doctors and hospitals are changing healthcare to be more patient-focused, coordinated and, in many cases, affordable.

  • Patient Centered Medical Home (PCMH) - PCMH places the patient and primary care practice at the center of care and creates a health care setting that is a collaborative partnership between the patient and personal physician. BCBS Plans are testing different blended reimbursement models to support PCMH practices in providing care that is highlighted by improved access, care coordination and integration across all elements of the complex health care system. PCMH providers are also offered incentive payments for demonstrating improvements in clinical quality, patient satisfaction and cost metrics.
  • Hospital Quality Measurement (HQM) - HQM effort currently makes public, third-party hospital quality data available for consumer display on the National Doctor and Hospital Finder and for sharing with Plans for local and national account business. The data includes CMS Process, Outcomes, and Hospital Patient Experience (HCAHPS) Measures, and complications indices for medical, surgical, obstetrics, and all-cause inpatient hospital mortality. Other available data include Joint Commission Accreditation.

Cost Initiatives include:

  • National Consumer Cost Tool (NCCT) - The purpose of NCCT is to enable members to obtain information on estimated costs for health care services.
  • Member Out-of-Pocket (MOP) - A way for members to obtain an estimate for out-of-pocket liability for health care services nationwide. Approach is to enhance NCCT data with detailed service line costs to enable calculation of the out of pocket estimate. Blue Plans will use the detailed service line cost data in conjunction with member benefits and accumulators to calculate member out-of-pocket estimates. The availability date for this feature has yet to be determined.
  • The Alternative Care Settings effort (ACS) - ACS is focused on developing consumer messaging about when to use urgent care centers, retail health clinics, and walk-in doctor's offices for member convenience, improved access and potential cost savings. The objective is to display ACS messaging on the National Doctor and Hospital Finder.

Patient Experience Initiatives include:

  • Patient Review of Physicians (PRP) - A member tool for reading and writing reviews of physicians and professional providers nationwide.
  • Hospital Consumer Assessment of Healthcare Providers and System (HCAHPS) - The current standard for hospital patient experience is the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient experience survey results, which are publicly available from the Centers for Medicare & Medicaid Services (CMS).