Pathway to care that helps patients get healthy faster—and stay healthy longer

The U.S. healthcare system is changing rapidly, but greater efficiency, improved care and lower costs are not coming fast enough. Today, this system costs Americans a remarkable $3 trillion annually, yet too often fails to deliver care that helps patients get healthy faster — and stay healthy longer. This demands urgent, bold steps to make healthcare more affordable while increasing the quality of care. 

Just as Blue Cross and Blue Shield companies pioneered the very idea of health insurance early in the 20th century, they are now leading the transformation of the U.S. healthcare system from one that pays doctors and hospitals for the volume of services they provide, to a model that rewards healthcare practitioners for improving patient health outcomes. One in three Americans trusts Blue Cross and Blue Shield to cover their healthcare needs, and The Blue System is moving swiftly to create a healthcare system that provides them with coordinated, high-quality and more affordable care.   


What started as a few small initiatives many years ago has grown to a portfolio of more than 570 locally developed, quality care programs across the country, providing patient-focused care to more than 25 million of our customers. Community by community, Blue Cross and Blue Shield health plans are working aggressively to improve healthcare quality and rein in costs, and have tied more than $71 billion in medical claims (one in five dollars spent annually) to programs that focus on prevention, wellness, improving access to care, disease management and coordinated care delivery.  

As a result, Blue Cross and Blue Shield customers are experiencing:

·        Fewer unnecessary emergency department visits;

·        Fewer hospital admissions and readmissions;

·        Reduced hospital infection rates; and

·        Better outcomes in key quality measures, including breast cancer screening, improved cholesterol control and adherence to best practices for treating diabetes. 

What’s more, Blue Cross Blue Shield experience is proving that higher-quality care leads to more efficient healthcare spending. We generated savings of more than $1 billion through a number of these programs in 2013. 

Importantly, these programs are customized to meet the unique local needs of the communities they serve. Blue Cross and Blue Shield of Massachusetts, for example, was among the first health plans in the country to establish a population-based accountable care payment model, which has reduced medical spending growth while improving preventive care and health outcomes in adults and children. At CareFirst Blue Cross Blue Shield in the Washington metropolitan area, a patient-centered medical home program helps to coordinate care for patients with the most complex health needs, encouraging physician office visits and providing web-based updates to the entire care team.  

Based on these collective experiences, the Blue System has identified four key strategies that are critical to a successful transformation of America’s healthcare delivery system.

First, change the way doctors and hospitals are paid by tying payments to quality and to success in treating people.   

Second, work with doctors and hospitals by providing them the tools and data they need to transform their practices, such as real-time patient information and hands-on technical assistance in adopting best practices.   

Third, help individuals be active partners in their own healthcare by providing wellness incentives, combined with information and tools that educate and enable individuals to make more informed healthcare decisions. 

Fourth, promote broader savings by eliminating unnecessary or duplicative testing; addressing rapidly escalating pharmaceutical costs that threaten patient access to new and life-saving drugs; and continuing to crack down on fraud, waste and abuse.  

Recently, Health and Human Services Secretary Sylvia Matthews Burwell announced a goal of tying 90 percent of all traditional Medicare payments — currently spent in the inefficient, volume-based, fee-for-service system — to quality-based models of care delivery and payment by 2018. The key to achieving this laudable goal and to transforming the U.S. healthcare system more broadly is making sure that the public sector draws on the clear successes that we are already achieving in the private sector.  Collaboration among all parties in the healthcare ecosystem is critical to our collective success.   

By building on our results and enabling more Americans to get the high-quality, patient-centered care they deserve, we can help ensure that effective healthcare is not just accessible, but affordable, as well. 

Serota is the president and chief executive officer of the BlueCross BlueShield Association.