As a consumer, how should you choose your care? Which doctors or facilities should you use? How do you determine quality – or recognize less than adequate care? How do you determine value relative to cost?

For years, most people have assumed they were paying more to get better care, but there’s a growing awareness that the quality of care is not adequate to the cost. The gap is growing between the recommended appropriate care for many conditions and the actual care that’s being delivered.

On average, less than 70 percent of recommended care is received by a patient suffering from congestive heart failure. Roughly half the recommended care is being provided to a patient with community-acquired pneumonia. Thirty percent of recommended care is received by someone with a hip fracture.

Reconciling recommended care and best practices with the actual treatments afforded patients with medical needs is the driver behind evidence-based medicine and pay for performance initiatives at BlueCross BlueShield of Tennessee. Getting the right care to the right person at the right time involves working with all stakeholders to encourage and achieve improved quality of care in a way that supports both members and providers, and eliminates medical errors and adverse health events related to treatment.

As an example, appropriate prescription drug use has an enormous potential to add value and quality to health and wellbeing, but criteria for appropriate use are needed to mitigate the many health risks and maximize the benefits. Each year, medication mistakes injure more than 1.5 million Americans. Drug errors and prescription overuse often result in adverse events such as emergency room visits, antibiotic resistance, accidental poisonings, drug addictions and death.

Tennessee lands near the top when it comes to the health consequence of its high prescription use rate. We stand 26 percent above the national average for accidental poisonings, with the highest portion of antibiotic-resistant pneumococcal isolates among states examined by the Centers for Disease Control. Along with the health risks comes a financial impact on the state. Costs for accidental poisonings in Tennessee alone totaled $593 million in a recent year. The dangers that prescription overuse and misuse pose to health and wallets should cause concern for everyone.

Education and collaboration on health care quality standards and value indicators are providing plan members, employers and providers with new mechanisms to help determine appropriate medical care and medication use. Combined with electronic and clinical health records that offer both provider and consumer viewpoints into a patient’s medical history, having access to more and better information helps drive the appropriate care.

To help consumers navigate their way through the health care system and make smart choices about their health and health care spending, BlueCross BlueShield of Tennessee is leading the way to better health with transparency tools for cost, quality and value. At BCBST.com, members can check treatment cost estimators, treatment options, hospital cost and quality indicators, physician information, prescription drug and dental procedure costs.

The newest technology from BlueCross BlueShield of Tennessee makes medical cost information immediately available to plan members before they leave the doctor’s office – or even before being treated. Real-time claims adjudication uses innovative technology to provide medical price transparency for members. In real time, at the point of service, physicians can determine covered benefits and the exact reimbursement due from both the member and the health plan.

As a first from BlueCross BlueShield of Tennessee, the real-time claims adjudication technology easily:
• Estimates member liability, even before receiving treatment
• Performs claim submission and claim estimation online, in real-time
• Determines accurate member costs at the point of service
• Reduces administrative hassles such as balance billing or refunds
• Helps simplify understanding of member cost and obligation

Especially helpful for members with a consumer-directed health plan using an HSA or HRA, the technology provides instant, accurate information with no guesswork on costs.

The Web-based tool is available and accessible for physician offices at no charge through BlueAccess, the secure portion of BCBST.com.