Good news for anyone who has health insurance with a Blue Cross Blue Shield Association (BCBSA or “Blue”) health plan through their employer! In 2024, the BCBSA introduced the Clinical Data Exchange Hub to enhance data sharing among Blue plans, particularly for out-of-area members. Opala customer in the Pacific Northwest is leading the way as one of the first to connect.
This new technology asset enables Blue plans to share medical record data collected from local providers with each patient’s health plan. This is a particular breakthrough for members who are considered “out of area” by their health insurance company.
Consider an employee who lives in the state of Texas, but their company is headquartered in Washington state. In this case, the Blue plan in Washington is this employee’s health insurance company. However, this employee likely receives all their healthcare services from providers in the state of Texas. According to the partnership among Blue plans, this out of area member leverages the provider discounts negotiated by the Blue plan in the state of Texas. With the BCBSA Clinical Data Exchange Hub, clinical data collected from that patient's provider in the state of Texas will be relayed to their health plan in Washington state. This innovation is important for several reasons.
Health plans are responsible for more than simply paying healthcare bills from providers when their members seek care. Ultimately, health plans ensure that their customers have access to high-quality healthcare. In addition to offering a network of providers with discounted rates, designing a benefit plan that provides coverage for safe and appropriate healthcare services, and financial protection for catastrophic or unexpected healthcare expenses, health plans offer programs and resources to members based on their unique healthcare needs and risk profiles. For these programs to be relevant and effective, health plans must match each member to the programs that are uniquely appropriate for them. Claims data, or information managed by the health insurance company as they pay a member’s healthcare bills, is rarely sufficient for this purpose.
Imagine that the employee in Texas is admitted to the hospital. Health insurance companies offer case management services with specific resources and clinical staff readily available to help members navigate a hospitalization. Beyond member experience, these case management services are designed to ensure that the patient is successfully discharged from the hospital. A key metric of a successful discharge is that the patient is not re-admitted soon after their discharge.
Hospital readmission occurs in approximately 13.9% of all hospitalizations in the U.S. costing a whopping $41.3 billion annually. Research suggests that nearly 27% of hospital readmissions could be prevented with improved discharge planning, patient education, and ongoing support. Case management services are designed to support patients in the days following their discharge with critical information and resources, such as understanding their discharge instructions, making follow up appointments with their doctors, and filling their prescribed medications. Unfortunately, preventable readmissions most often occur before the hospital bill reaches the patient’s health insurance company.
To support this data latency issue, the BCBSA Clinical Data Exchange Hub has prioritized a specific type of clinical data from medical records: real-time notifications of hospital admissions, transfers, and discharges. These notifications are collected from most hospitals in the country and will be relayed to each out-of-area member’s health plan, so that case management services are immediately dispatched to meet the needs of that member and prevent readmission.
Blue plans have the opportunity to voluntarily connect to the BCBSA Clinical Data Exchange Hub and gain access to real-time hospital alerts for their out-of-area members. For quick and simple implementation without burdening already overtaxed IT departments, many health plans are turning to healthcare interoperability partners, such as Opala, for quick time to value. Most recently, the largest health plan in the Pacific Northwest connected to the BCBSA Clinical Data Exchange Hub within a matter of months with Opala’s Blue Clinical Connect product.
As more health plans connect, the Blue Clinical Data Exchange Hub will enable Blue plans to serve all of their members with the same personalized and timely services available to local members. Health plans need medical record data beyond real-time hospital alerts, such as lab test results, cancer stages, and prescribed medication lists, and the BCBSA intends to rapidly expand data collected and relayed among Blue plans with adoption.
Overall, Blue plans will be more competitive against national health insurance companies because they can further harness their core differentiator: deep, local relationships with the provider healthcare delivery systems.