The Blue Cross and Blue Shield Association is a national federation of 37 independent, community-based and locally operated Blue Cross and Blue Shield companies that collectively provide health care coverage for nearly 104 million members—one-in-three Americans. For more information on the Blue Cross and Blue Shield Association and its member companies, please visit We encourage you to connect with us on Facebook, check out our videos on YouTube, follow us on Twitter, and check out The Bcbs Blog for up-to-date information about BCBSA.

View Blue Cross and Blue Shield Companies’ Strategies


Blue Cross and Blue Shield companies are industry leaders in delivering products and programs that simultaneously leverage national access and local support. The companies provide health care coverage to nearly 104 million members across all 50 states, Washington, D.C. and Puerto Rico, with corporate customers ranging from the smallest of small businesses to 76 percent of the Fortune 500. As such, the Blues’ reach in improving the health and wellness of individuals extends not only to the more than 150,000 Blue Cross and Blue Shield employees, but also to the tens of millions of employees who work for companies that offer employer-sponsored coverage from Blue Cross and Blue Shield.

The Blues’ broad and deep experience confirms that, although nearly everyone today knows the importance and the value of healthy habits, making the leap from “’knowing” to “doing” can be hard. Wellness programs designed to engage employees in healthier habits increasingly include behavior-based incentives and personalized programs and services. According to one study, 86 percent of employer groups reported offering incentives in 2013, up from 73 percent in 2011.1 While financial rewards can encourage initial participation in activities such as health assessments, they are generally more effective when tied to outcomes and/or included within the context of a broader employee wellness and engagement strategy. Non-financial incentives include tailored outreach and customer service approaches to reach, inform, and engage consumers about health care issues that matter most to them. And, in addition to engaging consumers through discrete incentives programs, health insurance benefit design itself can be an effective means to engage consumers.


Blue Cross and Blue Shield Companies’ Strategies for Improving the Health and Wellness of Individuals

As a national association of independent, locally operated Blue Cross and Blue Shield Plans, BCBSA works to gather insights and share lessons throughout the Blue System so that best practices can be expanded and replicated with other Plans to benefit thousands more customers and millions of additional members. The following examples represent just a few of the hundreds of programs Blue Plans have in place to engage consumers.

Combining Participation-based and Outcomes-based Incentives

Increasingly, incentive programs are not just rewarding employees for participating; they are rewarding employees for reaching measureable health goals or improvements. Working with a Blue Plan, one employer group offered its employees an opportunity to pay lower premiums through a combined participation-based and results-based healthy incentive program. Employees were rewarded with a reduction in their premium for completing an online health assessment or any of four biometric screenings and then meeting certain health improvement targets.

Providing High-Touch Customer Service to Encourage Informed Decisions

Consumers are best able to make informed health care decisions when they receive appropriate, understandable, and timely information about the quality and cost of care. One Blue Cross and Blue Shield Plan’s health concierge service enables members to maximize their health benefits and effectively plan their health care by taking advantage of expanded telephone support for more than 150 non-emergency procedures. The Plan’s dedicated customer service agents help the member understand benefits, find a provider, estimate costs and receive any necessary pre-certification for a treatment or procedure. Although this information can be found online, the Plan and participating employers concluded that consumers derive value from personal interaction.

Engaging Consumers in the Context of Broader Innovations in Benefit Design

Blue Plans also have begun embedding engagement methods into their products’ basic benefit designs. For example, as part of the benefit design that one Blue Cross and Blue Shield Plan offers to employers, members can choose among three levels of products, whose cost-sharing component varies depending on the level of engagement they agree to. Specifically, members’ out-of-pocket expenses are directly tied to the decisions they make—including the physicians they choose, their participation in wellness programs and their compliance with prescribed care plans.


Benefits and Impact

As a result of the incentive program, the employer group estimated avoided claim costs of $1.8 million after just two years of the program ($3,000 per person per year). This cost avoidance is tied to improvements in clinical outcomes, including reducing by half the share of employees with hypertension (from 54 percent in Year 1 to 25 percent in Year 2). The enhanced telephone support program included approximately 500,000 participating members in 2012, and resulted in more than $2,000 in average savings per claim when the member opted to seek treatment from a lower-cost provider. As a result, the Blue Plan is expanding both the scope and scale of the program in 2014.


Lessons Learned

By an almost two-to-one margin, employers cite lack of employee engagement as the largest challenge related to changing employees’ behavior concerning their health. According to a 2012 survey conducted by the National Business Group on Health and TowersWatson, employee engagement ranked No. 1, with 57 percent of reporting companies citing this as the biggest obstacle.2 Better health is an individual journey and employees need solutions that recognize and fit their individual needs. Employers are implementing programs that use behavorial economics, claims, and prescription data to create personal programs and outreach for the individual.


Key Take-aways for Employers

Incentives are helpful but will not sustain engagement without programs and tools that connect with individuals. Educational and support tools can make individuals feel more empowered to make needed health and lifestyle changes, reaping both the program rewards for these changes and better health outcomes. Moreover, to be successful, the information and programs offered must be personalized to resonate with individuals; they need to be designed—and perceived—to meet individuals’ needs. As such, programs must be tailored to each employer’s workforce and their specific health and wellness needs. One size will not fit all.

1 “New Health Care Survey Finds Spending on Wellness Incentives Has Doubled in the Last Four Years,” National Business Group on Health, February 27, 2013.

2 “Performance in an Era of Uncertainty: 17th Annual Towers Watson/National Business Group on Health Employer Survey on Purchasing Value in Health Care,” Towers Watson and National Business Group on Health, March 2012.


Investing in the communities they serve—and partnering across sectors and industries—enhances the ability of businesses to tackle the largest health issues facing the nation. The most successful programs are focused ones that use measurable results and community impact to guide investment strategy. As a national association of independent, community-based and locally-operated Blue Cross and Blue Shield Plans, BCBSA collaborates closely with its 37 Plans in all 50 states, Washington, D.C. and Puerto Rico to maximize the local impact of community engagements—totaling $356 million in community investments in 2012—and align around issues with national implications. This structured approach to giving has allowed the Blues to deepen partnerships on public health interventions, volunteering, and philanthropy that include evidence-based programming, plans that engage all relevant stakeholders and an emphasis on evaluation.


Blue Cross and Blue Shield Companies’ Strategies for Improving the Health of Communities

Following these tenets, Blue Plans across the country are working together to replicate success nationally while tailoring programs for different types of providers in innovative ways that leverage local market needs and characteristics. The following are examples of how Blue Cross and Blue Shield Plans are improving the health care system.

Partnering on Life-Changing Public Health Interventions

Blue Cross and Blue Shield Plans all across the country are deeply involved in community efforts focused on high-priority public health problems. One such problem is childhood obesity, a nationwide epidemic targeted by several Blue Plans. One Blue Plan, in collaboration with a local public/private partnership, developed an initiative that works to create healthier environments in the child care setting to help instill a lifetime of healthy behaviors. The program empowers child care providers to teach young children and their parents about healthy nutrition and physical activity practices. It is the first statewide initiative to combine multiple successful strategies and implement both a top-down and bottom-up approach to improve the health of children in child care, their families and their communities.

Partnering to Create an Environment in Which to Establish Healthy Habits

With the participation of local Blue Cross and Blue Shield Plans, BCBSA provided exclusive national sponsorship of the Partnership for a Healthier America’s Play Streets program in 2013. Play Streets established temporary physical spaces for children, families and communities to be physically active in ten cities across the country. Doing so encouraged economic development by showcasing local businesses and other key partners, and helped to motivate and guide community leaders to strengthen communities and build social capital.

Supporting a Culture of Volunteerism

Another Blue Plan not only supports employee volunteerism and charitable giving through company-sponsored activities, it also supports employees to be “intrapreneurs” (i.e. internal entrepreneurs) in initiating new ways to serve their local community. One example is a Community Giving Garden, an onsite garden providing fresh produce to hungry people in the community. The garden is maintained by Plan volunteers and has been a catalyst for a network of 15 state-wide corporate giving gardens.

Targeting Philanthropy at Programs that Generate Tangible Outcomes

Still another Blue Plan is funding Medically Integrated Wellness, a program created by the local YMCA that combines diet, exercise and education to improve the health outcomes of individuals with pre-diabetes and diabetes.

Investing in the Future Primary Care Workforce

Recognizing the critical shortfall in primary care physicians expected by the end of the decade, Blue Plans across the country are investing in the country’s primary care workforce through scholarships and student loan payback programs to medical students who choose primary care specialties, and by encouraging all providers to practice at the top of their licenses and inviting qualified nurses to serve as primary-care providers in their networks.

Benefits and Impact

The programs cited above are each yielding positive results. In the second project year of the childhood obesity partnership initiative, all 18 participating centers are exceeding most or all milestones for providing children with 90 minutes of active playtime daily and offering meals/snacks with healthy fruits, nutrient-dense vegetables, and lean protein. Among children who had been at the centers for more than six months, the percentage of those with unhealthy body weights dropped from measurements taken ten months earlier.

As a result of the Play Streets partnership, 48 Blue-sponsored Play Streets events throughout 2013 drew 72,000 attendees, created more than 42 miles of open space for children and their families to be physically active, and generated nearly 200 hours of physical activity programming for communities in need.

In 2012, more than 1,300 pounds of produce was harvested from the network of onsite gardens and donated to local food banks and non-profits. Additionally, 3,000 seed packets were assembled for distribution to further support access to healthy food.

In the YMCA program patients with diabetes or pre-diabetes experienced a 77 percent improvement in A(1c) levels and a 63 percent reduction in the amount of diabetic medications taken. More than 90 percent of participants lost weight, all pre-diabetic participants remained free of diabetes medication, and all participants expressed confidence that they could sustain the changes they made while in the program.

Regarding programs to expand the primary care workforce, Blue Plan investments in primary care education have resulted in thousands of men and women being trained as doctors and nurses and and choosing career opportunities in much needed fields of primary care.


Lessons Learned

The main challenge to a successful community investment strategy is finding the right partner. Culture, mission, and capabilities must all be aligned and expectations around roles, responsibilities, and outcomes must be clear from the beginning.

This type of collaboration takes a substantial communication and organizational effort. Even with a common goal of creating a healthier population, how each organization accomplishes that can vary greatly. Creating a collaborative environment where key stakeholders are engaged and involved in the strategy development is critical for success.


Key Take-aways for Employers

To ensure sustainability of investments, it is critical to tie community engagement to the culture and mission of the business itself. Moreover, while involving all key stakeholders throughout the planning process may extend the decision-making process, it ultimately will accelerate the adoption of the group’s direction.


Value-based care delivery models that reward providers for coordinating patients’ care, adhering to evidence-based guidelines and producing positive outcomes are proving to be effective ways to lower costs and improve quality. Blue Cross and Blue Shield Plans are working with doctors, hospitals and other health care professionals in 49 states, Puerto Rico and Washington, DC, to adopt new, value-based models of care. Today, 24 million Blue System members participate in more than 350 value-based payment arrangements under the care of roughly 156,000 primary care providers and more than 59,000 specialists—one of every four of the country’s active physicians. These programs take on many forms, based on local needs. But they all share certain characteristics. They:

  • Put the patient first.
  • Move away from fee-for-service reimbursement to arrangements based on value.
  • Instill accountability across the care continuum.


Blue Cross and Blue Shield Companies’ Strategies for Improving the Health Care System

Following these tenets, Blue Plans across the country are working together to replicate success nationally while tailoring programs for different types of providers in innovative ways that leverage local market needs and characteristics. The following are examples of how Blue Cross and Blue Shield Plans are improving the health care system.

Leveraging a Strong Foundation in Primary Care

Programs that apply value-based provider incentives can create stronger relationships between patients and their primary care physicians, and they can support better coordination across the spectrum of care. Since launching its patient-centered medical home program in 2009, one Blue Cross and Blue Shield Plan now has 3,600 physicians from almost 1,200 medical practices participating, providing enhanced care to more than one million members. This program has demonstrated strong cost and quality results, including:

  • Improved models and methods of applying risk adjustment and standard cost to metrics that allow for a fair comparison of provider performance.
  • 24 percent reduction in inpatient discharge rate for ambulatory-care sensitive conditions and nine percent lower ER visit rate.
  • Use of high-tech imaging reduced by eight percent, and generic drug dispensing rate increased by three percent.
  • Three-year cost savings of $155 million.
  • This Plan is now building on its medical home program to create stronger relationships between the medical home practices and specialists and hospitals.

Recalibrating Hospital Payment to Align with Quality and Efficiency

Responding to rapidly growing inpatient costs—many of which stem from system inefficiencies—hospital-based programs create incentives for hospitals to follow evidence-based practice and comply with industry quality standards. One Blue Plan program puts a portion of participating hospitals’ payment at risk and evaluates performance in three categories: hospital efficiencies, infection prevention (which accounts for half of the quality measures), and process-of-care measures. Payments are negotiated based on the level that can be achieved by a given hospital, which chooses the set of quality indicators it will be measured against.

In 2012, the participating hospitals prevented nearly 2,800 adverse events (e.g., improper surgeries and mislabeled specimens) and reduced hospital-acquired infections, deep vein thrombosis, and pulmonary embolism. The Blue Plan estimates that these quality improvements saved more than 380 lives and averted at least $48 million in unnecessary treatment costs over a five-year period.


A nurse coordinator assigned to a 42-year-old Blue Cross Blue Shield Plan member had noticed that the member had not been to her doctor’s office for an exam in a long time. The nurse coordinator called the member and spent time with her on the phone to ensure that she had scheduled an appointment to see her doctor. During the appointment, the member mentioned recently experiencing chest pain, so the doctor immediately performed an EKG in the office. Within a few weeks of that appointment, the member had three stents placed. The member called back her nurse coordinator to say, “Thank you. You probably saved my life.”


  • Supporting a System of Accountable Care Recognizing that a patient’s care is often delivered by multiple health care professionals, in the past year the Blues have doubled (to more than 200) the number of programs that extend accountability for quality and cost beyond the primary care or hospital relationship by including primary-care physicians, specialists, and hospitals together in contractual arrangements. In addition to financial incentives tying payment to coordinated care, these models leverage health plan data and analytics and investments in health information systems to equip providers with actionable information at the point of care (such as identifying gaps in care) to improve health outcomes and control costs across the entire care continuum. Moreover, such programs increasingly set a longer-term timeframe (e.g., three to five years) to reach various milestones. This shared-accountability model has succeeded at creating greater value—better medical outcomes while controlling medical costs, as exemplified by the results from one Blue Cross and Blue Shield Plan:
  • Significant success at achieving extremely high levels of control for patients with three highly prevalent chronic conditions—diabetes, cardiovascular disease, and hypertension.
  • Slower growth in medical spending (two percent and three percent less, respectively, in 2009 and 2010) supports the program’s goal of reducing annual health care cost growth trends by half over five years. 49
  • Contracted doctors’ costs were 3.3 percent lower in 2010 than for doctors not in the program, an average savings of about $107 per patient.
  • Some doctors’ groups spent as much as 10 percent less than colleagues paid under the traditional fee-for-service system.


A Blue Cross Blue Shield Plan member was a 57-year-old, self-described “meat and potatoes guy” and diabetic for nearly half his life. The member was enrolled in a value-based care program that: • Involves weekly correspondence with a registered nurse. • Monitors the member’s blood sugar levels through patient reporting tool. • Receives follow-up calls once a week to discuss insulin levels and proper nutrition

Three months later, the member admits it was hard to make lifestyle changes when he felt fine. But because of the time and attention his nurse gave him and the relationship they built, he was motivated to get his diabetes under control and was able to reduce his blood-sugar levels from an “out of control” 10.7 to a manageable 7.5 (the blood sugar range for a person without diabetes is between 4.2 and 6).


Benefits and Impact

Value-based payment programs that reward effective, efficient care are reducing costs and improving health outcomes, sometimes dramatically, as in the case of the hospital quality incentive program that is estimated to save 380 lives over five years.

Lessons Learned

Facing continually rising health care costs, businesses are eager to see value-based models grow in scale and impact. And while 24 million Americans are already cared for under Blue value-based payment arrangements, completing a fundamental transformation of the country’s $2.8 trillion health care system takes time and requires alignment and commitment of all stakeholders. Elevating awareness of value-based care models can help accelerate their nationwide adoption. Together, business leaders and their health plan partners can serve as champions of value-based care by promoting the proven success and future promise of these programs with their peers, employees, business organizations, community groups, media, and policy makers.

Key Take-aways for Employers

Value-based programs provide employers the opportunity to bend the cost trend over time while maintaining or improving quality, delivering superior benefit to their employees, and yielding greater value for their health care spend. Embracing these programs and educating and supporting employees as they participate in them accelerates impactful, sustainable improvement in the health care system.

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