Anthem Blue Cross and Blue Shield's coronary services network: A managed care organization's approach to improving the quality of cardiac care for its members

Objective: To describe a managed care organization's efforts to improve val ue for its members by forming a coronary services network (CSN). Design: To identify high-quality facilities for its CSN, Anthem Blue Cross and Blue Shield reviewed claims data and clinical data from hospitals that met its general quality standards. An external firm measured and risk-adjus ted applicant hospitals' mortality rates. Hospitals that demonstrated super ior performance were eligible to join the CSN. In 1996, 2 years after the C SN was formed, clinical outcomes of participants and new applicants were an alyzed again by the same external firm. Patients and Methods: Data on more than 10,000 consecutive (all-payer) inpa tients discharged after coronary bypass surgery in 1993 were collected from 16 applicant hospitals using a uniform format and data definitions. This a nalysis was expanded to 23 participating and applicant hospitals that disch arged more than 13,000 patients who underwent either bypass surgery or coro nary revascularization in 1995. We compared risk-adjusted routine length of stay (a measure of efficiency), mortality rates, and adverse outcome rates between CSN and non-CSN facilities. Results: From 1993 to 1995, overall length of stay in the network decreased by 20%, from 12.3 to 9.8 days (P less than or equal to 0.01) and severity- adjusted mortality rates decreased by 7.3%, from 2.9% to 2.7%. Initially, f acilities outside the network had comparable efficiency but much higher mor tality. However, they improved so much in both measures that their severity -adjusted mortality rate for bypass surgery in 1995 was no more than 10% hi gher than that of CSN hospitals. Conclusion: The creation of a statewide CSN that emphasized and improved th e level of performance among providers ultimately benefited the carrier's m anaged care members. The desirability of participation was evidenced by an increase in the number of applicant hospitals over the 2 years. This may ha ve stimulated quality improvement among competing providers in the region a nd among CSN facilities themselves.