Providing Affordable Health Care

Our efforts to control medical costs are paying off, and through our compliance with New Jersey’s medical loss ratio, in 2019, Horizon BCBSNJ delivered $40.5 million in 2018 premium rebates. Approximately 148,000 individual policyholders received rebate checks averaging $95. For approximately 29,000 small business owners, rebate checks averaged $898.

Here are some of the other ways we made health care more affordable in 2019.


Lowering Prescription Costs

We took aim at high prescription drug prices with the launch of a pharmacy pricing transparency tool. In partnership with our pharmacy benefits manager and a vendor partner, Horizon BCBSNJ launched an innovative software platform where doctors can quickly get patients the right medication at the best price. This innovative tool delivers up-to-date medication and alternative cost information in real time to doctors via patients’ electronic health records.

In addition to lowering out-of-pocket costs for our members, this solution also helps doctors spend more time caring for their patients by making prescribing more efficient and less time consuming. Since its launch, use among doctors has grown steadily. Doctors recognize the convenience of using the platform and understand the value of helping their patients reduce out-of-pocket costs. Each day this platform processes over 3,000 Horizon BCBSNJ member medications via this solution.

This pharmacy pricing transparency platform has processed Horizon BCBSNJ member medications originating from over 18,000 providers.


Leveraging Patient-Centered Care

We also saw the positive results of our efforts to drive down costs and improve outcomes through our patient-centered programs, including Patient-Centered Medical Homes, Accountable Care Organizations and Episodes of Care (EOC). More than 9,200 value-based providers serve more than 1.6 million members currently enrolled in one or more of these programs. In 2018, approximately $100.8 million in value-based payments were made to providers — that’s approximately 61% of the total amount Horizon BCBSNJ spends on medical care.

Year over year, results show that members who are treated by doctors, hospitals and other health care professionals that participate in one of Horizon BCBSNJ’s patient-centered programs are more likely to get preventive care that is coordinated. Results also show that clinical quality in patient-centered pediatric care is excelling, with significant improvements in immunization rates for more than 100,000 children and adolescents whose doctors participate in Horizon BCBSNJ’s pediatric patient-centered program.

Overall, the 2018 results (as compared with 2017 results) indicated:

  • 6% higher rate of breast cancer screenings
  • 4% higher rate for cervical cancer screenings
  • 11% increase in adolescent immunizations
  • 9% increase in weight counseling and monitoring visits
  • 21% increase in child well visits

Our nationally recognized EOC programs continue to expand, and are proving to help lower costs. We also launched programs with two large hospital systems serving as conductors in 2019. The annual gross savings projected for 2019 is nearly $34 million.

Innovation in Care Delivery: Data Tools and Resources


Sally Mravcak, M.D., Medical Director and Board Member, Vanguard Medical Group: “Horizon [BCBSNJ] has really provided us with the support that we need to put things into practice like care coordination and population health teams, providing data for us, helping us figure out what our utilization is, what our costs are, you know how our quality is — so we can look at those numbers and try to improve.”

Melissa Mothersil, Transformation and Quality Improvement Coordinator, Vanguard Medical Group: “As a whole, just the information provided from Horizon [BCBSNJ] through the claims data that we receive helps us to make improvements in inpatient admissions, specialist usage and all of our pharmacy information that we receive.”

Debbie Franco, R.N., Nurse Care Coordinator, Vanguard Medical Group: “On a day-to-day basis, we use HealthSphere, which provides us with data and utilization claims. It allows us to see when the patient has been to a specialist. It allows us to see gaps in care. It gives us the provider’s name that addressed the gaps in care so that we can make an outreach to their office and pull those reports so that our providers have them in our EMR [Electronic Medical Records].”

Robert T. Gorman, M.D., FAAFP, Senior Physician and Board Member, Vanguard Medical Group: “There is value in an insurance company working together with interested physicians to improve the quality of care delivered to their customers. And that given the right tools, we can do it in a way that is cost effective, so that it's a win-win for the patients and everybody comes out ahead. ”

Secret Shopper Study Pays Off

We saw significant claims savings, plus improvements in several quality measures when we collaborated with the Robert Wood Johnson Foundation on a “secret shopper” study. The study sent actors, portraying patients, into primary care practices to test the practices’ customer service, provider performance, adherence to evidence-based standards, and documentation and compliance.

Visits with the undercover patients were reviewed, along with the doctors’ notes from the patients’ medical records, by a team of researchers. The findings were shared with the doctors, along with suggestions intended to help each doctor improve care.

Overall, doctor behavior improved following the feedback, according to the study.