QI Program's Function/Process
Detailed processes and methodology are used to determine the overall efficacy of performance improvement activities and programs. The monitoring of specific indicators is designed, measured and assessed by all appropriate departments, disciplines and services to reveal trends and performance improvement opportunities in an effort to improve organizational performance. These indicators are objective, measurable, based on current scientific knowledge and clinical experience, broadly recognized in the industry and are structured to produce statistically valid performance measures of care and services provided.
- Identification of important issues that reflect significant aspects of care and service.
- Selection and/or development of adequate metrics.
- Selection of goals and/or benchmarks for each measure/metric.
- Measurement, tracking and trending.
- Identification of opportunities for improvement based available data.
- Root cause analysis.
- Implementation of interventions or corrective actions referring to the identified opportunities for improvement.
- Re-measure to determine the effectiveness of the interventions based on statistical significant improvement and/or reaching a goal or benchmark.
Horizon has a dedicated commitment to patient safety; it is of the utmost importance to Horizon and its membership. Promoting patient safety encompasses a wide range of activities in the Quality Improvement domain:
- Drug-Drug Interaction Reject (DDIR) Program
The goal of this program is to identify potential serious drug interactions at the point of service. Through its information systems, Horizon tracks which pharmacies are filling drugs with potential drug-drug interactions and which physicians are prescribing drugs that have potential drug-drug interactions with other drugs. Potential Drug-Drug Interactions are identified and rated in terms of potential severity, using the following severity levels; major, moderate and minor severity. Major severity interactions are defined as potentially life threatening or causing permanent damage to the patient's health. Moderate severity interactions are defined as potentially causing the patient's condition to deteriorate due to the interaction that may require additional care or extended hospitalization. Minor severity interactions are defined as interactions that are potentially bothersome, but otherwise not medically detrimental to the patient. The Pharmacy Benefits Manager, on behalf of Horizon Pharmacy Department, uses all three severity ratings to identify potential drug interactions. When any such interactions are detected, the requested prescription that triggers the potential drug-drug interactions will be systemically rejected by the information systems prior to the medication being dispensed to allow further inquiry and discussion to occur amongst the pharmacist, the patient, the patient's prescribing physician and the Horizon Pharmacy Department.
- Point of Service Edits
These edits, which go beyond the identification of potential drug-drug interactions, include dispensing duration, duplicate therapy monitoring, drug-regimen compliance screening, quantity limits, age edits and gender edits. Point of service edits are based on FDA approved package inserts, Horizon utilization experience, national utilization experience as well as Horizon developed or adopted clinical practice guidelines.
- E-Prescribe Program
The e-prescribing program allows physicians to send prescriptions electronically to retail and mail order pharmacies. This function assists clinicians at every point of the prescribing process, including member eligibility check, review of plan formulary, review of member medication history (with member's consent) and checking for allergies and drug interactions.
Prior Authorization Program: This is a program in which certain prescription drugs require Horizon's prior authorization before the prescription drug can be dispensed. If prior authorization is not obtained for the requested prescription drug, the requested drug rejects at the point-of-service. Specific prescription drugs may require prior authorization due to any of the following factors:
- The drug has the potential for significant inappropriate use or abuse
- Use of the drug carries a significant safety concern (adverse events could occur or patient monitoring needed)
Targets mailings to members and providers are sent to provide notice of any negative changes with regard to prior authorization.
- Dose Optimization Program
This program is part of the dispensing limit requirements for drugs that are FDA-approved for once a day dosing. This program encourages the use of higher strengths once a day and discourages the use of lower strengths that require multiple dosing throughout the day, thus generally improving the likelihood of patient compliance.
- Drug Recalls, Black Box Warnings and Safety Alerts
In certain situations, when a drug is withdrawn / recalled from the US market or when a drug has a new black box warning added, the Pharmacy Benefits Manager on behalf of Horizon Pharmacy Services, will mail letters to the relevant portions of Horizon's participating physician network and affected members. Physicians are provided a listing of their specific patients who have been identified as taking the affected medications so they are able to efficiently take action when needed. For recalls that do not include all lots but rather certain lots, a web posting outlining the recall information is posted to both the provider and member sections on www.horizonblue.com. Information from the FDA is continuously monitored to identify newly emerging drug safety issues and drug-disease interaction issues.
- Guided Health Program
The Guided Health platform from delegated vendor, Prime Therapeutics, allows for the integration of pharmacy and medical claims data to perform retrospective drug utilization reviews (DURs). The types of DURs through Guided Health, include the following:
- Engagement - Adherence (with or without medical claims)
- Controlled substance overutilization
- Triple therapy alert
- PPI Duration of Therapy
- Duration of hormone replacement therapy
- Statin use in diabetics
- Anticholinergic drug use in dementia
- Antipsychotic use in dementia
- Gaps in care
- Off-label use
- Drug Utilization Reviews (DURS)
This program includes analysis and evaluation of clinical data retrospectively and creates appropriate interventions that the DURs indicate should be undertaken. Interventions may consist of mailing letters to physicians on the various issues revealed by the DUR analysis, typically designed to improve patient safety. The final results of DUR interventions are also presented to the P&T Committee to assist it in its task of maintaining a safe formulary as well as making suggestions for additional interventions such as prior authorizations, dispensing limits, age edits, gender edits, etc. Examples of goals examined through the DUR process have included the following: improving controller medication use among members with asthma, improving cholesterol and blood pressure treatment for members with diabetes and reduction of elderly members on high-risk medications. Ad-hoc DURs and trending reports are conducted and presented at P&T Committee meetings regarding therapeutic classes and as new drugs become available in the US market. Horizon Pharmacy Department monitors new drugs post marketing surveillance for appropriate utilization.
- Medication Adherence: Current adherence program integrates pharmacy and medical claims data and targets providers through letter communications. Current chronic conditions targeted include: Asthma/COPD, Diabetes, Hyperlipidemia, Hypertension, Behavioral Health and HIV
- Narcotic Management Program
The purpose of the narcotic management program is to reduce inappropriate prescribing and inappropriate utilization through case based reviews. Different Horizon departments, such as case management and the special investigations unit collaborate to assist in making effective interventions. For example, participating physicians are sent quarterly reports about members who are identified as aberrant users of opioids. Benefits of this program include increased patient safety, identification and management of high-risk drug therapies and facilitation and coordination of patient care among multiple practitioners. For members who are consistently identified as aberrant users of opioids, a pharmacist will make a telephonic outreach to the provider.
- Enhanced Safety and Monitoring Program
A licensed pharmacist retrospectively reviews member pharmacy claims for controlled substances as identified by the Guided Health platform to help ensure safe and appropriate utilization. Outreach to the prescriber and/or member is completed if a safety concern is identified.
- Safe Use Now Program
Addresses the problem of misuse, abuse, addiction and diversion of controlled substances including opioid drugs. The primary objectives of the program are to: reach out to identified “high-risk” Horizon prescribers, engage prescribers through a multi-channel outreach campaign, provide prescribers with information about their high-risk patients and provide prescribers with training materials, resources and clinical suggestions.
- Pharmacy Case Management
Horizon regularly reviews and performs case management on high-risk and/or high-cost members to ensure the safe and appropriate use of prescription medications. Sources of member identification include internal and external reporting (e.g. HighTouch RX, Insights+, etc.). Examples of cases that are intervened include duplicate therapies, dose optimizations, brand-generic and oversupply. Horizon Pharmacists regularly work with members, providers and pharmacies to resolve these gaps following identification. Additionally, Horizon will work with value-based partners on gap closure of attributed opportunities where applicable.
Horizon's contracted pharmacy benefit management maintains a website to make available patient safety information, a drug-to-drug interaction tool and a drug database that informs members of useful information regarding drug therapy such as how to take drugs, potential side effects, etc.
Pharmacy related topics are published in the member and provider newsletters on various drug information such as, drug coverage and other clinical programs annually and quarterly respectively.
- Gaps in Care
The purpose of this program is to promote appropriate drug therapy and improve quality of life for our members through avoidance of medical complications and slowing disease progression. This program focuses on identifying evidence-based opportunities to modify or change drug therapy. The following are the potential conditions for which a member will be identified for intervention: need for additional therapy to optimally manage disease, inappropriate or ineffective drug therapy, non-adherence to prescribe drug therapy regimen. The recommendations are mailed to physicians. Additionally, a strong collaboration has been established between the various health systems operating in New Jersey and Horizon to close these gaps. The members' claims are tracked for changes in drug therapy and are monitored quarterly.
- Rapid Retro DUR Program
This program acts as a safety net to catch potential drug interactions that were not addressed at the point of sale. Pharmacists monitor claims within 72 hours of dispensing to identify potential drug safety issues. Outreach to the prescriber and/or dispensing pharmacy is completed if a safety concern is identified. This program works in conjunction with the point of service edits and the drug-drug interaction systemic reject program to identify any potential issues in order to intervene in any case that may be indicated within an appropriate timeframe.
Disparities in Health
Disparities in health reduce the overall quality of care provided within the health care system while adding to overall health care costs. In 2022, to address the multiplicity of the needs of the membership, the QI Program will continue to identify and address disparities in health outcomes among different member populations. Horizon programs to reduce disparities in health will be driven by discussions held during Disparities Workgroup and QIC meetings, as well as recommendations made by the QIC. The interventions selected to reduce health care disparities in clinical and service areas will be instituted during 2022 and will be included in the 2022 QI Work Plan. Current topics under the review include: Breast Cancer Screening (BCS); Cervical Cancer Screening (CS); Prostate Cancer Screening: and Social Determinants of Health. Horizon's ongoing efforts to reduce disparities will be coordinated and monitored through the QIC. The goal of is to implement interventions and community health events which reduce disparities between differing member populations.
Cultural Competency and Health Literacy
Horizon recognizes the cultural diversity and health literacy needs of its health plan members. The Plan is committed to promoting cultural competency, increasing health literacy, and decreasing health care disparities regardless of gender, age, race, ethnicity, disability, gender identity or sexual orientation. Horizon utilizes data from multiple sources to develop and implement policies and programs that increase cultural competency and health literacy. All staff and participating providers receive training on diversity, bias or inclusion. Additionally, efforts are made to promote diversity in hiring and recruiting.
Members speaking a language other than English have access to the AT&T language line whenever they need to interact with Horizon, and they can look for a provider speaking their language in the provider directory. Horizon also has a bilingual website dedicated to Spanish speaking members.
All members have translation services and materials available in Spanish, which is the predominant non-English language among Horizon's members. Documents can be requested in other languages upon request. Teletypewriter (TTY) services are also available for individuals with hearing impairments.
Complex Health Needs
The mission of the Horizon Chronic Care Program is to promote the wellbeing of members with chronic illnesses by empowering them to actively participate and take responsibility for their own health. Through the provision of education, coaching/counseling, and access to quality healthcare, members are better able to self-manage their disease(s) and enjoy an improved quality of life. The Chronic Care Program maintains open business hours of operation between 8AM and 5PM EST Monday through Friday. The Chronic Care Program is available through the Federal Employee Program (FEP) and Horizon Employee Program (HEU).
The Chronic Care Program is a multidisciplinary, continuum-based approach to health care delivery that proactively identifies populations with, or at risk for, chronic physical conditions. It includes coordinated healthcare interventions and communications for populations with conditions in which patient self-care efforts are significant. Chronic care supports the practitioner/patient relationship and plan of care, emphasizes prevention of exacerbations and complications utilizing cost effective, evidence-based practice guidelines and patient empowerment strategies, and evaluates clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall health.
The Chronic Care Program focuses on the following chronic conditions:
- Coronary Artery Disease (CAD)
- Heart Failure (HF)
- Chronic Obstructive Pulmonary Disease (COPD)
The Chronic Care Programs have disease-specific interventions based on the stratification level or severity of the member's condition. Stratification and assessment are inter-related, and both provide data used to assign a member to a risk level for intensity of specific interventions. Eligible members are assigned to one of three risk levels, or stratifications, based on the predictive model application or through an assessment accomplished with the input of the member. Low Risk is the lowest risk level and High Risk is the highest risk level, which requires the highest intensity.
Members are identified for the Chronic Care Program using Horizon BCBSNJ's own clinical identification algorithms, based on medical, laboratory, and pharmacy claims data, member medication compliance reports, individual utilization profiles, and using the Health Status Indicator (HSI) Specifications and Clinical Exclusion List.
Member Interventions: Member interventions include: educational mailings, telephonic educational coaching, assisting the member to understand treatment options, education on appropriate use of medications, appropriate nutrition, avoiding disease exacerbations, improving communication with his/her physician, and connecting members with community resources.
Outcomes: The FEP Chronic Care program assessment is completed annually through a member satisfaction survey.
Quality Improvement Program Components
The following are brief descriptions of the various components of the Quality Improvement Program. For a full description of the programmatic elements as well as to which lines of Horizon's business they apply, see the relevant administrative policies relating to that function.
HORIZON HEALTHY JOURNEY
The goal of Horizon's Preventive Health and Wellness Program is to improve the member's quality of health by encouraging them to pursue healthy lifestyles and maintain optimal wellness. Key components of the program include assisting members/covered persons to obtain needed immunizations and screening tests, and educating members on preventive health care, known to reduce illness, and accidents, and promote the early detection of potential disease conditions. The program uses a variety of reminder techniques for this purpose such as automated reminder telephone calls; health risk appraisals, interactive tools through the member portal; newsletters targeted to a specific populations; mailings, and preventive health calendars. The aim is to reach members in a manner to which they can easily relate.
Horizon's Preventive Health Program is based on preventive health care guidelines that are selected and maintained by Horizon. These guidelines were adopted from national organizations such as the Advisory Committee on Immunization Practices, the American Academy of Pediatrics; the American Academy of Family Physicians; the Agency for Health Care Policy and Research; American Cancer Society and the American Diabetes Association. The guidelines are age, gender, and risk-status specific and describe the prevention or early detection interventions recommended along with frequency and conditions under which the interventions are required. Target preventive health activities include, but are not limited to: childhood and adult immunizations, women's health needs, nutrition, high blood pressure, smoking cessation, and depression.
Internal staff members who utilize Clinical Practice Guidelines (CPGs) access information through the Lotus Notes database. CPGs can also be accessed through the Care Radius medical management system.
Horizon updates the preventive health guidelines and distributes them to participating physicians and members via newsletters. Providers can also access information via the provider portal.
Population Health Management
Horizon manages Commercial and Marketplace members through multiple programs to increase member satisfaction, improve health outcomes and reduce cost, known as the Triple Aim. The Plan utilizes a data-driven approach to population health management of its member population. This approach includes stratifying the population into four quadrants (Healthy, Rising Risk, Complex Care and Safety and Outcomes). In addition, the population is also segmented by location (zip code, city or county), age and gender.
The objective of the Population Health Management Program is to improve the overall health and wellness of the population through programs that encourage preventive health services, health and disease maintenance programs and appropriate utilization of practitioner and other provider services. Through population analysis, interventions are designed based on the target population's needs and barriers to help them achieve their best health. The Population Health Program is available to all active enrolled members, who may opt out via a telephone call to be placed on a do not contact list.
Annually, Horizon reviews and assesses the characteristics of the Commercial and Marketplace populations and selects subpopulations to ensure that adequate programs, staff and community resources are available to meet the health care needs of our members. Those subpopulations are children and adolescents, members with disabilities, and members with severe and persistent mental illness. Findings are presented, reviewed, and approved annually by the Quality Improvement Committee (QIC).
According to the Case Management Society of America, Care Management is a “collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to meet an individual's and family's comprehensive health needs through communication and available resources to promote patient safety, quality of care and cost effective outcomes” (CMSA, 2021).
The intensity of care management activities varies based on factors including, but not limited to:
- Clinical features of the individual case as reported by a member or attending/treating provider;
- Evaluation/treatment setting resources
- Member's clinical needs and situation
- Opportunities for care management intervention to have a positive impact on the member's circumstances.
Care Management Program Objectives
- Assure timely patient access to the appropriate type and level of care as early as possible.
- Manage health care benefits as effectively as possible while pursuing all members' needs from a patient advocacy perspective to align with the physician/provider's treatment plan.
- Identify needs that follow an acute care episode and assists with interventions for prevention and management of long–term health conditions.
- Identify members who may benefit from educational programs, materials and other helpful resources, including community based-services.
- Identify members, based upon eligibility under their benefits contract, which might benefit from referral to Horizon internal or contracted services such as the Chronic Care Program (Federal Employee Program and Horizon Employee Unit), Specialty Care Management services, Behavioral Health Services, and external vendor programs such as eviCore, AIM, CareCentrix, MagellanRx, pharmacy assistance, Turning Point, AbleTo, Precious Additions, 24/7 Nurseline; Horizon CareOnline Telemedicine and other Horizon external vendor programs.
- Collaborate with the member's health care professionals through treatment planning, discharge planning, transition of care in such venues as Interdisciplinary Community Based Care Model meetings, hospital and post-acute facility discharge planning meetings, Case Rounds, and individual outreaches to providers and vendors.
- Achieve optimum cost effectiveness while assuring access to providers providing quality care.
The Medical Management (MM) Program evaluates clinical necessity, access, appropriateness, and efficiency of services. This includes, but is not limited to the following programmatic components: prior authorization, concurrent review, discharge planning, retrospective review, care management, and chronic care management. The MM Program also generally seeks to coordinate, when possible, emergent, urgent and elective health care services. The MM Program evaluates overall utilization such as ER, admission and readmission rates, coordination of services, over and underutilization, and evaluation of new technology. In addition, the MM Program collaborates with the Delegate vendor oversight department in the oversight of physical health UM delegated functions. Refer to the Utilization Management and Case Management Program Descriptions for information that is more detailed.
The purpose of the Pharmacy Utilization Management Program is to identify different patterns of medication utilization and identify variables in treatment patterns for different disease states. The goal of this program is to improve patient outcomes and to utilize various interventions, including physician and member education, to ensure medically appropriate cost-effective prescription drug therapy in accordance with all applicable state and federal laws and regulations. Goals of the Pharmacy Utilization Management Program are as follows:
- To assure that adequate and appropriate resources are available to provide accessible health care services.
- To design interventions that improve clinical outcomes, optimize patient compliance, and maximize safety.
- To provide pertinent education to members, physicians and healthcare professionals.
- To identify medication utilization issues.
- To identify patterns of inappropriate prescribing based on recommended prescribing guidelines.
- To evaluate the impact of interventions.
- To augment the drug selection process for formulary inclusion.
- To further integrate Pharmacy Utilization Management activities with Medical Utilization Management, BH and Quality Improvement processes.
- To audit retail pharmacies and the pharmacy benefit manager to ensure appropriate utilization and reporting.
- To differentiate drugs based on physical/ (BH) versus pharmacy.
- To review quarterly utilization reports to monitor drug use patterns.
- To perform outcomes research based on pharmacy, physical/ (BH) and laboratory data.
Credentialing & Recredentialing
A significant part of Horizon's Quality Improvement Program is the appropriate and regular credentialing of providers. The Credentials Committee establishes standards for identifying competent physicians and other providers in accordance with regulatory requirements and accreditation standards. The Committee uses the standards to determine eligibility for participation in one or more of Horizon's networks. The goal is to develop a network of participating physicians and providers that demonstrates Horizon's commitment to continuously improve the quality of health care delivered to its members.
All physicians, healthcare professionals, facilities and ancillary providers participating with the health plan must submit their qualifications for review and approval by the Credentials Committee. Qualifications for physicians and other healthcare professionals include, but may not be limited to: current licensure(s), education and training, work history, board certification, hospital/facility privileges, malpractice history and be in good standing in the medical community. Facilities and ancillary provider qualifications include but are not limited to: licensure as applicable, accreditation or satisfactory site visit, malpractice history and be in good standing in the medical community. Re-credentialing is performed on all network physicians, healthcare professionals, facilities and ancillary providers every three years.
To ensure the quality and safety of care between credentialing cycles, the program performs continuous monitoring for sanctions, limitations on licensure, potential quality of care issues including member complaints and compliance with Horizon's performance standards, such issues are brought to the Credentials Committee, which takes action as warranted.
Network Management focuses on exploring and implementing opportunities to improve member access to care and services. Data is continuously gathered and analyzed throughout the Horizon organization to ensure that our Network(s) meet these needs and is able to deliver quality healthcare to our members.
Some examples of analysis include but are not limited to the following: Our quarterly geo-access reporting that identifies any potential network deficiencies within provider specialties that we would need to recruit into our network(s). We also conduct an appointment availability analysis to ensure that members have access to needed providers and that they are getting desired appointments within the required timeframes. Additionally, we conduct several annual in-service education seminars for our network providers to inform them of updates to our various programs, services, products and requirements. Horizon offers at least one training to network practitioners on topics of health equity, cultural competency, bias, diversity or inclusion annually. We use the provider feedback from these seminars to plan future programs.
Horizon Member Services seeks to establish and maintain effective communication with members and providers in order to deliver the highest level of service. Member and Provider satisfaction are evaluated from data that includes phone performance, member/provider complaint handling, and member/provider satisfaction surveys (CAHPS and other internally developed surveys). Survey data is reviewed quarterly, and continuous process improvements are developed to optimize service levels in areas such as first call resolution, Average Speed of Answer, information accuracy and content of written materials (health literacy).
Member/Provider satisfaction reports and complaint and appeal information are used to identify opportunities for improvement, review root cause / “end to end” processes and develop action plans as warranted.
Delegate Vendor Oversight
The Delegate and Vendor Oversight Department (DVOD) performs the formal process by which Horizon monitors, directs, and evaluates a set of activities by contractors who are responsible for the performance. Horizon maintains oversight responsibility of delegated activities and retains the right to modify or withdraw the nature of the contractual relationship, including the termination of the contract and/or the delegation of activities as specified in the relevant contract or delegation agreement.
The Delegate and Vendor Oversight Committee (DVOC) also seeks to ensure that the vendor or delegate's activities adhere to Horizon's policies and procedures, regulatory and accreditation standards and meet performance standards as required in the relevant contract or delegation agreement. In the event a delegate and/or vendor is not meeting performance expectations, the committee requires improvement and requests a corrective action plan, which is monitored until the issue(s) is remediated.
Behavioral Health (BH) Care Management Programs
The Horizon Care Management Program uses an integrative approach to deliver holistic care for our members. The integrative Care Management process begins at the time of member identification. The Care Management team uses advanced analytics predictive modeling algorithms to identify the right member at the right time. Once identified, members experience one Care Manager approach with physical health, behavioral health and pharmacy working together on a shared clinical platform. The Care Manager completes a needs assessment that will identify the member's potential needs across physical health, behavioral health, SDoH and pharmacy. A member-centric personalized plan of care is created to address member's identified needs, barriers and identified gaps in care to help guide them in their care journey. A proactive care plan that is inclusive of all treatment areas is applied to address all of their needs. Our integrated member-centric approach drives improved overall healthcare outcomes for our members. The improved member outcomes that integration can bring to our healthcare community are demonstrated in our member assessments and our pre & post-member Care Management engagement metrics.
The BH Integrated Care Management Programs include the following goals:
- Providing Behavioral Health support to members that are identified as at risk or with a diagnosis of depression, anxiety, bipolar, schizophrenia, autism disorders, alcohol or other substance abuse and eating disorders. Also identifying members with comorbid behavioral health and chronic Physical Health conditions with symptoms that complicate adherence to prescribed treatment plan and self-management of their conditions.
- Assisting members with behavioral health referrals by linking them to network providers.
- Support the transition of members who are in physical inpatient units to behavioral health services as appropriate.
- Assisting members with primary or secondary diagnosis of substance abuse or dependence with appointments within 14 days of diagnosis, establishing initiation of treatment and two (2) subsequent appointments (HEDIS Substance Abuse Treatment Initiation and Engagement).
- Improving community tenure, functioning and treatment compliance for members with behavioral health issue through complex case management (CCM).
- Prevent use of the ER for behavioral health reasons through proactive identification and providing assistance with referrals to specialty programs, appropriate authorizations and community resources.
- Improving communications between primary care providers and behavioral health providers.
- Performing diagnostic assessment of symptoms to determine the severity of the conditions (Patient Health Questionnaire).
- Providing all enrolled members with education about behavioral health conditions.
- Assisting members with depression and other behavioral health conditions to overcome barriers to treatment.
- Focus on behavioral health conditions as barrier to adherence with self-management.
- Monitoring the member's condition through assessment of treatment response.
- Collaborating, with the member's consent, routinely with behavioral health providers and physical health providers, as needed.
- Identifying and promoting an optimal, realistic level of an individual's wellness and functionality.
- Improving overall member and provider satisfaction with Horizon Blue Cross Blue Shield of New Jersey.
- Identifying needs following an acute care episode and assisting with interventions for long term behavioral health needs.
- Providing follow up after hospitalization support.
- Provide support via consultation to Horizon PCPs and pediatricians to improve the identification, evaluation and treatment of behavioral health conditions such as depression, anxiety and bipolar disorders. PCPs are afforded access to telephonic consultations with a behavioral health medical director (psychiatrist) to consult on psychotropic medication management and appropriateness of their Horizon member's current behavioral treatment plan.
- Post-partum support for member with comorbid Behavioral health symptoms and or diagnosis to assist in navigation for provider needs as well as community resources.
- Ongoing training for physical and behavioral health practitioners.
Education and Training
A team of clinical and non-clinical training professionals from the Clinical Operations Training team will create and deliver education and training materials. Trainings are provided in either a classroom setting, by WebEx, or via Horizon University to employees across the Enterprise. All courses are reviewed annually to ensure information is current. Education includes but is not limited to:
- Medical Management
- Health literacy
- Cultural competency
- Regulatory and key industry guidelines
- Quality reporting
- NJ Choice State Certification Training
Training modules are provided to Clinical Operations staff and include a knowledge check or attestation to assess completion. General orientation training is conducted for new employees. Focused/specialized ad hoc training, including system upgrades, and trainings identified by departmental leadership are created and offered. Areas receiving education include:
- Utilization Management
- Case/Care Management
- Quality Management
- Medical Directors
- Other Departments as requested
The QI Program through the QIC:
- Monitors regulatory requirements for quality management and compliance;
- Ensures that the appropriate actions are taken when areas of quality management non-compliance are identified; and
- Ensures quality management reporting system provides adequate information for meeting the regulatory external review and accreditation requirements of mandatory and voluntary review bodies.
Audits and Reports
System Control Audits
Quarterly audits are completed by the UM, Appeals and Credentialing teams on their system controls.
The audits include a review of modifications to UM, Appeals and Credentialing information to determine if they are compliant with Horizon's policies and to ensure that changes are appropriately tracked in our systems. The audits also monitor system security and prevention of unauthorized access to system data. Identified deficiencies are corrected and monitored for improvement.
Additional audits and reports include:
- Physician Appointment Availability Audit (Physical and Behavioral Health)
- Physician 24 Hour Access to Care Audit (Physical and Behavioral Health)
- Office Manager Satisfaction Surveys
- Geo Access Reports
Interrater Reliability Testing
Horizon Blue Cross Blue Shield of New Jersey complies with applicable Federal and State civil rights laws and does not discriminate against, exclude, or treat people differently on the basis of race, color, gender, national origin, age, disability, pregnancy, gender identity, sex, sexual orientation or health status in the administration of the plan, including enrollment and benefit determinations. For further information, see the Notice of Nondiscrimination and Information in Other Languages sections of the Horizon Blue Cross Blue Shield of New Jersey website.
New Jersey is a diverse state and so is the membership at Horizon. Horizon collaborates with numerous institutions, community centers, hospitals and practitioners implementing programs to decrease health care disparities, training providers and staff on cultural competency and developing programs on health literacy. In addition, Horizon is making a concerted effort to identify opportunities to develop and refine programs to address health disparities and improve health outcomes. The Horizon Foundation, through the yearly award of grants, is a testament to Horizon's compassion, social responsibility and commitment to New Jersey. Additionally, Horizon's commitment to diversity, equity and inclusion among its employees, members, physicians and business partners is demonstrated by Horizon's Pledge, which sets specific goals with respect to projects geared toward creating lasting change.
Value Based Programs
Value-Based Programs are administered by the Healthcare and Network Solutions (HNS) division of Horizon with the following goals based on the Triple Aim:
- To improve the health of the population.
- To achieve a sustainable trajectory in health care spending.
- To improve the patient experience.
To achieve these goals, Horizon works to establish collaborative provider relationships and looks to streamline processes to reduce clinician burnout, with clinician experience often called the Quadruple Aim. To reach these goals, Value-Based Programs has focused on:
- Redefining care delivery to emphasize population health management and delivery system alignment.
- Creating accountable consumers and purchasers.
- Enhancing data exchange.
- Enforcing clinical quality standards.
- Providing coaching and insights to identify care barriers and fragmentation.
Value-Based Programs Models
Value Based Specialty Care – Engages specialty care Provider Partners in our value-based strategy. Episodes of Care (EOC) defined around a specific medical condition, procedure or illness within a defined period of time are the primary models that Horizon uses to build an arrangement and engage with a Provider Partner who acts as the conductor orchestrating the full spectrum of care for that specific medical condition, procedure or illness.
Financial models can include upside only shared savings and upside/downside models including prospective bundles. Targets can be dollar cost targets or trend arrangements based on partners' historical performance, market or some combination thereof. Models can be retrospective or prospective.
The goals of Value Based Specialty Care include:
- Standardize and optimize quality and cost of care, with the patient at the center of decision-making;
- Improve toward and maintain high quality outcomes, tracking to discipline specific quality measures;
- Ensure adherence to evidence based medicine and clinical pathways resulting in appropriate utilization; tracking to discipline specific utilization measures;
- Promotes physician-directed medicine, while incorporating shared-decision making and patient engagement in managing their care; tracking to specific activity measures;
- Creates accountability to the patient for all care related to their particular procedure, diagnosis or health care event;
- Promotes collaborative, comprehensive “best-in-class” care for Horizon members across the full continuum, including building relationships with Primary Care and providers from other specialties in support of the best possible outcomes and slowing disease progression;
- Supports the view that health care is about best outcomes;
- Creates accountability to the patients, our members and the physicians to remove industry and plan created barriers to optimized, timely and efficient evidence-based treatment;
- Promotes clinical outcomes and cost transparency to inform optimal care delivery decisions;
- Enhances collaboration of all care providers across multiple care settings.
Value Based Programs
Shared Savings Programs
An organization of health care providers agrees to assume joint accountability for a patient's entire care. The program is comprised of hospital and practice based Accountable Care Organizations (ACO), large multispecialty groups, and a Virtual aggregation of smaller practices. The program offers a reimbursement model that accounts for both quality and total cost of care.
Risk Sharing Programs
For more functionally advanced provider partners, Horizon offers risk-sharing options that yield enhanced financial rewards for high performers. These programs include upside/downside risk by both parties and seek to encourage those providers performing well on cost, quality, and member experience goals to earn increasing year-end compensation tracked to enterprise and program goals.
The program's clinical goals are:
- Providing active management of chronic and complex conditions to optimize treatment plans, drive care coordination and ensure patient self-management.
- Identifying and managing patients at risk for high cost or morbidity in the future.
- Providing proactive care for a patient population to drive health promotion, disease prevention and patient engagement.
- Empowering providers to make appropriate care decisions for their patients inclusive of referral management and patient education.
Value-Based partnerships with select health systems and large providers designed as enhanced partnerships to increase the quality of care, patient/member experience with care and reduce costs. The goal is to achieve measured quality improvement and increase affordability for the provider's patient population. The program is designed similarly to the shared savings programs but with increased provider/plan collaboration and synergy.
The Commercial line of business is accredited by the National Committee for Quality Assurance (NCQA). The Quality Management Department, through the QI program, continuously monitors all applicable business areas to ensure their compliance with the most current NCQA Health Plan Accreditation standards and guidelines. The Quality Department's Accreditation Team provides education, assessment and feedback to business areas for continual readiness in between reaccreditation cycles. The Accreditation Team monitors compliance with standards on an ongoing basis and educates applicable business areas on changes to the standards annually.