Episodes of Care

Episodes of Care is the value-based model that Horizon BCBSNJ uses to engage physicians in certain specialties in our value-based strategy. In patient-centered Episodes of Care (EOC) programs, a practice or doctor acts as the conductor who orchestrates the full spectrum of care for a specific medical condition, illness, or life event within a defined period of time. Using outcome measures developed in conjunction with our physician partners, our goals are to achieve better quality outcomes, improve the patient experience and reduce the total cost of care.

EOC is an innovative care model that:

  • Promotes physician-directed medicine and patient involvement and decision-making in their care whereby the physician leads patient care across the entire episode
  • Promotes high-quality “best in class” care for Horizon BCBSNJ members
  • Promotes clinical outcomes and cost transparency to inform optimal care delivery decisions
  • Enhances collaboration of all care providers across multiple care settings

EOC program quality metrics are established by our partners and approved by Horizon BCBSNJ’s Quality Advisory Committee. Our EOC program incorporates both episode-specific metrics such as prolonged opioid use after hip/knee replacement and standard metrics for all episodes such as Emergency Room (ER) visits and readmission rates. Patient satisfaction surveys are conducted at the completion of an episode to ensure that members are satisfied with the care they received and were engaged in the health care decision making. In 2017, members across all Episodes rated their “overall satisfaction with communication and support provided” and ”overall satisfaction with the coordination of and involvement in your care” at 94 percent.

Most of our EOC programs use a retrospective payment model. As we continue to move through the evolution from fee-for-service to value-based care, we will introduce opportunities for shared risk and prospective episodes.

Review a listing of physicians/practices that participate in the following EOC programs:

  • Colonoscopy EOC Program
  • Coronary Artery Bypass Graft EOC Program
  • Diverticulitis EOC Program
  • Gastroesophageal Reflux Disease EOC Program
  • Heart Failure EOC Program
  • Hip Replacement EOC Program
  • Hysterectomy EOC Program
  • Irritable Bowel Disease with Depression/Anxiety EOC Program
  • Knee Arthroscopy EOC Program
  • Knee Replacement EOC Program
  • Low Back Pain EOC Program
  • Pregnancy EOC Program
  • Prostate Cancer EOC Program
  • Prostatectomy EOC Program
  • Shoulder Replacement EOC Program
  • Substance Use Disorder EOC Program

EOC in the News

Horizon Blue Cross Blue Shield of New Jersey, a pioneer in EOC payments, is using the pay strategy for procedures, acute-care events and chronic condition management.

Review this Healthcare Financial Management Association article in which Lili Brillstein, Director of New Models and Episodes of Care at Horizon BCBSNJ, discusses EOC program highlights and lessons learned.

Review Ms. Brillstein’s CIO Review article in which she encourages stakeholders who are able to demonstrate their value on improved quality, evidence-based treatment performance, and good patient experiences to explore and engage in value-based healthcare models now.