Episodes of Care

In patient-centered Episodes of Care (EOC) programs, a practice or doctor acts as the coordinator to orchestrate the full spectrum of care for a specific medical condidition, illness, life event, or within a defined period of time. Using national quality standards and best practices, our goals with EOC programs 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
  • Empowers physicians to become clinical leaders championing high-quality affordable care
  • 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 2016, member “Overall Satisfaction” across all episodes was rated at 94 percent.

Currently, all EOC programs use a retrospective payment model.

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

  • Breast Cancer EOC Program
  • Colonoscopy EOC Program
  • Coronary Artery Bypass Graft EOC Program
  • Crohn’s Disease with Behavioral Health Integration EOC Program
  • Diverticulitis EOC Program
  • Gastroesophageal Reflux Disease EOC Program
  • Heart Failure EOC Program
  • Hip Replacement EOC Program
  • Hysterectomy 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

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. Lili Brillstein, Director of New Models and Episodes of Care at Horizon BCBSNJ, is featured in a recent Healthcare Financial Management Association article in which she discusses EOC program highlights and lessons learned.