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Episodes of Care

Episodes of Care (EOC) is the primary model that Horizon BCBSNJ uses to engage specialty care physicians in our value-based strategy. In an Episode of Care (EOC), a practice or doctor acts as the conductor who orchestrates the full spectrum of care for a specific medical condition, procedure or illness within a defined period of time. The focus is on coordinated, collaborative care across the health care continuum to ensure that patients receive the highest quality and most comprehensive care. Using outcome measures developed in conjunction with our physician partners, our goals are to achieve the best long-term outcomes, create experiences that patients feel good about and reduce the total cost of care by eliminating unnecessary care.

EOC is an innovative care model that:

  • Promotes physician-directed medicine;
  • 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 BCBSNJ members across the full continuum;
  • Supports the view that health care is about best outcomes;
  • 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 in conjunction with our physician partners and approved by Horizon BCBSNJ’s Quality Advisory Committee. The program incorporates both standard metrics across all episodes (e.g., ER visits, readmission rates) and episode-specific metrics (e.g., pre- and post-functional assessment after surgical procedures, adenoma detection rates for colonoscopies).

Patient satisfaction surveys are conducted at the completion of an episode to assess patient experiences for all of the care they received. In 2018, members across all EOC programs measured rated their “overall satisfaction with communication and support provided” and “overall satisfaction with the coordination of and involvement in your care” at an average of greater than 92 percent.

Most of our EOC programs use a retrospective, upside-only payment model, which provides an opportunity for Horizon BCBSNJ and our physician partners to work together to create success for our members. As we continue to move through the evolution from fee-for-service to value-based care, we will introduce opportunities for providers to take on shared risk and prospective episodes.

Following is a list of current EOC programs in our portfolio (please click here for a list of physicians/practices that participate in Horizon BCBSNJ’s EOC programs):

  • Bariatric Surgery (NEW)
  • Colonoscopy
  • Coronary Artery Bypass Graft
  • Coronary Artery Disease
  • Diverticulitis
  • Gastroesophageal Reflux Disease
  • Heart Failure
  • Hip Replacement
  • Hysterectomy
  • Hysteroscopy (NEW)
  • Inflammatory Bowel Disease (Crohn’s Disease & Ulcerative Colitis) with Behavioral Health
  • Knee Arthroscopy
  • Knee Replacement
  • Low Back Pain
  • Pacemaker Defibrillator (NEW)
  • Pregnancy/Newborn
  • Prostate Cancer
  • Prostatectomy
  • Shoulder Replacement
  • Spinal Fusion
  • Substance Use Disorder with Behavioral Health

The following EOC programs are planned to launch in 2019:

  • Chronic Kidney Disease
  • Obesity
  • Rotator Cuff Surgery

In addition to the EOC program, Horizon BCBSNJ has a specialty care medical home model in place for patients with oncologic diagnoses. The model is similar to a Primary Care Medical Home (PCMH) in that members are attributed to a key provider (typically their oncologist) who is accountable for all of the care rendered to the patient, related to their oncology diagnosis.