Patient-Centered Programs

Horizon Blue Cross Blue Shield of New Jersey collaborates with physicians, hospitals and other health care leaders to build and implement patient-centered programs that are designed to improve quality, increase patient satisfaction and lower the total cost of health care.

Many of these patient-centered programs, like the Patient-Centered Medical Home program, are focused on improving care coordination and strengthening primary care services to help ensure patients get healthy and stay engaged in their health care. In addition, a major component of these programs is to improve the way health care professionals are paid. For example, under the fee-for-service payment approach, physicians are paid based on the volume of treatments or tests they perform. Working with our partners, we are creating payment models that reimburse providers for keeping their patient population healthy, which will help improve patient outcomes and affordability.

Patient-Centered Medical Homes

A Patient-Centered Medical Home (PCMH) coordinates patients’ health care needs, and helps ensure they receive the highest quality of care, at the right setting and at the right time. This patient-centered approach provides a personalized and comprehensive health care program that enables patients to become engaged in their health care. The benefits members have under their current Horizon BCBSNJ plan do not change. Participation in a PCMH does not decrease or limit any current benefits.

Horizon BCBSNJ, the New Jersey Academy of Family Physicians and the leadership of eight primary care practices collaborated to launch New Jersey’s first comprehensive, state-wide PCMH program.

The PCMH program includes resources for providers to help coordinate care and engage patients. Horizon BCBSNJ is providing practices with health technology tools and sharing timely patient data with physicians and their staffs. This provides the practices with the resources they need to provide better care to their entire patient population.

Accountable Care Organizations

A patient-centered Accountable Care Organization (ACO) program aims to create a healthier population, to improve the patient experience and to control the total cost of care. ACOs are comprised of health care professionals who are responsible for achieving measured patient quality outcomes and avoiding unnecessary and duplicative medical tests and treatments. An effective ACO is built on the foundation of primary care because of its strong focus on preventive and wellness care to keep patients healthy. We are partnering with health care leaders to create ACO models in New Jersey.

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:

  • Breast Cancer EOC Program
  • 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.