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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 (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.

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.