Horizon Healthcare
Innovations’ Medical Home
Pilots
Presentation to NJBGH
October 12, 2010
Contents
▪ Introduction to Horizon Healthcare
Innovations
▪ Brief overview of care model pilots
▪ Primary Care Patient-Centered Medical
Home
▪ Oncology care model
|1
Horizon Healthcare Innovations, (HHI)
Born Sept 2010
HHI is a subsidiary of Horizon Blue Cross Blue Shield of New Jersey,
founded in 2010 to energize the transformation of healthcare delivery
and create a system marked by quality and effective care, greater
efficiency and increased affordability. We acknowledge that the
status quo is broken.
To achieve our long-term aspirations, HHI will innovate, create and
collaborate with our partners including physicians, hospitals, community
leaders, employers, patients and other individuals who want to make a
difference. We are looking for partners in our quest.
|2
Horizon Healthcare Innovations (HHI) Overview
Vision
We will boldly innovate, in collaboration with others, to foster exemplary
healthcare in the communities we serve
Mission
To catalyze transformation that creates an effective, efficient, and affordable
healthcare system
Long-term Aspirations
▪
▪
▪
▪
Achieve a sustainable trajectory in healthcare spending
Improve quality, access, and population health care
Ensure more positive, collaborative relationships with providers
Strive for improved overall consumer satisfaction and engagement
|3
Contents
▪ Introduction to Horizon Healthcare
Innovations
▪ Brief overview of care model pilots
▪ Primary Care Patient-Centered Medical
Home
▪ Oncology care model
|4
We are in the process of developing 6 potential pilots, with the goal to launch
2-4 by the end of 2010
Primary Care
Patient Centered
Medical Home
(PCMH)
Accountable
Care
Organization
(ACO)
Efficient
Episodes
Inpatient
Management
Population management
▪ Creating a truly patient-centric model of care delivery supported by a
care team of heath professionals:
– HHI is driving physician practices to transform to take on greater
accountability, activity and responsibility for health
– Is inclusive of all members, but focuses on early and late stage chronic
patients
▪ Improving quality and reduce costs through local accountability,
standardized performance measurement, and innovative
reimbursement structures
Acute procedural episodes
▪ Reimbursing a single individual or entity for all the components of a
patient’s care related to a specific procedure or an acute episode of a
medical diagnosis within a defined period around that procedure or episode
▪ Encouraging eligible physicians to achieve compliance with the program
goals for quality of care and efficient delivery of inpatient care
Chronic care management
Oncology
Medical Home
▪ Transforming oncology practices to deliver treatment and patient guidance
Consumer
engagement
▪ Transforming the management of chronic disease – leveraging
that is evidence-based, consistent, and in the best interest of the
patient
technology to create consumer ownership of health and healthcare
thereby improving medication / treatment protocol adherence and selfmonitoring / healthy activities post diagnosis
|5
Guiding principles of the care model pilots
1
Promote high quality, ‘best in class’ evidence based care
2
Tie actions to results, tracking clinical decisions and quality performance
3
Establish closer payor/provider collaboration
4
Support providers to increase affordability
5
Encourage patient ownership and responsibility
6
Be easily scalable over the longer term
|6
Horizon’s medical homes aim to address both the systemwide and condition-specific issues that patients experience
Primary Care Specific Issues
• Current models promote transactional
interactions, not prevention and holistic care
• Little incentive and infrastructure to support
coordination among physicians
• Difficulty getting appointments scheduled
without long lead times
Planned
2011 pilots
Potential
later pilots
Oncology Specific Issues
• High level of patient anxiety
• No physician identified as responsible for the
patient’s overall care
• Significant side effects from treatment
• Difficult end of life decisions
Common Issues Addressed by Care Models
• No single physician accountable for total health care needs and costs
• No system accountability for inefficiency and waste
• Lack of patient / member accountability for their own health care
• Little non-clinical support causes patient confusion
• Lack of focus on overall patient health and wellness
• Fragmented delivery system with misaligned incentives
Pregnancy Specific Issues
Cardiology Specific Issues
• Above average number of high-risk patients in
NJ (e.g., diabetics, obese, 40+)
• High rate of multiple birth pregnancies and
cesarean sections
• Lack of support for mother and child throughout
and after the pregnancy
• Older patients with a high rate of co-morbidities
• Lack of support and guidance for necessary
lifestyle changes
• Multiple potential treatment options
|7
Contents
▪ Introduction to Horizon Healthcare
Innovations
▪ Brief overview of care model pilots
▪ Primary Care Patient-Centered Medical
Home
▪ Oncology care model
|8
The Horizon Healthcare Innovations Primary Care Medical Home uses
a team based approach to execute four patient-centered strategies,
transforming the care experience for patient and practice
Medical
Home
Enablers
Evidence
Based
Medicine
Information &
Infrastructure
Systems
Appropriate
Reimburseme
nt
Member
Benefits &
Incentives
Empowered
Decision Making
Team
Based
Care
Prevention & Health
Status Mgmt
Personalized Care
Management
Patient
Centered
Strategies
Access &
Availability of Care
Accountability & Responsibility
Measurement
& Reporting
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The PCMH model transforms delivery of primary care
From PCP care model…
…to Patient Centered Medical Home model
▪ Variation in Quality between and within
▪ Care standardized according to evidence-
practices - scheduled time and practice’s or
physician’s tracking mechanisms
▪ Care focus determined by immediate
episodic problems and presence of patients
(face to face time)
▪ PCP appointments often scheduled when
based guidelines and measured on quality,
patient experience and utilization
▪ Care collaboratively managed by team with a
▪
▪
patients deem necessary
▪ Patients left to coordinate their own care,
including visits to specialists
▪ Inconsistent reporting / documentation from
hospital and specialist visits
proactive plan to meet patients’ needs
Members build on-going relationship with care
team through increased communication
PCMH and patient collaborate to ensure
timely and appropriate outreach and f/u
appointments
▪ Referrals are coordinated by care team,
▪
information is shared with specialists.
PCMH co-creates care plan and educates /
engages patients to obtain positive outcomes
▪ PCMH tracks tests / consultations, and follows
up on ED / hospital visits
| 10
Patients will have a new experience with increased engagement and
participation throughout the care process
Patient Access
▪ Practice uses physician extenders to increase capacity and availability
▪ Strong links with providers facilitates access (e.g., behavioral health network)
▪ Patient and case
▪
▪
▪ Practice proactively
coordinator communicate
to ensure compliance
Practices use technology
to identify gaps in care
Practice monitors
performance
(1)
Before
the Visit
(4)
Ongoing
Patient-Centered
Coordinated
Care
▪ Practice tracks and
▪
monitors referrals, ensuring
exchange of relevant
clinical information
Practice coordinates with
relevant medical
community actors
▪
engages consumers to
schedule visits
Case coordinator
determines need and type
of visit with patient
(2)
During
the Visit
▪ Case coordinator reviews
(3)
After the
Visit
▪
and updates care plan with
patient
NP and PA address majority
of less complex patient
issues
| 11
Primary Care PCMH – Value Proposition
For Patients
•Improved experience. Individualized patient centric care
•Navigation through the Health Care System
•Prevention, wellness, optimization of health status through coordinated, evidence based
care
For Primary Care Physicians
•Specialty Revival through demonstration of the added value of comprehensive primary
care
•Greater Income opportunities
•Professional satisfaction
For Employers
•Lower Health Care Costs
•Improved Wellness and Productivity
• More satisfied employees engaged in co-managing their care, armed with better
choices of aligned provider care teams.
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HHI will provide operational support to facilitate
this transformation
Detail follows
2013
2012
2011
Formalizing processes and
products
Building the critical
 Value-based products
infrastructure
tailored to PCMH initiatives
 HHI-provided transformation  Increased population
coaching and case
management and
coordinators
information provided to
 Reimbursement aligned to
practices
process and quality scores
 Pooled supporting
 Improved access directly to
resources
care team
 Population management
with focus on chronic
members
 More defined relationships
Optimizing performance
outcomes with tools and
informatics
 Consider PCMH networkbased product
 Savings sharing introduced
with reimbursement tied to
shared savings
 Personalized tools and
informatics
 Technology enabled access
 Individual provider-based
portals for members to make
appointments, download lab
results, access health
content, etc.
for access to specialists
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Case coordinators will be embedded into the practice care team and
will be integral to the PCMH model
Care
planning
Referral
management
Community
management
▪
▪
▪
▪
Complete health assessment and individualized care plan for
including self-management components
Conduct pre-visit planning for patients
Review and update care plan
Follow up with patients between visits
▪
▪
▪
Use electronic system to track referrals
Ensure exchange of clinical information into EMR
Follow up with specialist/patient on referrals
▪
Create formal agreements with diagnostics, hospitals, EDs,
pharmacies, and community resources
Ensure real-time exchange of clinical info into EMR
Collaborate on discharge activities from Hospital and ED to PCMH
Evaluate and tighten network based on quality and cost
▪
▪
▪
| 14
Payment structure will evolve over time –
with a vision for savings-sharing in the future
Today
Phase 1
Savings sharing
Case coordination
Outcomes-based
FFS
Phase 2 vision
Savings sharing
Outcomes-based
Case
coordination
FFS
▪
Fee-for-service only
Case
coordination
FFS
▪
▪
▪
FFS
FFS as paid today
▪
Case coordination
payments (PMPM)
Case coordination
payments (PMPM)
▪
Savings sharing between
practice and plan
Outcomes-based payments
| 15
HHI will use tiers in the near term to encourage stepwise improvement
Advanced Medical Home
Early Stage Medical Home
HHI goals
 Engage practices and incent medical
home development
 Reward full transformation with higher
reimbursement for higher value care
 Encourage broad participation in medical
home initiative
Practice
requirements
HHI support
 Attainment of any level of
recognition  Attainment of additional Advanced
Medical Home requirements as agreed
 Demonstrated integration of case
upon by Horizon Healthcare
coordination activities into practice
Innovations
workflows beyond
 Demonstrated commitment to
 Demonstrated commitment to become an
improving quality, process, and
advanced medical home
utilization metrics
 Direct funding of infrastructure
 Significant upside for quality and
development (e.g. care team members)
process improvements
 Case coordination fee to support process
 Opportunity for savings sharing long
improvements
term
 Outcome based payments to reward
performance
Horizon Healthcare Innovations goes beyond existing
standards in defining the Patient Centered Medical Home
| 16
Initial target practices for PCMH pilot rollout are based on
current diabetes pilot
6+ practices
4-5 practices
2-3 practices
1 practice
▪
Initial PCMH pilot
rollout targets 33
practices spanning
North and South NJ
▪
Phased-rollout will
leverage geographic
proximity of practices
▪
Aggressive
recruitment plan with
priority to
unrepresented areas
no practice
Geographic distribution
of target practices
| 17
Contents
▪ Introduction to Horizon Healthcare
Innovations
▪ Brief overview of care model pilots
▪ Primary Care Patient-Centered Medical
Home
▪ Oncology care model
| 18
Our goal is transformed practice focused on patient-centered
coordinated care
Current Care Management
Future Oncology Medical
Home
Medical
oncologist
Radiation
oncologist
Patient
support &
guidance
Patient
& Care
Team
Pharmacy
?
Behavioral
Health
Patient
Surgical
oncologist
Hematologist
Urologist
Fragmented and variable care without
full use of EBM guidelines reduces
quality and creates waste
Care coordinator serves as the “patient
navigator” coordinating care and
guiding patients through treatment
Patients very anxious given their cancer
diagnosis and lack a single non-physician
point of contact and guidance
Realigned incentives reward practices
for care coordination, member support
and use of evidence based guidelines
| 19
HHI will measure performance against goals
Evidence based care and
high quality standards
Clinically
appropriate
 Following clinical guidelines
 Creating and following a care plan
Safe
 Preventing avoidable harm to the patient
 Avoiding preventable admissions to the
ER or IP
Improved
experience
 Delivering a care experience that
Patient focused
outcomes
Am I receiving
care consistent
with best
practice?
patients view positively
 Ensuring patient concerns are addressed
 Encouraging appropriate dialogue
surrounding end-of-life decisions
| 20
Over time, the reimbursement structure
will focus more on rewarding quality of care
Savings sharing
Case coordination
Outcomes-based
FFS
Payment structure will gradually evolve and be refined to drive behavior
Today
Phase 1
FFS
▪
Fee-for-service only
▪
▪
▪
Phase 2 vision
Outcomes-based
Savings
CC
CC
FFS
FFS
FFS as paid today
▪
Case coordination
payments (PMPM)
Case coordination
payments (PMPM)
▪
Savings sharing between
practice and plan
Outcomes-based payments
| 21