Horizon Healthcare Innovations’ Medical Home Pilots

Presentation to NJBGH

October 12, 2010

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Contents

▪ Introduction to Horizon Healthcare Innovations

▪ Brief overview of care model pilots

▪ Primary Care Patient-Centered Medical Home

▪ Oncology care model

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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.

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Horizon Healthcare Innovations (HHI) Overview

To catalyze transformation that creates an effective, efficient, and affordable healthcare system

Mission

We will boldly innovate, in collaboration with others, to foster exemplary healthcare in the communities we serve

Vision

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

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Contents

▪ Introduction to Horizon Healthcare Innovations

▪ Brief overview of care model pilots

▪ Primary Care Patient-Centered Medical Home

▪ Oncology care model

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We are in the process of developing 6 potential pilots, with the goal to launch 2-4 by the end of 2010

▪ 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

▪ Transforming oncology practices to deliver treatment and patient guidance that is evidence-based, consistent, and in the best interest of the patient

▪ Encouraging eligible physicians to achieve compliance with the program goals for quality of care and efficient delivery of inpatient care

▪ 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

▪ Improving quality and reduce costs through local accountability, standardized performance measurement, and innovative reimbursement structures

▪ Transforming the management of chronic disease – leveraging technology to create consumer ownership of health and healthcare thereby improving medication / treatment protocol adherence and self-monitoring / healthy activities post diagnosis

Population management

Chronic care management

Acute procedural episodes

Primary Care Patient Centered Medical Home (PCMH)

Inpatient Management

Efficient Episodes

Accountable Care Organization (ACO)

Consumer engagement

Oncology Medical Home

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Guiding principles of the care model pilots

Promote high quality, ‘best in class’ evidence based care1

Tie actions to results, tracking clinical decisions and quality performance2

Establish closer payor/provider collaboration3

Support providers to increase affordability4

Encourage patient ownership and responsibility5

Be easily scalable over the longer term6

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Horizon’s medical homes aim to address both the system-wide and condition-specific issues that patients experience

Primary Care 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

Oncology Specific Issues

• Older patients with a high rate of co-morbidities• Lack of support and guidance for necessary

lifestyle changes• Multiple potential treatment options

• 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

Pregnancy 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

Cardiology Specific Issues

• 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

Common Issues Addressed by Care Models

Planned 2011 pilots

Potential later pilots

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Contents

▪ Introduction to Horizon Healthcare Innovations

▪ Brief overview of care model pilots

▪ Primary Care Patient-Centered Medical Home

▪ Oncology care model

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Measurement & Reporting

AppropriateReimburseme

nt

Member Benefits & Incentives

Evidence Based

Medicine

Information & Infrastructure

Systems

MedicalHome Enablers

Patient Centered Strategies

Team Based Care

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

Accountability & Responsibility

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The PCMH model transforms delivery of primary care

…to Patient Centered Medical Home modelFrom PCP care model…

▪ PCMH and patient collaborate to ensure timely and appropriate outreach and f/u appointments

▪ PCP appointments often scheduled when patients deem necessary

▪ Care collaboratively managed by team with a proactive plan to meet patients’ needs

▪ Members build on-going relationship with care team through increased communication

▪ Care focus determined by immediate episodic problems and presence of patients (face to face time)

▪ Care standardized according to evidence-based guidelines and measured on quality, patient experience and utilization

▪ Variation in Quality between and within practices - scheduled time and practice’s or physician’s tracking mechanisms

▪ Referrals are coordinated by care team, information is shared with specialists.

▪ PCMH co-creates care plan and educates / engages patients to obtain positive outcomes

▪ Patients left to coordinate their own care, including visits to specialists

▪ Inconsistent reporting / documentation from hospital and specialist visits

▪ PCMH tracks tests / consultations, and follows up on ED / hospital visits

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Patients will have a new experience with increased engagement and participation throughout the care process

Patient-Centered Coordinated

Care

▪ Practice tracks and monitors referrals, ensuring exchange of relevant clinical information

▪ Practice coordinates with relevant medical community actors

▪ Case coordinator reviews and updates care plan with patient

▪ NP and PA address majority of less complex patient issues

Patient Access

▪ Practice uses physician extenders to increase capacity and availability▪ Strong links with providers facilitates access (e.g., behavioral health network)

▪ Practice proactively engages consumers to schedule visits

▪ Case coordinator determines need and type of visit with patient

▪ Patient and case coordinator communicate to ensure compliance

▪ Practices use technology to identify gaps in care

▪ Practice monitors performance

(3)After the

Visit

(2) During

the Visit

(1) Before the Visit

(4) Ongoing

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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 facilitatethis transformation

2011

2012

2013

Building the critical infrastructure HHI-provided transformation

coaching and case coordinators

Reimbursement aligned to process and quality scores

Improved access directly to care team

Population management with focus on chronic members

More defined relationships for access to specialists

Formalizing processes and products

Value-based products tailored to PCMH initiatives

Increased population management and information provided to practices

Pooled supporting resources

Optimizing performance outcomes with tools and informatics

Consider PCMH network-based 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.

Detail follows

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Case coordinators will be embedded into the practice care team and will be integral to the PCMH model

▪ 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

▪ 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

Care planning

▪ Use electronic system to track referrals

▪ Ensure exchange of clinical information into EMR

▪ Follow up with specialist/patient on referrals

Referral management

Community management

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Payment structure will evolve over time –with a vision for savings-sharing in the future

Today Phase 1 Phase 2 vision

FFS FFS

Casecoordination

Outcomes-based

FFS

Casecoordination

Savings sharing

▪ Fee-for-service only ▪ FFS as paid today

▪ Case coordination payments (PMPM)

▪ Outcomes-based payments

▪ Case coordination payments (PMPM)

▪ Savings sharing between practice and plan

Savings sharing

Outcomes-based

Case coordination

FFS

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HHI will use tiers in the near term to encourage stepwise improvement

Engage practices and incent medical home development

Encourage broad participation in medical

home initiative

Reward full transformation with higher reimbursement for higher value careHHI goals

HHI support

Direct funding of infrastructure development (e.g. care team members)

Case coordination fee to support process improvements

Outcome based payments to reward performance

Significant upside for quality and process improvements

Opportunity for savings sharing long term

Attainment of additional Advanced Medical Home requirements as agreed upon by Horizon Healthcare Innovations

Demonstrated commitment to improving quality, process, and utilization metrics

Practice requirements

Attainment of any level of recognition

Demonstrated integration of case coordination activities into practice workflows beyond

Demonstrated commitment to become an advanced medical home

Early Stage Medical Home

Advanced Medical Home

Horizon Healthcare Innovations goes beyond existing standards in defining the Patient Centered Medical Home

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Initial target practices for PCMH pilot rollout are based oncurrent diabetes pilot

Geographic distribution of target practices

6+ practices

4-5 practices

2-3 practices

1 practice

no 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

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Contents

▪ Introduction to Horizon Healthcare Innovations

▪ Brief overview of care model pilots

▪ Primary Care Patient-Centered Medical Home

▪ Oncology care model

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Future Oncology Medical Home

Patient & CareTeam

Medical oncologist

Hema-tologist

Surgical oncologist

Urologist

Radiation oncologist

Behavioral Health

Pharmacy

Patient support & guidance

PCPUrologist

Medical onc.

Hema-

tologist

Surgical

onc.Behavioral

Health

Patient

?

Radiation

onc.Pharmacy

Current Care Management

Fragmented and variable care without full use of EBM guidelines reduces quality and creates waste

Patients very anxious given their cancer diagnosis and lack a single non-physician point of contact and guidance

Care coordinator serves as the “patient navigator” coordinating care and guiding patients through treatment

Realigned incentives reward practices for care coordination, member support and use of evidence based guidelines

Our goal is transformed practice focused on patient-centered coordinated care

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HHI will measure performance against goals

Patient focused outcomes

Evidence based care and high quality standards

Am I receiving care consistent

with best practice?

Following clinical guidelines

Creating and following a care plan

Clinically appropriate

Preventing avoidable harm to the patient

Avoiding preventable admissions to the ER or IP

Safe

Delivering a care experience that patients view positively

Ensuring patient concerns are addressed

Encouraging appropriate dialogue surrounding end-of-life decisions

Improved experience

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Over time, the reimbursement structure will focus more on rewarding quality of care

Today Phase 1 Phase 2 vision

FFS FFS

CC

Outcomes-based

CC

FFS

Savings

Payment structure will gradually evolve and be refined to drive behavior

▪ Fee-for-service only ▪ FFS as paid today

▪ Case coordination payments (PMPM)

▪ Outcomes-based payments

▪ Case coordination payments (PMPM)

▪ Savings sharing between practice and plan

Savings sharing

Outcomes-based

Case coordination

FFS