Texas Primary Care and Health Home Summit Health Plans and Primary Care Practices: Partnerships Yield Benefits for Both Austin, TX April 5-6, 2018 Steven R. Peskin, MD, MBA, FACP Executive Medical Director Horizon Blue Cross Blue Shield of New Jersey 1 Health Plan and Primary Care Practices: Partnerships Yield Benefits for Both The Triple Aim Learning Objectives ita ap rC e Pe Car f
ce du st o Re Co Describe core elements of Horizon BCBSNJ patient centered care models Explain collaboration between payer and clinical organizations and contrast to traditional model Analyze quality and efficient performance of patient centered modes Enhance the Patient Experience 3 The Triple Aim The Triple Aim We are achieving better health and better care at lower costs.
Innovative programs: Patient-Centered Medical Homes (PCMHs). Accountable Care Organizations (ACOs). Episodes of Care (EOC). Pediatric Patient Centered Program OMNIA Alliance Im p He rov a e Po lth the pu of lat the io n Through collaboration, we are helping to create an effective, efficient and affordable health care system.
1 ita ap rC e Pe Car f ce du st o Re Co 2 Triple Aim Enhance the Patient Experience 3 4 Improving Quality to Drive Down Costs Working with clinical organizations to reward care quality, not quantity
Approaches and solutions that ensure affordable, sustainable, desirable products Proprietary and Confidential $ Flexible, value-based programs: one size does not fit all Meaningful collaboration that maximize data and technology 5 Shift to Value-Based Contracting From fee-for-service Focus on unit cost Payment for unit cost and units of service Adversarial Proprietary and Confidential To pay-for-value
Focus on total cost of care, quality process and outcomes measures, and member experience Payment for mutually agreed upon measures of value Collaborative 6 Population Health Management Care Delivery Physicians at front line of care delivery across most specialties, sites of care Care Planning Various levels of providers work with physicians to determine care plans, transitions Proprietary and Confidential Care Coordination Communication between specialties essential to treating complex patients
7 Program Support Proprietary and Confidential 8 Program Support Practice Engagement Proprietary and Confidential 9 January 2014 vs 2015 PCMH, ACO, and EOC Attributed Members by County Map 2014 2015 Source: Attributed Members are based on January 2014/2015 attribution. Practice Locations are based on zip codes and there maybe more than one practice per zip code. For PCMH, Pediatrics and ACOs, practices' zip codes are based on the Primary Site file from innovations. For EOC, practices' zip codes are based on the file from innovations. There is no EOC attribution/episode count on these maps. 10 Outcomes from Existing Value-Based Programs ~$94.9M
67% 1.5M+ Paid in care coordination and shared savings payments in 2016 Of total medical spend paid to physicians/hospitals participating in value-based programs Of total enrollment covered through value-based programs 3% Lower rate of emergency room visits 16 Distinct episodes of care programs 3% Lower rate of hospital
admissions 4% Improved control of diabetes cost Proprietary and Confidential 11 Transformation Continuum PatientCentere d Medical Home Proprietary and Confidential Episode s of Care Accountable Care Organization Expansion of value-based programs to
include entire continuum of care 12 Transformation Continuum To address the challenging market dynamics and deliver market-leading value to New Jersey residents, Horizon BCBSNJ will Collaborate with Committed Providers Promote Population Health Management Engage Members in Care Management Engage members by actively Strengthen capabilities in supporting positive health medical management and behaviors and preventive care coordination through care sharing of data, technology and expertise that enhances clinical decisions at point of care Distribute value created that includes all stakeholders
Reward achievement of Quadruple Aim objectives Proprietary and Confidential 13 Transformation Continuum Clinical Expertise Network of Physicians & Facilities Clinical Population Health Infrastructure Proprietary and Confidential Shared Vision and Commitment Leading Market Share & Consumer
Insights Advanced IT & Analytical Capabilities Care Management Programs and Resources 14 Virtual, Integrated Delivery System is Positioned to Align Incentives and Capabilities New Jersey provider partners Patient Management Expertise Leading Brand Equity Network of Physicians & Facilities Clinical Population Health Infrastructure
Provider Capabilities Virtual Integrated Delivery System Hospital System Non-Hospital Facilities Employed & Affiliated Physicians Health Plan Joint Governance Leading Consumer Insights Care Management Programs and Resources IT & Analytical Capabilities Sales & Marketing Capabilities Horizon BCBSNJ Capabilities
Value to Health Care Consumer Improved Management of High-Risk Members Simplified Navigation of Health Care System Controlled Growth in Health Care Costs Enhanced Service Levels for Consumers Proprietary and Confidential 15 Enablement Capabilities: Horizons Focal Areas Horizon has made significant investments to evolve our capabilities and resources in order to establish and grow our large-scale, value-based models with our provider partners. Clinical & Clinical & Network Network Operations Operations -- Dedicated Dedicated Alliance Alliance support
support teams teams -- Care Care Management Management transformation transformation Technology Data Product, Sales & Technology--& &Practice Data transformation Practice transformation Product, Sales & Analytics Marketing Analyticsexpansion Marketing expansion -- Health Health Information
Information Exchange Exchange -- Automated Automated Attribution Attribution models models -- Big Big Data Data & & Consumer Consumer Analytics Analytics tools tools Proprietary and Confidential -- Innovative Innovative network network product product
launch launch -- Broker Broker engagement engagement & & education education -- Cost Cost transparency transparency tools tools 16 Key Lessons Learned to Date Payers should consider a portfolio approach to value-based programs Strategic Execution Models must work in tandem with Providers other value-based contracts Value-based partnerships must be considered more than a contract Payers & Providers must collaboratively prioritize early-stage initiatives
Governance & Communicatio n Technology & Operations Provider compensation/incentive models must be designed to drive change Payers must leverage the existing assets/structure of Provider partners Payers must promote programs through provider education & engagement Payers require material investments to enable value-based models Technology solutions should be staged to allow for an evolution of data sharing and integration Payer data must be meaningful and actionable for Providers Proprietary and Confidential 17 QUESTIONS
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