Further, envision a scenario in which these specialists are invited to design their payment program, from the model's intent to key quality metrics.
Those are some highlights of Horizon Blue Cross Blue Shield of New Jersey's Episodes of Care (EOC) program, a value-based model designed to focus specialists on the provision of quality- and value-based care across nine separate episodes, from joint replacement to hysterectomy to oncology.
Hailed as a national leader in advancing the episodes model as a prototype for value-based specialty care, Horizon is careful to distinguish its EOC program from a bundled payment initiative, for two key reasons.
"First, our EOC program is a quality-based program; it's not only about the payment or payment structure," explained Lili Brillstein, director of the Horizon Episodes of Care program during a recent webinar, Episodes of Care: Improving Clinical Outcomes and Reducing Total Cost of Care Through a Collaborative Payor-Provider Relationship.
Secondly, bundled payments typically refer to a prospective model in which a bundled amount of money is paid to a provider or group of providers in advance of services being delivered, while Horizon's retrospective model pays providers after services have been provided.
The upside-only nature of Horizon's retrospective model contributes to the program's collaborative nature, Ms. Brillstein added. "If the metrics are met, savings are shared. If the metrics are not met, we’re not punishing our partners."
There is other evidence of collaboration and of Horizon's desire to see the providers succeed in the EOC program. One example is the payor's use of case mix-adjusted budgets at the practice level rather than the prevalent member-specific risk-adjusted budgets. "This budgeting allows Horizon to create an opportunity for providers to move the needle [on a metric], and benefit from that. The opportunity for cost savings and shared savings also is dramatically improved."
Another case in point is Horizon's invitation to prospective providers to talk through the episode's construct, intent and design prior to its launch.
Horizon's engagement of providers in the EOC program has "changed the spirit of the relationships between the payor and the provider," Ms. Brillstein noted. "It’s like nothing I’ve ever seen before. Our provider partners have become our ambassadors for the program."
Select EOC results presented during the webinar indicated that outcomes are better for EOC partners—in the area of reduced readmissions, for example—than they are for physicians not in the EOC program.
Horizon expects to launch at least three more episodes in 2016, including a Crohn’s Disease episode that will take into account behavioral health services for those members. While the payor fully expects to move to a prospective model, it believes its current EOC model is preparing them for that eventuality, softening the transition from fee for service to prospective payments.
"[That transition] doesn’t just happen. You don’t sign the paper, and suddenly know what to do. It is an evolutionary transformative process," concluded Ms. Brillstein.
Click here to listen to an interview with Lili Brillstein: Horizon BCBSNJ Episodes of Care: No-Risk Retrospective Model Paves Way for Value-Based Migration