horizon healthcare innovations’ medical home pilots
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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. Horizon Healthcare Innovations, (HHI). - PowerPoint PPT PresentationTRANSCRIPT
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