1. Texas Primary Care and Health Home Summit
11/14/2018
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

2. Health Plan and Primary Care Practices:
Partnerships Yield Benefits for Both

3. The Triple Aim Learning Objectives
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
Reduce Per Capita
Cost of Care
Enhance the
Patient Experience 3

4. Improve the Health of the Population
The Triple Aim
The Triple Aim
Through collaboration, we are helping to create an effective, efficient and affordable health care system.
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 1 2
Improve the Health of the Population
Reduce Per Capita
Cost of Care
Triple
Aim
Enhance the
Patient Experience 3 4

5. Improving Quality to Drive Down Costs
Working with clinical organizations to reward care quality, not quantity $
Flexible, value-based programs: one size does not fit all
Approaches and solutions that ensure affordable, sustainable, desirable products
Meaningful collaboration that maximize data and technology
Since 2010, Horizon Blue Cross Blue Shield of New Jersey has partnered with providers and employers on value-based care arrangements. This was a true shift in our collaboration efforts and began the transformation of health care delivery.
Our geographic area has the highest premiums in the country, even after subsidies, with a level of quality that does not reflect the high costs we pay.
By shifting to a value-based approach, there is more collaborative/less unsynchronized care, and a focus on total cost, quality and patient experiences
Our value-based programs are centered on our ability to collaborate with participating doctors and hospitals, not just contract with them. These types of programs provide financial incentives for medical professionals to deliver the right care, at the right time, in the right setting.
Proprietary and Confidential

6. Shift to Value-Based Contracting
From fee-for-service
To pay-for-value
Focus on unit cost
Payment for unit cost and units of service
Adversarial
Focus on total cost of care, quality process and outcomes measures, and member experience
Payment for mutually agreed upon measures of value
Collaborative
Horizon BCBSNJ is committed to moving from a fee-for-service to a fee-for-value payment model.
Fee-for-value refers to a health care system that reimburses doctors, hospitals and other health care professionals for the quality of care they deliver and improved patient outcomes.
The transition within the health care industry from a fee-for-service model to accountable care structures aligns incentives and created the framework for the fundamental shift in who manages risk.
This shift requires providers to understand the risks associated with the populations they manage and adopt tools and processes currently used by insurers to manage risk.  
Proprietary and Confidential

7. 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
Care Coordination
Communication
between specialties
essential to treating
complex patients
Population Health Management is the next generation of patient-centered care.
It is a model of care where doctors, hospitals and other health care professionals are responsible for the outcomes of a group of patients (or populations).
If, on average, the doctors deliver high quality, efficient care to a population, they are rewarded for their high performance.
Encourages doctors and other health care professionals to keep their patients healthy, thereby reducing unnecessary utilization of expensive services, like Emergency Room visits, hospitalizations and multiple office visits.
This requires better organized, more personalized, coordinated and proactive care that leverages shared information systems and care processes.
This helps us achieve the Triple Aim
When doctors are incentivized to provide this level of care, patients are more likely to avoid unnecessary treatments or procedures.
Providers began to work with us to improve population health management and invest in the technology and reporting to see tangible results.
Proprietary and Confidential

8. Population Care Coordinator
Program Support
Better Health, Better Care, Lower Costs
Population Care Coordinator
Data & Technology
Engage, Educate & Empower Patients
Playbook/ Program Support
Payment
Reform
Proprietary and Confidential

9. Program Support – Practice Engagement
Engaged Practice Team
Onboarding/ Training Programs
Web Portal – Calendar & Updates
Biweekly Updates
Monthly Webinars/ Weekly Data Exchange Calls
In-person Meetings/ Conf. Calls
Quarterly PCC Meetings
Quarterly Physician Advisory Meetings
Annual Summit
Proprietary and Confidential

10. January 2014 vs 2015 PCMH, ACO, and EOC Attributed Members by County Map
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

11. Outcomes from Existing Value-Based Programs
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% 16
Lower rate of emergency room visits
Distinct episodes of care programs 3% 4%
Lower rate of hospital admissions
Improved control of diabetes cost
Proprietary and Confidential

12. Accountable Care Organization Patient-Centered Medical Home
Transformation Continuum
Episodes of Care
Accountable Care Organization
Patient-Centered Medical Home
Expansion of value-based programs to include entire continuum of care
Horizon’s Episode of Care (Bundled Payment) model is retrospective, meaning costs are reconciled against a target price after an episode of care.
All providers throughout the continuum get paid at fee-for-service rates as their care is delivered. All episodes are reviewed against quality benchmarks and patient experience thresholds. Then, if costs come in below budget, savings are shared with the provider who is contracted for the episode management.
Since its inception in 2010, our EOC program has experienced explosive growth and impressive outcomes Horizon BCBSNJ paid $3 million to 51 specialty medical practices as part of the shared savings the groups produced across five episodes in 2014, while treating 8,000 Horizon BCBSNJ members.
PCMH vs ACOs –
PCMH is solely for Primary Care Doctors
ACOs include multi=specialty and can be hospital based
We have seen great success for these models individually, but we have to take to the health care system level to help manage the full spectrum of care.
ACOs are comprised of hospitals and/or health care professionals who are responsible for achieving specific patient quality outcomes and avoiding unnecessary and duplicative medical tests and treatments.
Participating physician groups help create a healthier patient population through a coordinated approach to care among providers within the ACO. ACOs are designed to increase accountability to achieve measured patient quality outcomes and decrease unnecessary and duplicative medical tests and treatments.
We have signed 20 ACOs, over the years and, as you would expect, some of them are now transitioning to Organized Systems of Care.
 Shared-savings arrangements: rewards ACOs, advanced PCMH practices and EOC providers for lower health care costs while meeting performance standards on quality of care and enhancing the patient experience.
Proprietary and Confidential

13. Transformation Continuum
To address the challenging market dynamics and deliver market-leading value to New Jersey residents, Horizon BCBSNJ will…
Promote Population Health Management
Collaborate with Committed Providers
Engage Members in Care Management
Reward achievement of Quadruple Aim objectives
Strengthen capabilities in medical management and care coordination through sharing of data, technology and expertise that enhances clinical decisions at point of care
Engage members by actively supporting positive health behaviors and preventive care
Horizon BCBSNJ is working with specific hospitals and physicians that have advanced data- sharing technology.
The doctors, hospitals and other health care professionals who use these tools can focus on improved clinical outcomes and enhanced efficiencies and member service, which should result in increased revenue and membership.
Horizon BCBSNJ will collaborate with hospitals and physician groups to develop the capabilities and expertise necessary to deliver population health management to our members.
Consumers are increasingly demanding better quality of care and improved health care outcomes at lower costs.
As the industry shifts to individual coverage and expanding coverage to those who were previously uninsured, our outreach had to improve.
Building strong connections among the patient, physician, and office team can help patients feel a sense of ownership and empowerment when it comes to their health and health care decisions.
Distribute value created that includes all stakeholders
Proprietary and Confidential

14. Shared Vision and Commitment
Transformation Continuum
Shared
Vision and
Commitment
Leading Market Share & Consumer Insights
Clinical Expertise
Network of Physicians & Facilities
Advanced IT & Analytical Capabilities
Clinical
Population Health Infrastructure
Care Management Programs and Resources
Horizon is working together with our partners that have the same vision and commitment.
We are ringing our expertise and they are bringing their clinical expertise to improve the health care system throughout the continuum.
Proprietary and Confidential

15. Virtual, Integrated Delivery System is Positioned to Align Incentives and Capabilities
New Jersey provider partners
Virtual Integrated Delivery System
Patient Management Expertise
Leading Consumer Insights
Hospital System
Care Management Programs and Resources
Leading Brand
Equity
Network of
Physicians & Facilities
Sales & Marketing Capabilities
Non-Hospital Facilities
Employed & Affiliated
Physicians
Clinical Population Health Infrastructure
IT & Analytical Capabilities
Health Plan
Provider Capabilities
Joint Governance
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
These arrangements are a win for all those involved, including the 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

16. Enablement Capabilities: Horizon’s 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 & Network Operations
Dedicated Alliance support teams
Care Management transformation
Practice transformation expansion
Technology & Data Analytics
Health Information Exchange
Automated Attribution models
Big Data & Consumer Analytics tools
Product, Sales & Marketing
Innovative network product launch
Broker engagement & education
Cost transparency tools
Clinical Transformation is key to changing the way care is delivered in New Jersey
The Clinical Transformation Team will focus on:
Network Optimization
Pharmacy Management
At-Risk Care Coordination
ER Use
Reducing Avoidable readmissions
All partners will focus on these initiatives based on the specific opportunities that we have jointly identified.
Working groups have been working together for several months on developing initiatives.
Proprietary and Confidential

17. Key Lessons Learned to Date
Strategic Execution
Payers should consider a portfolio approach to value-based programs
Models must work in tandem with Provider’s other value-based contracts
Value-based partnerships must be considered more than a contract
Payers & Providers must collaboratively prioritize early-stage initiatives
Governance & Communication
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
Technology & Operations
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

18. QUESTIONS