Value-Based Model Engages Provider Specialists

Lili Brillstein

The move from the fee-for-service model, where payments are made with no connection to whether patients ever get better or have a good experience, is happening across the country.

Horizon Blue Cross Blue Shield is at the forefront of this move in the specialty care value-based space, and specifically in Episodes of Care. 

Horizon’s Episodes of Care Model, the country’s largest Episodes of Care program, is built in conjunction with Horizon’s provider partners (in episode design, quality metrics are all collaboratively defined), and provides a unique model for engaging specialists in the value-based continuum.

At the upcoming Oncology Market Access Strategy Summit in San Francisco, February 20-21, 2019, Lili Brillstein, director, Episodes of Care, Horizon Blue Cross Blue Shield of New Jersey, will discuss the model, its evolution, lessons learned, and results so that others may begin to engage in preparing for this move. Her talk, “Episodes 101-How Can Pharma Get Engaged?” will also explore how various stakeholders can begin to engage in the model. 

Managed Healthcare Executive spoke with Brillstein ahead of her presentation for additional details on Episodes of Care.

Managed Healthcare Executive (MHE): What is Horizon’s Episodes of Care model?

Brillstein: The Episodes of Care model is the model that we use to engage specialists in our value-based strategy. It’s a model that looks at all of the care rendered to a patient during a particular healthcare event, or related to a particular diagnosis or procedure, during a specified period of time. It aims to consider the health of the patient as the patient might consider it (i.e., all of the related components of the healthcare episode) rather than just one piece at a time (i.e., surgery, post-acute care, etc). The model relies on collaboration, communication, and coordination across the full continuum of care. Unlike fee for service, which focuses on all the care rendered by one particular physician or practice, value-based models (of which Episodes is one), focuses on all the care rendered to one particular patient, across the full continuum of care.

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MHE: What clinical conditions have you done to date? 

Brillstein:

• Orthopedics: hip replacement, knee replacement, knee arthroscopy, shoulder replacement, low back pain;

• OB/GYN: maternity/newborn, hysterectomy, hysteroscopy

• GI: colonoscopy, GERD, diverticulitis, IBD (includes behavioral health component)

• Cardio: CABG, CAD, HF

• Oncology: breast, prostate

• Substance use disorder

MHE: Is oncology a topic for Episodes of Care?  If so, which conditions?

Brillstein: Yes. We have two models for oncology: Episodes of Care, and Oncology Medical Home; breast, colon, lung, and prostate cancers included.

MHE: How would Horizon address the costs of drugs in their Episode of Care model?

Brillstein: Drugs are included in our Episode of Care model. We use historical data, including drugs, to understand utilization and calculate baseline costs.

MHE: Is the Horizon model upside only, or dual risk?

Brillstein: The model has been upside only since its inception. We believe that it is critical to establish partnerships with our providers and for us to learn collaboratively how to create success in these models before moving into risk-based models. We are introducing risk into some of our agreements in 2019; many of our most mature partners (i.e., those who have been in the program the longest) are anxious to move into risk now that they have an understanding of the model, the stakeholders in their continuum of care, the opportunities and the data.