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Benefits Products & Services

Health plan calls in the doctor

NJ insurer's outcomes-based health program is built on cooperation with medical practices

By Thomas A. McCoy, CLU

The largest health insurer in New Jersey has developed a program that encourages employees to take responsibility for monitoring and improving their health, instead of waiting to treat episodes of sickness. That sounds like what a traditional wellness program tries to accomplish, but what's different about this program, offered by Horizon Blue Cross Blue Shield of New Jersey (Horizon), is that it revolves around the employee's own physician.

Horizon's Patient Centered Medical Home Program (PCMH) provides some initial funding for doctors' offices that sign on to the program's goals for chronic condition care. Horizon also reimburses participating medical practices based on patient outcomes, rewarding long-term results instead of volume of services.

The idea is to get all the key players in the health care delivery and reimbursement system—the employer, employee, medical provider and insurer—working together to improve both the physical health of the employee and the fiscal health of all parties.

Horizon launched the program in January 2011. So far, some 200,000 Horizon members are participating in conjunction with 700 physicians and health care professionals in Horizon's network.

When Horizon signs up a medical practice as part of the PCMH program, it provides the practice with funding to hire a Population Care Coordinator, a nurse whose job it is to monitor health concerns of the Horizon members. The health conditions monitored by this professional are those involving long-term conditions such as blood pressure and diabetes control, and routine screenings that are part of preventive care.

This preventive monitoring, while it is clearly critical to the employee's health and long-term cost control, depends on actually getting the patient into the office for those tests and check-ups. Often, overburdened medical practices (likely to become more so under the Affordable Care Act) don't have enough resources to encourage patients to make those appointments. The Population Care Coordinator fills that gap.

Another aspect of the Population Care Coordinator's job is … uh … coordinating. Sometimes multiple tests from multiple providers can run up unnecessary costs. It also can leave the patient confused. Under the PCMH program, the Horizon insured deals with one professional in his or her doctor's office who communicates directly with him and with other medical providers about prescribed treatments and tests.

Bill McGuane, benefits manager for the County of Monmouth, New Jersey, is an early adapter of the PCMH program. He first learned about the plans for the program in 2010 when he was working in benefits administration in the private sector. He was intrigued by the potential advantages of coordinating a patient's care.

"One of the weaknesses in a traditional program, whether it's fully insured or self-insured, is the lack of integrated care and gaps in care, which adds to costs," says McGuane. "By the time someone actually steps into a doctor's office, the care has to become traumatic in nature." What makes the PCMH program effective, he believes, is the role of population care coordinators and their "eyeball to eyeball" contact with Horizon insureds at the doctor's office.

Gerald O'Keeffe, principal benefits clerk with the County of Monmouth, adds, "The employee might be hesitant to discuss his health with a case manager from a health insurer on the phone. It's much easier to talk with a nurse who is working out of his own doctor's office."

Monmouth County self-insures the medical benefits for its total base of 3,000 employees and retirees, with Horizon serving as its main TPA. So far, about 1,000 of the county's employees are utilizing the program.

The doctor's perspective

McGuane recently asked a physician who participates in the program how he thought it was working. "He couldn't have been more complimentary of the program. He even volunteered to come to our meetings and speak to our employees about it," McGuane reports. "He said the Population Care Coordinator was easing the administrative burdens in his office and making it easier to get people into the office for screenings or into wellness programs."

A key test of the medical community's acceptance of the program will come when individual medical offices have had a PCMH program in effect for 18 months. At that point Horizon will stop funding the Population Care Coordinator position, and the cost will have to be assumed by the medical practice.

"To the best of our knowledge here at the County, almost every medical office we deal with in the program has indicated they are ready to absorb that cost," says McGuane.

Since the program has been available for only two years and experienced rapid growth in that time, it is too early to measure its ultimate success. However, Horizon reports the following encouraging signs: an overall 8% higher rate in improved diabetes control and a 6% higher rate in screenings for breast cancer and cervical cancer at PCMH practices compared to patients in practices that are not participating in the program.

Horizon has begun making outcomes-based payments to participating medical practices that have met Horizon's standards for patient outcomes and efficiency. "Those payments should increase over time," notes Dr. Steven Peskin, who heads up Horizon Healthcare Innovations, which oversees the PCMH program.

Dr. Peskin explains that by segmenting the various chronic care populations within the medical practices, Horizon sees opportunities not only to monitor their care more efficiently, but also to offer wellness-type programs for them. "Some of our practices are offering evening classes, for example, on topics such as nutrition or how to more effectively manage your asthma."

He notes, "The program's usefulness depends on the exchange of clinical data between Horizon and the participating medical practices." By combining the insurer's administrative and claim data with the practices' medical records, "we can give the practices a better idea of how they're doing.

"We are very gratified to see that the transformational work that we are doing collaboratively is paying off in terms of quality and total cost," he says.

The timing for Horizon's program is good. Employers, along with their benefits consultants, are looking for new ways to differentiate their health benefits offerings by providing high-quality care while controlling costs for the employer and employee.

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