Episodes of Care A Value-Based Model for Specialty Care June 22, 2017 NJSOM Annual Meeting, Atlantic City, NJ Amy Smith MSN, RN, NEA-BC, Manager, Episodes of Care This document is proprietary and confidential. Do not print or distribute without permission.

Trigger Event/Diagnosis Post-trigger services Episodes of Care Value-based model designed to engage specialists. Full spectrum of services related to and delivered for a specific medical condition, illness, procedure or health care event during a defined time period. Coordination, communication, collaboration across the continuum. Day 1 Last Day Presenter: Jim to open discussion with Overview of EOC program today and future need for Prospective EOC, importance of being first payer in NJ to offer model - Lili to add supporting comments Horizon is currently viewed as an industry leader around episodes of care. Advising CMS on bundles in a variety of specialties. We have market leader status. Trigger Event/Diagnosis e.g., surgery, chemo, diverticulitis Post-trigger services e.g., SNF, rehab, hospital readmission Pre-Trigger Services e.g., labs, radiology Proprietary and Confidential: Do not print or distribute without permission.

Standardize & Optimize Care and Cost of Care EOC Primary Goal Standardize & Optimize Care and Cost of Care Compare like patients and like outcomes Study variation in utilization and cost of care Presenter: Jim to open discussion with Overview of EOC program today and future need for Prospective EOC, importance of being first payer in NJ to offer model - Lili to add supporting comments Horizon is currently viewed as an industry leader around episodes of care. Advising CMS on bundles in a variety of specialties. We have market leader status. Proprietary and Confidential: Do not print or distribute without permission.

Migration from FFS to VBC is Evolutionary Need to begin at the beginning and have some patience…

Current Portfolio & Launch Dates Pilot 2010 Launches Total Hip Replacement Total Knee Replacement 2013 Launches Knee Arthroscopy Low Risk Pregnancy Colonoscopy 2014 Launches Combined Low/High Risk Pregnancy 2015 Launches Breast Cancer CHF 2016 Launches CABG Hysterectomy IBD (w/ Behavioral Health) Prostate Cancer Prostatectomy Colon Cancer Lung Cancer 2017 Launches Low Back/Laminectomy Diverticulitis GERD/Upper Endoscopy Shoulder Replacement Prospective Onc - Breast, Colon, Lung, Rectal Retrospective Pilot Launch No risk Collaboration Collective Learning Paradigm Shift Refocus Reward Excellent Outcomes No additional downstream agreements Prospective Launch Risk-based More immediate Requires more structure More complex admin

Retrospective Upside-Only Model Contract with an Episode Conductor All providers of care within the continuum of the episode are paid at their contracted fee for service rates Episode assessment is made, post episode Quality Patient Experience Total Cost of Care If metrics are met, savings are shared Proprietary and Confidential: Do not print or distribute without permission.

NJSOM Virtual Practices What is the Virtual Model? How Do I Join? What’s in to for me? Current NJSOM EOC Partners: Drs. Robert Fein and David A. Richards (The Center for Hematology and Oncology) New Jersey Hematology Oncology Associates LLC (Need to add the other 3)

Breast Cancer Episode Definition Episode Construct and Qualifying Criteria- Episode Triggers The Breast Cancer episode can be triggered by the following - Inpatient claim with the triggering diagnosis in the principle position Outpatient Evaluation and Management (EM) claim with the triggering diagnosis in any position Professional Evaluation and Management (EM) claim with the triggering diagnosis in any position The mastectomy trigger codes include codes for lumpectomy/partial mastectomy and simple mastectomy or modified radical mastectomy Proprietary and Confidential: Do not print or distribute without permission.

Breast Cancer Episode Definition Cont’d Episode Duration: 90 days look back 180 days look forward, post trigger Goals of the Episode Incorporate best practices ensuring episode specific quality measures are achieved Enhance patient experience Reduce costs by eliminating, for example, inpatient/emergency room services Proprietary and Confidential: Do not print or distribute without permission.

Standard Quality Metrics Program Standard Quality Measures -Patient Education -Care Coordination -All Cause Re-admission -ER Visit Within the Episode -ER Visit Outside Episode Window -Infections- Procedural Episodes Only Proprietary and Confidential: Do not print or distribute without permission.

Program Specific Quality Measures Proprietary and Confidential: Do not print or distribute without permission.

Program Progress New Analytics’ Partner Breast Cancer Episode with a Behavioral Health Component (2018) Enhanced Reporting Bi-Annual Collaboration Meetings Claims’ Discussion with HNJH (May 4) Re-Release of EOC Program Manual Development of Program Budgets and Distribution of Shared Savings Proprietary and Confidential: Do not print or distribute without permission.

Sample Report- Cost Per Member Proprietary and Confidential: Do not print or distribute without permission.

Sample Report- Shared Savings Proprietary and Confidential: Do not print or distribute without permission.

RESULTS Highlights Evolutionary Nature of the Program Includes some long term and some short term partners Original 5 practices

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