1. 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
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2. 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.

3. 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.

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

5. 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

6. 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
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7. 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)

8. 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
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9. 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
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10. 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
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11. Program Specific Quality Measures
Proprietary and Confidential: Do not print or distribute without permission.

12. 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.

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

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

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

16. We Want You To Partner With US
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