Horizon Exclusive: Payer-provider collaboration is the fix for healthcare

The healthcare world is changing as payers and providers alike begin to recognize that collaboration, quality, and payment reform are central to the goal of improving our healthcare system. Health insurers, in particular, are in a unique position to drive this change by implementing programs and initiatives that compel providers to focus on delivering quality--rather than quantity of--care. Accountable care organizations, patient-centered medical homes, and bundled payments are all examples of projects payers are undertaking to incentivize providers toward reform.

Horizon Blue Cross Blue Shield of New Jersey has demonstrated its desire to act as a driver of change through the establishment of its subsidiary Horizon Healthcare Innovations (HHI), which aims to catalyze an effective, efficient, and affordable healthcare system. When I first heard about this new company, I was intrigued and wanted to know more about its specific projects and whether it's achieving any of its goals. So, FierceHealthPayer spoke with HHI President and Chief Operating Officer Richard Popiel (pictured) to gain insight into the visionary company he's charged with leading.

FierceHealthPayer: Can you describe the problems within today's healthcare system and explain how HHI is hoping to change them?

Richard Popiel: Most healthcare stakeholders agree that our delivery system is broken and the only way to begin a true transformation is to put our narrow interests aside and create a system that works for patients. All of us want and deserve higher quality care at an affordable price. The majority of families throughout our country receive fragmented, reactive healthcare and many patients are unaware or do not fully understand their health status. Patients need the proper preventive information to take control of their own health. Finally, the way health plans pay providers must be reformed to support this shift.  

HHI's goal is to collaborate with healthcare leaders to transform New Jersey's health delivery system. As a subsidiary of Horizon Blue Cross Blue Shield of New Jersey, we are launching pilot programs, like Patient Centered Medical Homes (PCMH) and Episode of Care models, to deliver improved patient care at a lower cost for our members. A key component of most new care models is to pay physicians and other providers for delivering better care at lower costs. Paying doctors for the number of tests ordered or treatments given doesn't create a healthier population.    

FHP: What have been the most successful programs HHI has implemented thus far?

RP: We are currently analyzing initial data from our pilots that began in January 2011. We hope to have results around improved quality outcomes and lower costs next year.

We see great promise in the PCMH and think it is the right model to transform and revitalize primary care. We placed population care coordinators, who are nurses, within our partner practices. These nurses are providing tools for the practices to focus on the sickest patients. We are seeing some great success stories as these practices engage the patients and are able to connect them to social services, address addiction challenges, and help with transitions in care to avoid readmissions. This type of engagement is crucial to delivering better quality care and greater patient satisfaction.

On these same lines, Horizon Healthcare Innovations is committed to measuring our pilots and sharing our findings, both positive and negative, with other healthcare leaders. In July, we launched an academic research consortium to independently study our pilot programs. These experts will also advise us on pilot designs and adjustments to help us achieve measurable improvement. The consortium is comprised of nine leading researchers from the University of Pennsylvania, Rutgers University, Harvard School of Public Health, and Carnegie Mellon University.

FHP: What type of programs has HHI developed to engage consumers through technology? What kind of response have you received from consumers?

RP: Engaging consumers is critical to improving the overall health of our population. Giving patients user-friendly tools, communicating clearly with patients, and ensuring that they understand how to stay healthy will have a tremendous impact on improving quality and their healthcare experience. Under our Congestive Heart Failure telemonitoring program, Medicare Advantage patients were given bluetooth-enabled scales and pulse oximeters to measure their weight and blood oxygen levels daily in the comfort of their own home. These indicators are transmitted securely and confidentially to Horizon nurses, who immediately contact the patient to prevent further complications or notify their doctor if the indicators raise any concern. 

While we are currently studying the results, we received positive stories where immediate action was taken to prevent what would have been visits to the ER and hospital admissions. This program has the potential to greatly improve patient outcomes for congestive heart failure patients, which will decrease the total cost of care for these patients.

FHP: What are the biggest challenges HHI has faced?

RP: Change is the biggest challenge. When you get down to it, with healthcare reform and other improvements around provider payment and consumer engagement, we are approaching a seismic shift in how the healthcare delivery system operates. For example, if hospitals fail to decrease readmission rates, they will be penalized by the Centers for Medicare & Medicaid Services. Physicians will have to show they're adding real value to their full patient population. Insurers need to work as a partner with other stakeholders and improve cost transparency and data exchange. But with such great change comes great opportunity to improve collaboration and build mutual trust.

FHP: Do you think other health plans could implement similar programs and, if so, what recommendations and/or lessons learned would you share with them?

RP: Absolutely. The success of these new care models and payment designs will determine if we are able to reach "Triple Aim" goals of improved patient care and experience at lower costs. Insurers have comprehensive patient data, strong IT systems, and the ability to share this valuable information with doctors, hospitals, and other providers. This information can be a tremendous resource to providers. Business as usual is not the solution. Health plans throughout the country need to step up and be a catalyst of change.  

As for recommendations, the priority is collaboration. Our Patient Centered Medical Home model was designed hand-in-hand with the New Jersey Academy of Family Physicians and participating primary care physicians. And the partnership needs to continue as the program grows. For example, we have weekly workgroup sessions with our partners to discuss potential opportunities, best practices, challenges, and solutions. Our Episode of Care pilot for hip and knee joint replacement was founded on collaboration with five leading orthopedic surgeons. Our staff meets continuously with these surgeons to discuss everything from payment methodology to best practices to measuring patient satisfaction.

- Dina (@HealthPayer)