By Allen Karp, Executive Vice President of Healthcare Management and Transformation

If you could change one thing about healthcare in New Jersey, where would you focus your attention – on cost or quality?

If you are like most, cost was probably your first thought. There is certainly a case to be made for cost.

According to a recent study by the Health Care Cost Institute, New Jersey spends more on healthcare than all but four other states. That is simply not acceptable or sustainable. Health care costs are consistently the top concern of New Jersey’s employers and consumers are making it abundantly clear that they do not just want something done about health costs, they need relief.

But while lowering costs is critical, no one wants lower costs at the expense of quality health care. That is why we view quality as the linchpin for transforming healthcare in New Jersey. Cost savings, in our view, must be a byproduct of quality improvements and should never be pursued independent of or at the expense of quality.

Improving outcomes

But what exactly is quality? And what can we, as an insurance company, do to affect the quality of care you receive from your physician or hospital?

At a clinical level, quality care is about better outcomes. Did you get well? Did you avoid serious complications or side effects?

But quality is also about preventative care – things you do to keep from getting sick in the first place. Did you get your mammogram? Were you screened for colorectal cancer or high blood pressure?

As an insurance company, we can influence quality in two ways: by structuring reimbursement arrangements to provide incentives that promote better quality care and by sharing rich insights and providing your physicians with tools that help them take better care of you.

In our Episode of Care program, for example, we work with physicians to define together high quality standards of care for 26 medical conditions or procedures. The physicians and their teams are responsible for coordinating all aspects of care related to our members. When they do that in a way that achieves the agreed-upon quality and cost goals, they share in the savings that are produced.

Three years ago, we launched New Jersey’s most comprehensive and innovative quality improvement effort when we formed the OMNIA Health Alliance, a partnership with seven of New Jersey’s leading health systems and physician practices. Together, we collaborate to build new models of care and new reimbursement arrangements in which those providers agree to tie their compensation more directly to the outcomes they deliver – rewarded for high quality, penalized when they fail to hit the agreed upon quality targets.

We also work with primary care physicians to help them address gaps in preventative care. Medical experts have created best practices for the care or treatment of people across all ages, states of health, and diseases. A gap occurs whenever there is a deviation from that best practice.

By 2021, we are committed to working with our network doctors to reduce the overall gaps in care by 10 percent. Further, we are evolving the definition of quality so that it focuses on the overall needs of our members and is patient-centric rather than disease-centric. With that view, we are committed to doubling the percentage of members that have no gaps in their continuum of care. To help us get there, we are providing doctors a financial incentive – on a sliding scale – to reward them for delivering better quality that we know helps our members stay healthy and avoid more costly care that is often needed when a health problem is not addressed early.

Using data to improve care

Incentives, of course, can be a powerful force in fostering better care. But we are also providing our doctors with something even more valuable – data.

In 2011, we started sharing raw claims data and packaged reports with eight medical partners covering some 20,000 members. We’ve since evolved these reports into an interactive web-based tool that allows physicians to analyze their patient populations and derive insights about how they can provide better care.

We have also rolled out a new data-sharing platform called HealthSphere that collects and aggregates clinical information from different systems to create a 360-degree view of the patient. Having this in-depth view of a patient can lead to more targeted, proactive, and effective care.

We continue to develop advanced analytics and population health management platforms as well as clinical decision support tools that enable our providers with actionable insights at the point of care to improve the health of our members.

Our focus on quality, however, does not end there. We recognize that a member’s health may also be affected by a range of factors that have traditionally been beyond the reach of the health care system such as access to nutritious foods, adequate housing and the availability of transportation and other non-medical resources – the so-called ‘social determinants of health.’

So, we are partnering with health systems and community health organizations on a demonstration project to build a model to address these factors and quantify the improvements in cost and overall health. The program, which was piloted with RWJBarnabas Health and focused on high-risk members in four Newark zip codes, will expand to 100 zip codes across New Jersey.

We are also improving the quality of care our members get by doing more to treat people holistically by putting body and mind on equal footing. To do this, we have deployed new tools and brought in new partners to give doctors the resources they need to integrate behavioral and physical health care for their patients.

We have metrics for all these individual programs, but the larger question remains: Have we moved the needle in terms of overall healthcare quality in New Jersey? It’s an important question. In 2018, New Jersey ranked 25^th in state health system performance – right in the middle of the pack.

But data on our patient-centered, value-based care programs show we are starting to have an impact:

• 4 percent lower rate of hospital inpatient admissions
• 6 percent higher rate of colorectal cancer screenings
• 7 percent higher rate of breast cancer screenings
• 24 percent lower rate of readmissions for patients with diabetes
• 2 percent reduction in potentially avoidable ER visits

We are on the right path but, there is still plenty of room for improvement. I was a football player in my younger days. For me, achieving the Triple Aim - improving the cost, quality, and patient-experience of health care – is a lot like football. Success requires everyone doing their part and only comes when all of us do our part together.