By Thomas Vincz, Public Relations Manager

If there’s one area of medicine that could benefit from higher quality, lower costs and simpler patient experience, it would be cardiovascular care.

Heart disease, after all, is the leading cause of death both nationally and in New Jersey. Patients with heart conditions typically see several different specialists as they endure numerous diagnostic tests and treatments. This can lead to stress and confusion over redundant procedures along the way that add expense – but not quality – to the patient experience.

Heart care is the ideal candidate for a more coordinated solution focused on better long-term outcomes.Dr. Sanford Gips, MD, FACC, FSCAI, an interventional cardiologist, found just that with the Episodes of Care (EOC) program from Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ). Gips’s practice, The Heart House, an independent physician group with several New Jersey locations, was the inaugural member of Horizon BCBSNJ’s Coronary Artery Disease EOC in 2018 and the second member of the Heart Failure EOC in 2015.

In a Horizon BCBSNJ EOC program, physicians, group practices and Horizon BCBSNJ work together to improve the quality of care to give patients a better health experience and lower their overall cost of care. A doctor or practice is responsible for orchestrating a patient’s “episode” of cardiac care – from the first office visit to diagnostic testing to treatment, including surgery if needed, to recovery and rehabilitation. This approach ensures patients receive high-quality treatment and an experience they can feel good about. If the doctor is successful in meeting certain quality measurements and cost targets, he or she shares in the savings achieved from the episode.

“As a physician, we recognize that the fee-for-service model is unsustainable,” said Gips, referring to the practice of health insurers reimbursing doctors for every test and procedure instead of those that will benefit the patients the most. “The EOC program emphasizes quality over quantity, in addition to evidence-based medicine and patient satisfaction. More care is not always better care.”

The cardiac EOCs are two of the 26 episodes available from Horizon BCBSNJ’s program, which is one of the largest programs of its kind in the U.S. Compared with some of the other EOCs, like knee replacement where the care is organized around well-defined procedures, heart failure is more complex, said Gips.

Heart failure patients have more complicated issues to address. They’re generally older, with more dangerous co-morbidities, like diabetes, and fewer social connections. These patients are often readmitted to a hospital after surgery simply because they’ve forgotten to fill their prescriptions or they don’t have anyone checking up on them to make sure they stay on top of their conditions.

To address these challenges, Gips has helped redefine his practice’s protocols. Prescriptions for these patients are filled at the hospital before they leave; a nurse within his office calls the patient about a day after discharge; and three days after discharge, patients are scheduled for an in-office visit.

“Heart failure patients do a lot better with many touchpoints,” said Gips.

Hospital readmission is just one of many quality targets that cardiologists and Horizon BCBSNJ have agreed to evaluate as part of the heart failure EOC. The number of emergency room visits and adherence to clinical guidelines, for example, also play a part in determining whether participating doctors have reached the quality goals for each cardiac episode.

An episode can be triggered by several factors, including the initial diagnosis or a visit to an acute care facility, said Gips. Episodes factor in health care claims associated with a heart condition 30 days before the triggering event and 90 days following. The EOC program bundles all related claims and then compares the total cost of the episode against the benchmark historical cost. In 2019, Horizon BCBSNJ reported more than 1,600 heart failure episodes.

Horizon BCBSNJ designed the EOC program to be retrospective and “upside-only.” That means that doctors are paid in accordance with their fee-for-service contracts and once the episode is reviewed in retrospect, the practice can share in 50 percent of the savings achieved over the benchmark cost.

Ahead of the curve in value-based care

While the EOC program does aim to reduce costs, elevating the quality of patient care is the focus of the close collaboration between Horizon BCBSNJ and its episode partners. Medical decisions are always left in the doctor’s hands, not Horizon BCBSNJ’s. “For Dr. Gips’s patients, The Heart House is the conductor that is responsible for care coordination,” said Marlon Addison, manager of provider partnerships with Horizon BCBSNJ’s Specialty Care Value Based Models group. “Horizon is there to help physicians improve care for our members.”

That means providing the doctors with patient data and metrics so they get a clear picture of their patients’ health and understand both the most efficient and effective ways to deliver care.

“We are able to steer our patients toward the best care possible,” said Gips. “For example, with congestive heart failure, it’s often better to see the patient in the office instead of sending them to the ER. True, it’s less costly but more important, it’s often easier and a better experience for the patient.”

Horizon BCBSNJ tracks the patient experience through patient satisfaction surveys. According to Addison, the satisfaction scores for the EOC programs have been high.

But Horizon BCBSNJ is also concerned about another kind of satisfaction. “At Horizon, we talk about not just a Triple Aim, but a Quadruple Aim, which includes physician satisfaction,” said Dr. Ralph Pothel, medical director at Horizon BCBSNJ. “We want to make sure the health care professionals we work with achieve the impact they want in terms of better patient care as well as realize shared savings from the improved care they’ve delivered.”

Gips counts himself among the satisfied. “Horizon has been ahead of the curve when it comes to embracing population health,” said Gips. “The EOC program has been working very well and I, along with my patients, are very happy.”