Results from 2017 show that the orthopedic specialists in Horizon Blue Cross Blue Shield of New Jersey’s Episodes of Care (EOC) Program outperformed their non-EOC peers for the same procedures in terms of both outcome quality and cost. The results are based on an analysis of 2017 data for patients in Horizon BCBSNJ’s EOCs for Hip Replacement, Knee Replacement and Knee Arthroscopy compared to patients undergoing the same elective procedures with other, non-EOC practices in New Jersey.

The results come as a Health of America Report by the Blue Cross Blue Shield Association (BCBSA) shows that treating orthopedic pain conditions, inclusive of elective or planned orthopedic surgical procedures, accounts for more than 14 percent of healthcare spending nationally among commercially insured Blue Cross Blue Shield (BCBS) members. The BCBSA report shows that from 2010 – 2017 the average price of knee and hip procedures increased by 6% and 5%, respectively. Over the same period of time, planned orthopedic surgeries increased by 44 percent among Americans ages 35 to 64.

The EOC model is part of Horizon BCBSNJ’s value-based program in which doctors are rewarded for achieving the triple aim of better care quality, lower costs and a better patient experience. When the EOC specialists – who manage the full spectrum of care related to a specific procedure, disease diagnosis or health event -- achieve the triple aim, Horizon BCBSNJ shares cost savings, which the specialists receive on top of their fee-for-service reimbursements.

“Orthopedic procedures constitute a significant portion of overall health care spending, with tremendous variation in care and cost of care, which is why Horizon initiated its EOC program in 2010 and began working with specialists to create a better approach to hip and knee procedures,” said Allen Karp, Executive Vice President for Healthcare and Transformation Management for Horizon BCBSNJ. “Our most recent results continue to prove that when doctors and insurers work together to focus on what’s best for a patient we can deliver to those patients better quality care at a lower overall cost.”

According to 2017 results, when compared to those in traditional practices, Horizon BCBSNJ members engaged with an EOC orthopedic doctor experienced a:

• 21% lower cost for knee replacements
• 30% lower cost for hip replacements
• 20% lower cost for knee arthroscopies

On measures of quality in 2017 results, Horizon BCBSNJ members engaged with an EOC orthopedic doctor also experienced a:

• 9 percent lower 90 day infection rate following a hip replacement
• 43 percent lower 90 day infection rate following a knee replacement
• 58 percent lower 30 day readmission rate following a knee replacement
• 24 percent lower 30 day readmission rate following a hip replacement.

“The beauty of our program is that both Horizon and our provider partners work collaboratively across the entire care continuum to do what is clinically best for the patient and it is that improvement in care that lowers the overall cost,” said Lili Brillstein, Director of Specialty Care Value Based Models for Horizon BCBSNJ. “By incentivizing providers and putting the patient at the center of care, both Horizon and our medical partners are creating better patient outcomes, as well as developing best practices that improve quality for all patients in the long-run.”

The three orthopedic procedures are among a total of 20 episodes Horizon BCBSNJ has launched with provider partners since 2010, with at least four more scheduled for 2019. Nearly 40,000 Horizon BCBSNJ members participate in one of the company’s Episodes of Care programs, including 1,312 in Hip Replacement, 2,312 in Knee Replacement and 1,742 in Knee Arthroscopy. From 2014 through 2018, Horizon BCBSNJ has achieved $90 million in gross savings across all of its EOC programs, prior to any payments to specialists for shared savings.

Dr. Stephen Zabinski, MD, of Shore Orthopedics Associations in Somers Point and one of the original specialists in Horizon BCBSNJ’s initial hip and knee placement episode in 2010, said the program continues to improve for all parties as it evolves.

“Horizon’s episodes program has not only been uniquely collaborative, but has created new incentives for specialists to think more strategically and efficiently in how we approach the full continuum of our patient’s procedures and needs,” Zabinski said.

Approximately 1.5 million Horizon BCBSNJ members, 4,500 primary care doctors and thousands of specialists participate in Horizon BCBSNJ’s value-based programs, including Episodes of Care, Accountable Care Organizations and Patient-Centered Medical Homes.