Transformation Through Collaboration: Horizon's Patient-Centered Program Is Delivering Results

The American Journal of Accountable Care, September 2014, Volume 2, Issue 3

Since 2011, Horizon Healthcare Services, Inc has collaborated with physicians and hospitals throughout New Jersey to transform healthcare delivery. This article details the early successes and key ingredients of Horizon's patient-centered programs.

A 23-year-old patient-member of Horizon Healthcare Services, Inc (Horizon), seemed headed for an all-too-typical experience within our fragmented healthcare delivery system. She was coping with a series of complex physical and emotional challenges that had already resulted in multiple visits to the emergency department, several hospital admissions, and a regimen of up to 14 different medications. Care was being delivered, but in an uncoordinated and piecemeal way. Fortunately, the patient was about to experience how her care—and life—could change through a patient-centered approach to healthcare delivery.

The patient received primary care through a practice—an early adopter of Horizon’s Patient-Centered Medical Home (PCMH) Program—that included a nurse on staff serving as a population care coordinator (PCC). The PCC detected the patient’s utilization pattern and brought it to the attention of the primary care physician (PCP), who in turn immediately contacted the patient and engaged her and her family in a detailed discussion about her experiences. In short order, the PCP developed a personalized care plan. In the 2 years since, the patient’s care has been well coordinated; her conditions are under control, and her hospital visits and medications have been minimized. She is now fully engaged in her own care, and her quality of life has vastly improved.

This experience epitomizes the results Horizon has been achieving through our patient-centered programs. Since 2010, Horizon’s efforts have grown to include hundreds of patient-centered practices, resulting in more than 500,000 Horizon members now experiencing the benefits of better-coordinated, personalized care.

Program Mechanics

Practices that join Horizon in their collaborative patient-centered initiatives agree to take on greater accountability to provide their patients with more comprehensive and coordinated healthcare. In addition, patient-centered practices receive up-front payments to support their transformation efforts and additional staff resources, including the PCC highlighted above. Practices also have an opportunity to receive outcome-based or shared savings payments for improving quality outcomes and controlling unnecessary utilization and cost of care.


Recent results confirm that patient-centered practices deliver more effective, better coordinated healthcare. When we compared Horizon members in traditional primary care practices with over 200,000 members receiving care at practices participating in Horizon’s PCMH Program in 2013, we found that patient-centered practices achieved a 14% higher rate in improved diabetes control and a 12% higher rate in cholesterol management. In addition, those practices delivered 8% and 6% higher rates in breast and colorectal cancer screenings, respectively.

We also found that more active care is being provided at a lower cost: the cost of care of patient-centered practices was 4% lower than that of nonparticipating practices. In addition, patient- centered practices achieved a 4% lower rate in emergency department visits and a 2% lower rate in hospital admissions.

These results are encouraging. When people get and stay healthy through accountable and coordinated care, everyone benefits: the patient receiving the care; the doctors and other health professionals delivering the care; and the employers and consumers who shoulder the cost of the care.

A core element of this success has been Horizon’s collaboration and engagement with leading primary care practices. Through this effort, we have defined 3 healthcare transformation pillars that are helping us achieve the Triple Aim of delivering better health outcomes, creating a better patient experience, and controlling the per capita cost of care. The transformation pillars are:

- Payment reform

- Improved health plan design

- Care delivery transformation

Payment Reform

The fee-for-service payment model dates back to the dawn of organized medicine in the nineteenth century. What we now recognize as the misaligned incentives of the fee-for-service payment model comprise one significant factor contributing to annual healthcare costs in the United States exceeding $2.8 trillion. A recent report published by the Institute of Medicine estimates that up to 30% of this $2.8 trillion does nothing to improve patient health.

We and our clinical practice collaborators are addressing the disproportionately high cost of healthcare in numerous ways. We aim, for instance, to eliminate wasteful and duplicative testing, and inefficient and sometimes painful visits to hospitals for primary care. This leads to better patient outcomes and an improved experience of care with lower out-of-pocket costs to individuals and lower costs for the system overall. Also under Horizon’s payment reform model, physicians are incentivized and compensated for delivering quality with efficiency, so their economics aren’t driven by the volume of tests ordered or services rendered. In addition to the upfront payments for care coordination, practices have the opportunity to earn outcome-based or shared savings payments for delivering better health outcomes and a better patient experience, and for controlling the cost of care.

Improved Health Plan Design

The key to sustaining momentum for Horizon’s patient-centered efforts is to ensure that our members and employer group accounts are fully informed about the benefits of this model of care and are encouraged to use these patient-centered practices. Our company recently intensified its commitment to this model of care by introducing 2 new patient-centered health plans for small businesses (50 or fewer employees). The new plans, offered at a 15% discount compared with the lowest-priced non-patient-centered Horizon plan for small businesses, also extend savings to employees; when care is delivered by a patient-centered practice, the employee pays no deductible or coinsurance. These products showcase not only the benefits of patient-centered care, but the fact that those delivering it are New Jersey’s leading providers.

Care Delivery Transformation

Delivering patient-centered primary care is significantly different from delivering traditional primary care. Primary care practices go through a clinical, structural, and cultural transformation as they move from a sick-care model to one focused on getting and keeping individuals healthy through preventive care, wellness activities, and individual empowerment.

Over the past few years, we have found 3 core areas within care-delivery reform that have had the greatest impact on delivering better care and controlling costs. They are:

- Population care coordinators

- Patient engagement

- Data and technology

Population Care Coordinator

Horizon requires each of its patient-centered practices to employ a population care coordinator (PCC). The PCC is a nurse who works within the practice to develop and implement care plans for high-risk or at-risk individuals. One of the PCC’s many responsibilities is to follow up with any patient in the practice who has been hospitalized, with the goal of having that patient seen in his or her primary care physician’s office shortly after discharge. Each PCC delivers population-health management within the practice for patients who are identified by enrollment information, claims data, and practice-level data for clinical screenings, preventive services, and/or chronic-care management.

Horizon’s Clinical Innovations team designed a 2-day PCC training program that every PCC hired by a practice is required to complete. The program includes sessions on the sharing of best practices and presentations by subject matter experts on relevant topics (eg, motivational interviewing, enhancements to quality and efficiency reporting and analytics, clinical updates on the management of chronic conditions). Horizon’s investment in PCC training, mentoring, coaching, and support is substantial, because we are convinced that high-performing PCCs are a key differentiator and success factor of our program.

Patient Engagement

Our patient-centered program also provides direct resources, created by Horizon and a contingent of patient-centered physicians, to assist practices in engaging and communicating with their patients. Building strong connections among the patient, physician, and office team can help patients feel a sense of ownership and empowerment when it comes to their health and healthcare decisions. The resources help educate patients, and they include welcome kits; letters introducing patients to the benefits of a patient-centered practice and the important role it plays within the healthcare system; fact sheets with answers to frequently asked questions; and scripts that staff members can use, during phone calls with patients, to explain what being in a patient-centered practice means to their personal healthcare.

Data and Technology

Another core component of Horizon’s PCMH Program is ensuring that practices use actionable data to improve performance on the Triple Aim goals. For example, practices receive detailed information on their patient population on both the individual and aggregate levels. This includes performance reports, care management reports, and a report that highlights gaps in care. These reports, coupled with a practice’s clinical knowledge of its patients, are important components of the transformation of care delivery. We also recommend that practices make investments in health information technology to better manage these data in a timely and more effective manner.

In addition, Horizon developed the Care Plan Tool, a secure Web-based database that operates as a repository for information and clinical data. Practices can enter data that reflects work performed to address patients’ needs for acute, preventive, and wellness care. Using this technology, practices record, store, report, and manage clinical data, gaps in care, hospital admissions, and laboratory tests. The software tool also helps practices create detailed care plans and maintain a list of members’ needs.

As New Jersey’s largest health insurer, Horizon continues to expand patient-centered programs throughout the state. The PCMH Program currently includes more than 3700 physicians at 900 practice locations. More than 500,000 members currently receive care at one of these practices; our goal is to see the majority of our 3.7 million members in a patient-centered program within the next 2 years. We encourage everyone in the healthcare delivery system to become part of the transformational changes that are unfolding. The model’s emphasis on wellness and health management is central to the goals of helping people lead longer, healthier lives; reforming the economics of medicine; and helping physicians practice at the top of their license.