Horizon offshoot expands its patient-centered care model to Medicaid beneficiaries

NJBIZ STAFF//November 2, 2011//

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Medicaid patients in Newark are the focus of an expanding a program intended to ease strain on emergency rooms, increase preventative care and support family physicians.

Horizon Healthcare Innovations and Horizon New Jersey Healthcare, subsidiaries of the state’s largest insurer, Horizon Blue Cross Blue Shield of New Jersey, announced Wednesday its patient-centered medical home program — already installed at the Forest Hills Family Health Associates practice — will now include 1,800 Medicaid beneficiaries.

Under the PCMH initiative, doctors are paid fees for coordinating comprehensive care for Horizon members, and have the opportunity to earn more money if the program demonstrates better patient outcomes and more efficient care. That’s a departure from the current fee-for-service model.

Eight primary care centers in New Jersey have adopted the PCMH model, which supports 24,000 Horizon-insured patients. Preliminary results indicate the program’s mission is “directed in the right place,” said Dr. Richard Popiel, president and chief operating officer of HHI. Popiel said matured data from the first six months of the year indicate improvement in the majority of priority metrics identified by HHI, including patient readmissions and hospital admissions.

“This is our first step, which won’t be our only step, to involve Medicaid patients in the patient-centered medical home,” Popiel said.

The program pays for doctors, population care coordinators and nurses, who identify high-risk patients, monitor gaps in care and develop care plans. The PCMH practices charge a monthly member fee as another way to supplement revenue to support the program.

“Practicing under the patient-centered medical home model actually transformed our practice,” said Dr. Thomas Ortiz, founder and medical director of Forest Hills Family Health. “We’ve been able to identify many patients in my population of patients that have high-risk problems that frequently visit the emergency room or get hospitalized for, maybe, reasons that don’t require hospitalizations … we’ve been able to reach out more effective to communicate to those patients to let them know ‘You have a medical home, we’re available 24/7.’”

Already, he said, that’s “had an impact on our emergency room visits and our inpatient hospitalizations.”

Medicaid is not increasing its fees paid for the increased attention in the PCMH pilot. Dr. Philip Bonaparte, chief medical officer of Horizon New Jersey Health and vice president of clinical affairs for Horizon Blue Cross, said Horizon is making up then difference in cost.

“We embrace this model because we believe it does the things that meet our mission,” Bonaparte said.

Popiel said he could not reveal how much HHI has spent to support the PCMH program but said if performance is high, practices could see a 25 percent increase in revenue associated with Horizon members.

Ortiz said Medicaid’s low reimbursements have limited access to care for many of his patients, meaning increased hospitalizations. “With this project, it gives us some hope that we can get the fees to a reasonable level where we can do better case management … and provide more prevention, which we have not focused on at all in New Jersey.”

“We are very focused on knowing what (our outcomes) are, and whether the changes that are being made actually can produce the kind of differentiating quality and affordability results that we are looking for, so metrics are crucial,” Popiel said, adding that the academic consortium HHI enlisted earlier this year helped to identify the areas of measurement for the program.

Bonaparte said the Medicaid results are measured slightly differently from the other PCMH results, but the framework is roughly the same. Once results at Forest Hills are measured against the goals of the program, tweaks will be made and rolled out to other PCMH in the state, he said.