Horizon Blue Cross Blue Shield Launches Integrated Mental-Physical Pilot

Lilo H. Stainton | October 19, 2016 | Health Care
A new program for patients with Crohn’s disease will integrate mental and physical treatments in order to improve health and reduce costs

crohn's disease
In the latest step in New Jersey’s march toward value-based care, Horizon Blue Cross Blue Shield has launched a pilot program that seeks to integrate mental and physical treatments to improve care for patients suffering from Crohn’s disease. Value-based care rewards providers for outcomes, not patient volume.

The effort is the latest in more than a bakers’ dozen of “Episodes of Care” programs Horizon has implemented to better coordinate all treatments throughout the diagnoses, treatment and recovery from a variety of conditions, ranging from pregnancy to prostate cancer. But it is the first time the company, the state’s largest insurance provider with over 3.8 million customers, has woven a mental health component into the fabric of a program.

Research has shown that truly integrating behavioral health services, designed to treat mental illness and substance use disorders, with primary care — and vice versa — leads to healthier, happier patients and reduces the cost of care over time. And while there has been steady progress toward value-based care — which has been shown to improve health and reduce expenses — regulatory and payment hurdles have posed challenges to coordinating behavioral and physical healthcare.

While the Crohn’s pilot will start small, with just 50 patients, Horizon expects it will serve as a model for future efforts. The company will partner with seven physicians at Digestive HealthCare Center, a gastro-intestinal specialty group with offices in Hillsborough, Somerville and Warren. Beacon Health Options, a group that oversees behavioral health services for Horizon, will provide the mental health component.

[related]“This Episode of Care will probably be a defining factor in value-based care going forward,” Horizon spokesman Tom Vincz said, referring to the way the company seeks to further the integration of physical and behavioral health.

Mary Ann Christopher, Horizon’s Chief of Clinical Operations and Transformation, said the program evolved over the past eight months as the company focused new attention on models that can better treat the whole patient. “This really does offer new hope in healthcare,” she told attendees at the NJ Spotlight on Cities conference last Friday.

Horizon said Crohn’s Disease, a chronic and incurable inflammation of the digestive tract that can cause severe pain and other debilitating symptoms, made sense for this pilot as many sufferers also develop mental illnesses that can further degrade their wellbeing.

“Bringing a behavioral health component into this episode can help us understand how to improve care for the whole person, which can ultimately enhance the patient experience, improve patient outcomes, and reduce costs,” said Lilli Brillstein, director of the Episodes of Care programs.

In the pilot program, professionals from Beacon Health will train staff at Digestive Healthcare in how to conduct mental health screenings and appropriate referrals for follow-up care, if needed. When patients come in, they will be assessed for physical symptoms associated with Crohn’s and also for mental health issues that may or may not be related to their GI disorder. Care will be carefully coordinated among nurses, doctors, laboratory services and any outpatient programs, including counseling or other treatments for mental illness.

Dr. Charles Accurso, with Digestive HealthCare, said the new program “will allow us to take a fully integrated approach to Crohn’s disease, with the goal of achieving the best possible outcomes for patients by bringing behavioral and medical treatments into harmony.”

Horizon will track this work and the patients’ progress over a year and determine how the coordinated treatment can reduce costs and improve patient outcomes, as compared to baseline measurements for standard courses of care. The pilot program will last as long as it is successful, the company said.

Efforts to reward quality care are not new in New Jersey, but they have gained significant momentum in recent years and were further accelerated by the passage of the federal Affordable Care Act, which took full effect in 2014. But a growing number of studies suggest that efforts to coordinate and integrate behavioral care have lagged behind and a growing number of patients are flooding hospital emergency rooms when facing a psychiatric crisis.

Horizon’s interest in value-based care started to take shape in 2010, with the advent of Patient Centered Medical Homes, a program designed to better coordinate treatments around primary care. Efforts to engage hospitals in the mix soon followed, a model that grew into Accountable Care Organizations under the ACA. The Episodes of Care program, which dates to 2012, was the company’s way of looping in specialist practices, which are responsible for some of the most costly treatments patients face.

The Episodes of Care portfolio started with a focus on better managing orthopedic care and has grown to include programs built around knee and hip replacements, hysterectomy, breast, colon and lung cancer, and heart failure, among others. (A colonoscopy effort developed in 2014 also involved Digestive Health.) The various Episodes programs now involve more than 900 doctors and nearly 8,500 patients, Horizon said.

“We focus on all the issues related to that (medical) event,” Brillstein said, not just the role of an individual doctor.

Each program includes clinical and financial targets, developed through an analysis of several years of claims data and in-depth discussions with the providers about what works best, Horizon explained. Doctors are paid a set fee for providing coordinated treatments, as opposed to a fee-for-service model, and the insurance company shares any savings that result with their provider partners.

“We don’t have a stick,” Brillstein said, noting there is no financial risk to the physicians if these targets aren’t met. “Our goal is to partner with (providers) to create success.”