Linda Schwimmer Discusses Her Experiences in the Healthcare Industry

While working for Horizon Healthcare Innovations, Linda Schwimmer, JD, president and CEO of the New Jersey Health Care Quality Institute, gained insights on how best to transition to a pay-for-outcomes system and was able to actively work with healthcare stakeholders who were engaging in these models.

Transcript (slightly modified)

What did you work on at Horizon Healthcare Innovations and how have you applied that experience to your work at the New Jersey Health Care Quality Institute?

Right after the Affordable Care Act was enacted, Horizon Blue Cross Blue Shield which is the largest and oldest health insurance plan here in New Jersey, created a standalone subsidiary and the reason why they did that was they really saw that the healthcare system as we know it was broken and something fundamentally different had to happen in order to have a sustainable system. They very intentionally created this new company and brought in 50% of the employees in the company who were actually from outside of Horizon because they wanted to have that external, different way of looking at things. And, I was part of that external, different way of looking at things, and my role there was stakeholder engagement. And so, really reaching out to all different players so to speak in the community, whether it was hospital systems or physicians, other health care providers, businesses, consumer groups, etc., to really try to get different points of view on how we can move away from a fee-for-service system, so one that really just pays for volume and instead looked at new models of care delivery like patient-centered medical homes, accountable care organizations, bundled payments, which is really when you pay 1 large amount for procedure for the whole thing.

Really how to engage groups to design those sort of models, we wanted to make sure that it wasn’t just coming from Horizon, but for instance, when we were working on the bundled payment system, we put together a working group of orthopedic surgeons from across the state and we showed them their data and we showed them how they differed in terms of efficiency, length of stay, complications, cost and how they differed in outcomes and then really kind of had discussions around how can we improve quality, how can we control for costs and then how can we basically share that savings back with you, the surgeon, to incentivize you, to deliver better care and control the costs.

That was 1 whole working group that was going on for years and then the recommendations became a part of the model that the plan uses now. And, the working group was really, according to the surgeons as least, was one of the most satisfying interactions that they’d had both with their colleagues as well as with the plan because it really enabled them to improve as surgeons, to learn as a group, and to sort of question why do we do it like this as opposed to like that.

The patient-centered medical home initiative was another really exciting initiative. We engaged the Academy of Family Physicians, New Jersey Academy of Family Physicians, and really tried to support primary care’s development to become what it really should be, which is more than just a gate keeper and a place that people stop to get a referral to go to see somebody else, but really what patients really need, which is someone to help coordinate their care, to be a constant point-of-contact, to be that 1 trusted provider that communicates with all the other physicians or specialists that somebody might need, to sort of be a guide and a partner in the health care system. Again, that sort of interaction was very intensive. We created what we called a playbook, which was really, ‘In these types of situations, here’s various strategies,’ and some strategies worked for 1 type of patient but not for another so giving them the tool book, giving them greater reimbursement levels, enhanced reimbursement, giving them their data to see how their outcomes compared to their peer’s outcomes and then what the takeaways were from that in terms of how they could improve or how they could interact with our hospital systems better so they knew what was going on with their patients.

This isn’t anything that needs new technology or creating a new cure for an exotic disease. I mean this is really stuff about communicating, having the information, and paying them appropriately for that extra time they needed to take for the patients that needed the extra time. So those are the types of things now that as Horizon looks to Horizon and all the other plans across the country frankly, are looking to move away from fee-for-service to payment-for-outcomes. This groundwork is really the type of stuff that was needed to design these models and it’s the type of engagement that’s needed in order for all of these new payment models to be successful.

So, I still have all that knowledge in my brain and I brought it here to the Institute and we have what we call the QI Collaborative, which is a learning network to support these communities, particularly Medicaid, but we expect that it will expand to other communities as well, and support these communities and their journey to deliver more comprehensive care, to engage other partners, such as community partners, in the new payment models.