Horizon shifting hospitals between OMNIA alliance, plan tiers

Horizon Blue Cross Blue Shield of New Jersey has been silently shuffling hospital tiers within its OMNIA Health Alliance and plan, which is still facing limited opposition, ROI-NJ has learned.

Alliance members, which included some of the state’s largest health systems and the largest physician group, may see a change.

AtlantiCare Regional Medical Center — a member of the Pennsylvania-based Geisinger system — became a new Alliance member this year, a spokeswoman confirmed Tuesday.

Egg Harbor Township-based AtlantiCare has two hospital campuses, in Egg Harbor Township and Atlantic City.

“AtlantiCare has been a Tier 1 provider for some OMNIA members since January of 2016 and become a Tier 1 member for all OMNIA members in January of 2017 after joining the OMNIA Health Alliance,” according to a statement from AtlantiCare.

The health system will join the ranks of Atlantic Health SystemHackensack Meridian HealthHunterdon Medical CenterInspira Health NetworkRWJBarnabas Health and Summit Medical Group as Alliance members.

Alliance members have arrangements per provider for value-based reimbursement plans, and work more closely with the state’s largest health insurer. They agreed to lower reimbursement rates in exchange for greater volume of patients (as a result of lower cost).

Tier 1 hospitals are in-network with Horizon and provide patients lower-cost care through low or no copays.

Tier 2 hospitals are considered standard in-network with Horizon, but patients do not get any incentive to use them.

During a grueling eight-hour joint Senate hearing in October 2015, a month after the OMNIA Health Alliance and product were announced, Horizon was asked if it was possible, at a later date, for Tier 2 to move into Tier 1.

CEO Robert Marino said, at the time, the possibility is there.

This appears to be that possibility realized.

This movement appears to be a balancing act to ensure Tier 1 continues to meet state regulations for network adequacy.

Another move Horizon made is making Trenton-based Capital Health System, which previously sued Horizon over the OMNIA plan and was Tier 2, a Tier 1 hospital, according to a source not authorized to speak on the record.

For example, Princeton HealthCare System’s Plainsboro hospital will be moving to Tier 2 from its previous spot in Tier 1.

Capital Health, also in the region, was chosen to move into Tier 1.

The same holds true for Shore Medical Center, which was Tier 1 and is in the same region as AtlantiCare.

Politico reported Shore is also being moved to Tier 2.

Horizon is still defending the OMNIA brand in a lawsuit maintained by three providers in the state — a decrease from the original seven.

A number of plaintiffs dropped out in return for value-based reimbursement agreements with Horizon — including Capital Health — was sparked, in part, by the way the tiers were marketed by Horizon. Hospitals were upset by the insinuation that Tier 2 meant lower quality, and called for Horizon to reveal how it chose tiers on the grounds of breach of contract.

The recent movement in the OMNIA structure also brings into question the announcement of Tier 1 member Cooper University Health’s intent to acquire Trinity Health’s Tier 2 hospitals in New Jersey — all three of which are Tier 2 members.

Horizon declined to confirm the movement in tiers, or AtlantiCare’s new Alliance status.

“Tiered network plans continue to expand both in New Jersey and nationally and most — if not all — New Jersey hospitals are either Tier 1 or part of a narrow network offered by an insurer here,” said spokesman Kevin McArdle. “Carriers can and do routinely adjust products and networks to meet consumer demand, respond to changing market conditions and satisfy regulatory requirements. Horizon is the only carrier in New Jersey to have every acute care hospital in our network and we are committed to driving the shift to patient-centered, value-based care that is delivering lower costs, improved quality outcomes and an enhanced patient experience.”