Integrated Care & Cost Management

HORIZON Health Ventures, LLC (HHV) is a health care management solutions provider delivering products and services that maximize the cost efficiencies in and accuracy of appropriate health care delivery to save time, money and potentially lives.

We offer a unique model of integrated, turn-key cost management solutions for active and retiree populations while taking the guesswork out of vendor identification and management by utilizing providers that deliver best-in-class services at the lowest net cost.

It is no secret: Our healthcare system is fragmented, suffering from what George Halvorson, Chairman & CEO of Kaiser Permanente, calls "clinical linkage deficiencies."

"These systemic deficiencies, evidenced by conflicting incentives and lack of coordination, cost lives and fuel the unsustainable spiral of US healthcare expenditures.“

For example, the Dartmouth Institute for Health Policy & Clinical Practice estimated that 30% to 40% of all hospitalizations are avoidable and that among regions, Medicare costs can vary 2- or 3-fold higher to treat similarly ill patients without better outcomes. As late as 2005, 5 preventable medical errors caused more deaths than breast cancer, automobile accidents, or drowning. In January 2009, an article in The New England Journal of Medicine stated that using a simple surgical checklist could reduce the death rate from surgery by half, decrease complications by more than a third, and save U.S. hospitals about $15 billion per year.

Improving communication between providers and patients, ensuring easy access to relevant information and eliminating waste from unnecessary, inappropriate and unsafe care is crucial for improving quality and reducing costs — and making the system financially sustainable.

HORIZON Health Ventures knows this can be achieved through greater integration of healthcare delivery, cost management and member engagement.

Integrated care and cost management can be better understood by considering its opposite, "Fragmentation".

"Fragmentation" in healthcare delivery means the systemic misalignment of incentives, or lack of coordination, that spawns inefficient allocation of resources or harm to patients. Fragmentation adversely impacts quality, cost, and outcome.

HORIZON Health Ventures seeks to facilitate that communication by bringing together best-in-class solutions proven to eliminate waste in the healthcare system. Our comprehensive suite of solutions address:

  1. Utilization (appropriate use of healthcare resources at the right time, the right place and for the right reason)
  2. Costs (direct and indirect)
  3. Satisfaction (with healthcare and perceived benefit – access, ability to engage patients, families and providers to improve care coordination)
  4. Clinical outcomes (such as complications, functional status)

HORIZON Health Ventures:  Serving Benefit Advisors and their Clients

Plan Design Consultation and Incentives: 
HORIZON Health Ventures provides you and your clients with both plan design and incentive-based consultative services.  We develop an understanding of your clients employee culture, readiness to change and other factors.

Contract Negotiation and Program Oversight: We negotiate the most aggressive vendor contracts with the most favorable terms on your behalf eliminating significant amounts of time, energy and resource.  With nearly 100 years of collective cost management experience, HORIZON’s team of specialists is in the best position to negotiate, administer and validate cost containment relationships ensuring that your clients are maximizing their savings, year over year.

Reporting and Analytics
: As part of our management reporting package, we provide a monthly dashboard consolidating utilization and cost factors across the spectrum of healthcare services, including medical and pharmacy costs.  Our report provides monthly trends in patient utilization, costs and other clinical statistics.

 We also provide comprehensive quarterly reports, which can be reviewed in person with your management team. These reports include additional data such as disease prevalence, medical and pharmacy utilization, financial performance and ROI from the programs implemented. Finally, we provide comprehensive analysis relative to pharmacy payment integrity, performance guarantee adherence, patient engagement and member satisfaction.


Partnership:  Our advisors – Our partners.  Together we work with you to bring real solutions, real impact and real value to your clients without ever-compromising the operational or financial relationship that you maintain with your clients.



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Success Stories
Association Employer – New Jersey – HORIZON Solution: Employer Group Waiver Plan (EGWP)

Number of Retirees: 239
This Association had been managing their retiree pharmacy program and filing for the Retiree Drug Subsidy (RDS) since 2006 through its insurance carrier. After evaluation of current drug spend and projected RDS for 2014, the plan decided to move to a fully insured Employer Group Waiver Program (EGWP). Based on current enrollment, no change in plan design or drug plan, the group saved $430,000 or $1,800 PMPY. This was hard dollar savings and did not infer savings from the elimination of attestation, administration or from the elimination of OPEB liabilities.

Success Stories
Government Association - Washington, DC- HORIZON Solution: Employer Group Waiver Plan (EGWP)

Number of Retirees: 108
This Association had been managing their retiree pharmacy program and filing for the Retiree Drug Subsidy (RDS) since 2006 through its Pharmacy Benefit Manager (PBM). During the course of the relationship, the PBM never introduced the Employer Group Waiver Program (EGWP) to either the Association or their insurance broker. In May 2013, HORIZON Health Ventures introduced the concept of EGWP to the broker who immediately addressed the capability with the client. Keeping all pharmacy benefits the same, HHV was able to save this plan $189,000 or 28% of drug trend for 2014.

Success Stories
Municipal Employer –Michigan – HORIZON Solution: Employer Group Waiver Plan (EGWP)

Number of Retirees: 1,200
Managed for many years by the same carrier, this municipality moved their group retiree pharmacy program to HORIZON Health Ventures and its proposed Employer Group Waiver Program (EGWP) for a 13% savings to the plan. In addition, the group did so while improving their plan design on generic drugs. At the direction of HORIZON Health Ventures, the EGWP provider lowered copayments on generic products both at retail and mail thus resulting in greater steerage to lower cost products and thus a lower premium. In addition, based on this client’s plan year, (along with the new plan design adopted), the client was able to secure a rate cap for 2015 fixing their costs at a maximum liability until January 1, 2016.

Success Stories
Union – New Jersey – HORIZON Solution: RDS Reopening

Retirees Covered: 1,032
Reopening subsidy = $1,518,000
Additional subsidy = $280,000
18% additional subsidy recovered upon Reopening

Upon hiring HHV and RDS Reopening Services requested an audit of past Retiree Drug Subsidy filings from CMS. The request was approved and based on missed eligibility and inaccurate reconciliation of subsidy eligible claims, this client successfully Reopened their RDS filings from 2009-2012 recovering over $90,000 in additional subsidy. 

Success Stories
Municipality – New Jersey – HORIZON Solution: Pharmacy Benefit Management

Total Lives Covered – 2,900
Annual Drug Spend - $4,400,000
Issue – Adverse drug mix in the Proton Pump Inhibitor (PPI’s) category resulting in $297,000 in unnecessary drug spend.

Resolution – Plan design modification mandating PPI’s be purchased Over-the-Counter (OTC) along with full subsidy of a $0 copayment to the member.

Recommendation to eliminate member cost share for mandatory purchases of OTC PPI’s resulting in $177,000 net savings to the plan. Significant savings to both plan and member realized through slight modification of design and no member disruption.

Success Stories
Corporate Employer – Pennsylvania – HORIZON Solution: Medical Bill Review

Total Lives Covered – 400
Number of bills reviewed - 5
Total Amount of Hospital Bills Reviewed - $1,135,914
Negotiated Amount Paid by Plan Sponsor - $446,874

After hiring HHV for Cost Containment Services (Medical Bill Review), five out-of-network hospital bills (different patients with different health conditions) were reviewed for appropriateness and necessity. Due to the identification egregious billing practices, undocumented charges and reasonableness audit, successful negotiation was realized reducing the amount paid by $690,000.

According to a recent Towers Watson survey, the average company's healthcare plan cost increased 5.5%, while the "best performers" reported an increase of only 1.6% in 2013. The lower increase was attributed to 5 critical actions:

1. Design health plans that emphasize high performance.

2. Establish favorable contracts with pharmacy benefit managers and drive members to use generic drugs.

3. Understand and respond to the underlying population health risks of employees.

4. Contract with highly effective partners (health plans, pharmacy benefit managers, and providers) and aggressively negotiate financial terms with a growing focus on value-based arrangements.

5. Establish coverage tiers.