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Episodes of Care

Episode-based payment seeks to align provider incentives with successfully achieving a patient's desired outcome during an “episode of care,” which is acute or specialist-driven health care delivered during a specified time period to treat a physical or behavioral condition. Episodes reward high-quality care, promote the use of clinical pathways and evidence-based guidelines, encourage coordination, and reduce ineffective and/or inappropriate care. Episode-based payment is applicable for most procedures, hospitalizations, acute outpatient care (e.g., broken bones), as well as some forms of treatment for chronic (e.g., cancer) and behavioral health conditions (e.g., ADHD). Under the initiative, participating insurance companies will add additional episodes every year with the goal of implementing 75 episodes by the end of 2019.

For more information on individual Episodes of Care, please reference the following:​

This figure depicts a typical Episode of Care.

This figure depicts a typical Episode of Care. Episodes of Care focus on the health care delivered in association with acute health care events and are triggered by specific claims filed by a facility, provider group or individual provider. The episode duration, or episode window, can include the time before the trigger (pre-trigger), during the trigger period and after the trigger (post-trigger). Services and procedures such as diagnostic imaging, medications, and outpatient services performed by multiple providers before, during, and after the triggering event can be included depending on the episode.





For questions about the initiative, email