Inside Healthcare - RedCoat Publishing

The debate on healthcare reform is centered on ways to reduce costs and increase quality, which are two objectives MetroPlus Health Plan of New York has been achieving for years. President and CEO Dr. Arnold Saperstein said the culture of his organization demands nothing less.

“All managed care plans are designed to reduce costs, but everyone here works every day to continuously improve the quality of care for our members; it’s ingrained in our culture,” he said.

MetroPlus is a wholly owned subsidiary of the New York City Health and Hospital Corporation, the largest public hospital system in the US. Most of the company’s more than 370,000 members are in Medicaid Managed Care, and many face steep health and financial challenges. Saperstein explained that the company’s service population is primarily made up of low-income, inner-city patients with chronic conditions.

The challenging healthcare environment hasn’t slowed MetroPlus down in its pursuit of better, more accessible quality care. The company has implemented a number of programs and processes that have earned it a number one rating for quality and customer satisfaction in New York Medicaid’s Consumer Guide in three of the last four years.

Dr. Arnold Saperstein, president and CEO

This fall, the company is launching a Medicare product that will expand the number of people who can take advantage of the company’s valuable services. MetroPlus already offers Medicare Advantage Plans for people who are dually eligible for Medicaid and Medicare and for Medicare eligibles who are living with HIV/AIDS. As of January 1, 2010, however, any qualified Medicare beneficiary can enroll in MetroPlus.

“HHC Medicare use has increased over the years, and a number of the patients were interested in our services but were unable to enroll. We are excited to welcome them to our organization and take advantage of this opportunity for us to grow,” Saperstein said.

One of MetroPlus’ fastest growing programs is its Partnership in Care Special Needs Plan, which reached 3,000 members this year, making it the largest HIV managed care program in the US. Saperstein said the program gives doctors and other healthcare providers an extra pair of arms in handling patients with this supremely complex disease. MetroPlus’ team includes HIV specialist physicians, nurse case managers, and social workers. This team collaborates with the care team at MetroPlus affiliated facilities to monitor each member’s continuity of care and medication adherence. When a patient misses an appointment, for example, a case manager reaches out to him or her to offer help.

MetroPlus uses the HHC intranet to facilitate better communication between case managers and physicians and implemented a new algorithm that tracks potential medication interactions. Saperstein said doctors sometimes dread working with managed care plans because they fear interference or delays, but so far, the organization has received much positive feedback.

“Our goal is to provide services that are a value-add for the physicians,” said Saperstein. “We don’t directly treat these patients, but we can collect and interpret information physicians can use to help them provide higher quality care.”

Another value-add MetroPlus has had in place for the last three years is its telehealth service, which Saperstein said is primarily for diabetes patients. The organization installs a unit in the patient’s home that transmits his or her glucose reading to an RN at HHC’s home care division. If there is a significant variation in that reading, the RN calls the patient. According to Saperstein, this service has helped a number of motivated but uneducated patients bring their disease under control.

Information and incentives
At the same time, MetroPlus has been implementing a number of quality improvement initiatives. Most recently, the company adopted a new predictive modeling system that uses data from ED visits, appointments, and medications a member has used to find gaps in care that make him or her a high risk for inpatient admission, for example.

The system launched last year, and since then Saperstein and his team have been focused on gaining buy-in with HHC physicians by working with corporate and hospital leadership and putting clinical coordinators on the ground in hospitals to share the information with doctors.

So far, he said, feedback has been positive. Many of the MetroPlus doctors have created an account through MetroPlus’ Web portal, which is linked to this system, and they are working with the clinical coordinators.

The most significant quality program for MetroPlus, however, has been its pay-for-performance program. The joint MetroPlus-HHC program links financial incentives, close to $8 million worth per year, to quality standards the two organizations have set for their member facilities.

The program started in 1998, when MetroPlus began awarding the facility with the best results on a set of quality indicators. In 2002, the organization upped the ante to focus on preventative health, awarding those facilities with the highest percentage of screenings or wellness visits. In 2005, the company expanded the program to include chronic disease outcomes. For example, the facility with the lowest average hemoglobin A1C level for its diabetes population, or the facility that lowered that level most significantly, receives the prize.

Saperstein hopes that, despite the changes likely to come in the next year or so as a result of healthcare reform, MetroPlus will be able to continue this highly effective program.

“There are a lot of pressures and unknown variables providers are dealing with right now,” he said. “Our goal is to make it as easy as possible for them to maintain a high level of quality and keep that goal of continuous improvement front and center.”

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