MetroPlus' mission is to provide our members with access to the highest quality, cost-effective health care including a comprehensive program of care management, health education, and customer service. This is accomplished by partnering with the New York City Health and Hospitals (H+H) and our dedicated network of providers.
The goals and objectives of the Quality Management Program Description (QMP) are to support MetroPlus Health Plan in realizing its mission. The QMP facilitates the continuous improvement in medical (including pharmacy and dental) and behavioral health care and service provided to MetroPlus Health Plan’s complex, culturally and linguistically diverse membership.
The scope and content of the QMP designed to continuously monitor, evaluate and improve the clinical care and service provided to members and their service delivery systems.MetroPlus Health Plan’s QMP involves all levels of staff as well as provider and member representatives.Specifically, the QMP includes, but is not limited to the following responsibilities and monitoring of key performance measures:
- Quality of Care, including quality improvement and health promotion activities
- Continuity and Coordination of Care
- Quality Improvement Projects
- Quality Improvement Projects (QIP) for Medicare, FIDA, and SNP Members
- Quality Improvement Projects/Studies for Medicaid/CHP, HIV SNP, MLTC, Essential Plan, QHP and HARP members.
- Case Management
- Pharmacy Management
- Behavioral Health
- Quality of Service
- Patient Safety
- Utilization Management
- Member and Physician Satisfaction
- Availability and Accessibility
- Delegation
- Member Complaints, Grievances, and Appeals
- Member Resource Support Tools: The Plan maintains a website. The site has tools and links to assist members with understanding and managing their benefits and health.
- Cultural Diversity. The Plan monitors the language needs of non-English speaking members through usage patterns of the language line.
- Human Resources
The MetroPlus Quality Management Department strives to offer important information and support to our members. We are extremely proud to have received the highest “quality measures” score from the New York State Department of Health for our work in helping our members get the preventive and chronic care needed to stay healthy. Listed below are some of the initiatives that were conducted in 2016 and continue in 2017:
- The New York State Department of Health awarded MetroPlus Health Plan the highest “quality measures” score among Medicaid managed care plans statewide. Our quality measures score reflects the high quality of care we provide to our Medicaid recipients every day. The areas where MetroPlus scored particularly highly include timeliness of prenatal care, administration of flu shots, smoking cessation, asthma medication management and diabetes management. MetroPlus also received high scores for postpartum care and well child visits. These results reflect the investment MetroPlus makes in keeping its members healthy. The MetroPlus staff works closely with members throughout the year to remind and arrange for doctors’ appointments, conduct community events, share information with providers and help members adhere to their medication regimens to improve their health.
- The MetroPlus Rewards Program encourages members to participate in healthy activities that can improve their health and well-being. All eligible members are automatically enrolled in the program and can earn reward points upon activity completion. The outcome is happier, healthier members who are engaged in their health and care. The program results in improved quality measures and lower health care costs. Members can register anytime at metroplusrewards.org.
- MetroPlus implemented a member texting program. Campaigns include but are not limited to encouraging Adolescent Well Visits, Annual Dental Visit, Asthma Self Care, Breast Cancer Screening, Cervical Cancer Screening, Prenatal and Postpartum Care, and Diabetes Self Care. Many texting programs are interactive allowing MetroPlus another way to communicate with our members!
Clinical and Service Initiatives
Measures
The 2017 quality program targeted many clinical and service measures for improvement. Below are short descriptions for some of the work we did along with MetroPlus’ most recent results. Results are compared to national and state-wide benchmarks. Benchmarks used include, but are not limited to, New York State Wide Average (SWA), Medicare national averages, Medicare Star Rating Thresholds and NYS QARR benchmarks.
Interpreting the Tables Below:
To gauge performance MetroPlus compares the Plan’s HEDIS®/QARR score to a relevant industry benchmark, such as NYS QARR benchmarks or the CMS Star rating thresholds. Plan scores higher than the benchmark indicate that the Plan is capturing health care information and using it to encourage its members to seek services that help them regain, maintain or improve their health care better than other plans. Improving quality is hard work; MetroPlus has a team of dedicated health care professionals who work every day toward improving health services for its members.
CLINICAL INITIATIVES
MetroPlus sends personalized, preventive health communications to make members aware of any gaps in preventive or chronic maintenance care. Members are provided with preventive health guidelines, member newsletters and personalized communications throughout the year to help them maintain their health. Some of the services members are encouraged to receive as follows:
Adult BMI Assessment
BMI used as a screening tool to identify whether an adult is at a healthy weight. Excess weight increases the heart’s work and will put a person at risk for chronic conditions, such as hypertension, diabetes, and heart disease.
MetroPlus sends educational mailings, reminders and text messages to encourage members to attend an annual well visit, which includes a BMI assessment. Educational materials on lifestyle changes to maintain a healthy weight posted on the member portal. The purpose is to educate members about the importance of a healthy BMI and its effects on risk for chronic conditions. Through the MetroPlus Rewards Program, an incentive offered to members who complete the 3-week Step-Up Challenge to help start members get more physically active. Additionally, we give our network providers patient information on who needs a BMI assessment. The table below captures the percentage of adults who have completed their annual BMI assessment.
| ADULT BMI ASSESSMENT |
| |
HEDIS 2015 |
HEDIS 2016 |
HEDIS 2017 |
QARR 2016 / Medicare Star Benchmarks |
| |
(MY 2014) |
(MY 2015) |
(MY 2016) |
50th Percentile |
75th Percentile |
90th Percentile |
| Exchange |
* |
56 |
66 |
86 |
86 |
90 |
| Medicaid |
88 |
86 |
92 |
87 |
92 |
95 |
| Medicare |
94 |
94 |
97 |
81 |
94 |
98 |
| FIDA |
* |
96 |
98 |
81 |
94 |
98 |
* Not available/Not reported.
Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (W34)
Well-child pediatric visits to promote good health and development are recommended for all children. During a well-child visit, a pediatrician provides preventive care by assessing a child’s physical, behavioral, developmental, and emotional status. A well-child visit is a critical opportunity to detect a possible developmental delay or disability, early treatment of which can lessen the future impact on both the child and family.
MetroPlus sends educational mailings, reminders and text messages to parents/guardians encouraging them to take their child for a complete an annual well visit and needed shots, tests, screenings, and counseling. Educational materials and newsletter articles on the importance of the annual well visit to the pediatrician are distributed to and discussed with members during community events and posted in the member portal. The purpose is to educate parents/guardians about the importance of regular preventive care and remind them of needed services. Incentives offered to members who complete their well visits through the MetroPlus Rewards Program (metroplusrewards.org). Additionally, MetroPlus works closely with our Pediatricians and assists with making well-child appointments. The table below captures the percentage of children who attended a preventive or ambulatory care visit.
*: Not available/Not reported.
Comprehensive Diabetes Care
Diabetes is one of the leading causes of death and disability in the United States. Approximately 24 million Americans, or close to 8 percent of the population, have the disease. Much of the burden of illness and cost of diabetes is related to potentially preventable long-term complications that include heart disease, blindness, kidney disease and stroke. Timely screening and careful treatment can significantly reduce and delay the onset of complications from diabetes.
MetroPlus sends reminders, through mailing and text messaging, to members with diabetes encouraging regular screenings, such as eye screening, HbA1c testing, monitoring for nephropathy, and maintenance of blood pressure and adherence to medication. Educational materials and newsletters on the importance of managing diabetes are posted in the member portal. Community events are held in community offices to assist members with completing eye screenings and flu shots. A registered nurse contacts members throughout the year to educate and help members address personal issues and barriers to care. Providers were notified of members who are overdue for diabetic screenings. Furthermore, incentives are offered to members who complete their comprehensive diabetes care through our MetroPlus Rewards Program (metroplusrewards.org). The table below captures the percentage of adults who completed comprehensive diabetes care, which includes blood pressure below 140/190, hemoglobin A1c testing and nephropathy.
| DIABETES CARE OUTCOMES |
| |
HEDIS 2015 |
HEDIS 2016 |
HEDIS 2017 |
QARR 2016 / Medicare Star Benchmarks |
| |
(MY 2014) |
(MY 2015) |
(MY 2016) |
50th Percentile |
75th Percentile |
90th Percentile |
| Exchange |
| HbA1c Testing |
93 |
95 |
94 |
90 |
92 |
94 |
| Nephropathy |
84 |
93 |
94 |
92 |
92 |
93 |
| BP<140/90 |
* |
46 |
* |
72 |
74 |
75 |
| Medicaid |
| HbA1c Testing |
91 |
93 |
93 |
89 |
91 |
93 |
| Nephropathy |
85 |
92 |
91 |
92 |
93 |
95 |
| BP<140/90 |
66 |
67 |
62 |
68 |
72 |
73 |
| Medicare |
| HbA1c Testing |
96 |
95 |
97 |
94 |
95 |
97 |
| Nephropathy |
92 |
97 |
97 |
94 |
96 |
98 |
| BP<140/90 |
63 |
63 |
70 |
65 |
72 |
78 |
| FIDA |
| HbA1c Testing |
* |
100 |
100 |
94 |
95 |
97 |
| Nephropathy |
* |
100 |
92 |
94 |
96 |
98 |
| BP<140/90 |
* |
59 |
64 |
65 |
72 |
78 |
*: Not available/Not reported.
Breast Cancer Screening
Breast cancer is the second leading cause of cancer-related deaths among women in New York. Regular checkups and screening tests can find breast cancer at an earlier stage when treatment works best. MetroPlus sends educational materials and reminders, through mailing and text messaging, to women who are due for a mammogram. Educational materials and newsletters on the importance of early detection of breast cancer are posted in the member portal. Members were outreached telephonically to educate and address issues, as identified. The goal is to educate members about the importance of screening and early detection. Mammogram events are held to address access issues and assist members in completing their mammogram. Incentives offered to members who complete their breast cancer screening through the MetroPlus Rewards Program (metroplusrewards.org). Additionally, we give our network PCPs patient information on who needs a mammogram. The table below captures the percentage of women screened for breast cancer.
| PERCENTAGE OF WOMEN APPROPRIATELY SCREENED FOR THE BREAST CANCER |
| |
HEDIS 2015 |
HEDIS 2016 |
HEDIS 2017 |
QARR 2016 / Medicare Star Benchmarks |
| |
(MY 2014) |
(MY 2015) |
(MY 2016) |
50th Percentile |
75th Percentile |
90th Percentile |
| Exchange |
85 |
77 |
68 |
75 |
76 |
80 |
| Medicaid |
72 |
73 |
73 |
68 |
72 |
73 |
| Medicare |
84 |
84 |
83 |
70 |
78 |
84 |
| FIDA |
* |
85 |
83 |
70 |
78 |
84 |
Cervical Cancer Screening
Cervical Cancer Screening is done through a Pap test. Pap test looks for changes in cells on the cervix that could turn into cancer if left untreated. Pap tests recommended for all women between the ages of 21 and 65 years old.
MetroPlus sends educational mailings and text messages to our members. Educational materials and newsletters on the importance of timely cervical cancer screening are posted in the member portal. Providers are notified of members who are due for cervical cancer screening. The MetroPlus Rewards Program (metroplusrewards.org) provides incentives to members who complete their cervical cancer screening. The table below captures cervical cancer screening rates.
Timeliness of Prenatal Screening
A healthy pregnancy leads to a healthy birth. Getting early and regular prenatal care improves the chance of a healthy pregnancy. The health care provider monitors the pregnant woman’s health and the growth of the fetus during prenatal visits. Recommendations for a schedule of prenatal visits are as follows: monthly for pregnancy before 28 weeks; between 28-36 weeks, visits done every two weeks; and becomes weekly on week 36 until delivery.
MetroPlus sends educational mailings and text messages to our pregnant members. The text messages remind and educate members on the importance of regular prenatal check-ups as well as offers tips on having a healthy pregnancy. Educational materials and newsletters on the importance of prenatal visits for a healthy pregnancy are posted in the portal. Providers are notified of pregnant members to ensure members complete their prenatal visits. The MetroPlus Rewards Program (metroplusrewards.org) provides incentives to pregnant members per prenatal visit completed. The table below captures timeliness of prenatal care rates.
*: Not available/Not reported.
Medication Therapy Management (MTM)
Medication Therapy Management (MTM) helps members and their doctors make sure that the member’s medications are working to improve their health. Members qualify for this program if they are in a Medicare drug plan and have more than one chronic health condition (such as asthma, diabetes, and depression), take several different medications for these conditions and the medications cost a certain amount that is established by the federal government. MetroPlus works with CVS, our Pharmacy Benefit Manager, to make sure that a pharmacist or other health professional can offer members a comprehensive review of all their medications. Pharmacists talk to members about:
- How well their medications are working
- Whether their medications have side effects
- If there might be interactions between the medications, they are taking
- Whether their medication costs can be lower
- Other problems they may be having the medications
Members get a written summary of this discussion, including an action plan that recommends what they can do to make the best use of their medications. The table below captures medication review completion rates.
| MEDICATION THERAPY MANAGEMENT |
| |
HEDIS 2015 |
HEDIS 2016 |
HEDIS 2017 |
Medicare Star Benchmarks |
| |
(MY 2014) |
(MY 2015) |
(MY 2016) |
50th Percentile |
75th Percentile |
90th Percentile |
| Medicare |
* |
36 |
65 |
51 |
59 |
75 |
| FIDA |
* |
41 |
57 |
51 |
59 |
75 |
*: Not available/Not reported.
Care of Older Adults (COA)
Healthcare needs change with age. It is therefore important that older adults get health checkups that will help their providers track health concerns and provide guidance for conditions related to aging. Members should have a review of their medications and get a functional status and pain assessment conducted by a provider at least annually. For a medication review a provider reviews a list of all medications (prescriptions, OTC, vitamins, herbal remedies, etc.) a member is taking to help them understand how and when to take them, find potential drug-drug interactions, and discuss the possible side effects. For functional status assessment, a provider assesses a member’s activities of daily living (ADL) such as ability to eat, dress and bathe oneself. Providers also check members’ cognitive status, sensory abilities and other areas such as ability to shop for groceries and drive. Providers also ask members about any pain they may be experiencing. MetroPlus outreaches to members about upcoming plan-hosted events where members can receive a medication review, functional status assessment and pain assessment. MetroPlus also utilizes in-home providers to conduct home visits to complete this assessment. In addition, targeted outbound calls are conducted by MetroPlus staff to provide these services. The overarching goals of these activities are to educate members on how to proactively address these issues with their providers and simultaneously help providers track and monitor members who present concerns in these areas. The table below captures medication reviews conducted, functional status assessment and pain screening.
| CARE OF OLDER ADULTS |
| |
HEDIS 2015 |
HEDIS 2016 |
HEDIS 2017 |
QARR 2016 / Medicare Star Benchmarks |
| |
(MY 2014) |
(MY 2015) |
(MY 2016) |
50th Percentile |
70th Percentile |
90th Percentile |
| Medicare |
| Functional Status Assessment |
38 |
70 |
92 |
67 |
78 |
92 |
| Pain Screening |
90 |
91 |
91 |
62 |
80 |
94 |
| Medication Review |
89 |
90 |
91 |
79 |
88 |
93 |
| FIDA |
| Functional Status Assessment |
* |
65 |
91 |
67 |
78 |
92 |
| Pain Screening |
* |
83 |
90 |
62 |
80 |
94 |
| Medication Review |
* |
66 |
89 |
79 |
88 |
93 |
*: Not available/Not reported.
Service Initiatives
At every point of contact, MetroPlus strives to improve the customer experience.
MetroPlus knows that a good experience with customer service is very important to members. As part of continually improving this experience, the following are accomplishments in 2017:
Customer Services
One of the plan’s main objectives is to improve access and quality of services for our members. Customer Services is responsible for assigning Primary Care Providers (PCP) and assisting members with scheduling first time and specialty appointments. Our outbound Customer Service teams outreach all new members within their first 30 days of enrollment to members of the importance of scheduling an appointment with their PCP.
- Call Center Redesign: We are restructuring the Call Center so dedicated staff will now handle that member and provider calls. The restructuring will help expedite handling of calls. We are in the last stages of finalizing this redesign and expect to implement in early 2018.
Virtual Hold Technology (VHT): VHT implemented in 2017. This option gives our callers a choice to select a call back without losing their place
Customer satisfaction and quality of service are of the upmost importance for MetroPlus. To measure caller satisfaction and improve the quality and efficiency of our calls we provided our callers with the option of taking a brief survey at the end of each call. The majority of callers surveyed (98%) are very satisfied with the services and how the call was handled.
On behalf of all of us, we would like to say thank you for being a part of MetroPlus Health Plan. Remember we will be here to answer any questions you might have and to help you get the health care that’s right for you.
For Medicaid
Contact our Customer Services Department at 1.800.303.9626 (TTY: 711), Monday to Saturday, from 8:00 AM to 8:00 PM
For Medicare
Please call our Customer Services Department at 1.866.986.0356, Monday through Saturday from 8:00 AM to 8:00 PM. After 8:00 PM
For Qualified Health Plan (QHP) members, please call our Customer Services Department at 855-809-4073 Monday through Saturday from 8:00 AM to 8:00 PM
Sundays and Holidays you may contact our 24/7 Medical Answering Service at 1.800.442.2560.