Quality Management Program

Quality Management Program Description

2018 Summary
MetroPlus’ mission is to provide a caring, high quality customer experience to preserve and improve the health and lives of New Yorkers with our integrated healthcare system. Our vision is to be the number one plan of choice for the communities we serve. This is accomplished by partnering with 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, 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.
  • Social Determinants (SoDs) of Health:  The Plan works with members to ensure their food security, housing, socialization, etc. by partnering with community-based organizations and city and state agencies designed to alleviate SoDs.
  • 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 one of the highest “quality measures” score in the state 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 2018 and will continue in 2019:

MetroPlus’ high quality score awarded by the New York State Department of Health reflects the high quality of care we provide to our Medicaid recipients every day. The areas where MetroPlus scored particularly high include childhood immunization status with lead screening, immunizations for adolescents, weight assessment counseling for children/adolescents, well child visits, colorectal cancer screening, breast cancer screening, statin therapy for patients with cardiovascular disease and controlling high blood pressure. These results reflect the investment MetroPlus makes in keeping its members healthy. The MetroPlus staff works closely with members & providers throughout the year to ensure that members get the care they need.  This includes reminder notices and arranging for doctors’ appointments, conducting community events, and helping members adhere to their medication schedules to improve their health.
  • MetroPlus Member Rewards Program is now finishing its second year and 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 completing a healthy activity. Over 13,500 members have participated in the Step-Up Challenge and have taken over 622,688,885 steps towards better health.  In 2018, there were 26 healthy activities for members to earn rewards for. Members can register anytime at metroplusrewards.org and start earning points immediately.
  • MetroPlus 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! In 2018, we also used text messaging to gauge our members satisfaction with MetroPlus.
  • Community Events: MetroPlus partners with NYC Health and Hospital facilities, vendors, community organizations to plan and organize events to provide needed health services such as dental screenings, flu shots, mammograms, well child/adolescent visits, diabetic eye screenings to members in convenient and accessible locations.  During 2018, MetroPlus sponsored over 60 community events throughout New York City.
  • Health Education: MetroPlus works closely with our members and their providers to ensure appropriate, high-quality care is provided. We educate providers and members on different aspects of health and wellness (clinical guidelines, prevention and screenings, disease management, quality measures, etc.) through various media (direct mailings, website, provider/member portals, social media, texting, public health advertisements, events, posters, webinars, workshops, site visits, telephonic and face-to-face encounters, etc.).  MetroPlus also supports members with chronic disease, such as Asthma, COPD and Diabetes. We provide our members nurse coaching calls. Our nurses work with our members to provide education, help members decide when & how to see providers and seek services such as classes and peer support programs to help them live the healthiest life possible.
  • Pharmacy: The 90-day fill program is available for all maintenance, chronic medications. These are medications you will be taking every day for an extended period to stay healthy. There are many benefits to filling a medication prescription for 90 days at a time.  Members who have a 90 day supply of medication tend to not run out of medication or experience delays in trying to refill.  That means members take their medication more! You may also be eligible for a discounted copay! Talk to your doctor or pharmacist about receiving a 90 day fill for your maintenance medications.
  • Integrated Care Management (ICM) Program: The Integrated Care Management Program provides services to members that have complex health conditions and need care management to improve health outcomes. ICM uses Registered Nurses, Licensed Practical Nurses and Licensed Social Workers, to identify and assess the physical, behavioral, cognitive, functional and social needs of members for care management services. A professional nurse or social worker will help members with transportation to medical appointments, getting medications ordered by their provider and help getting services they may need like food and other support to stay as healthy as possible.                                                                      
  • Transition of Care (TOC) Program:  This program helps members that were in the hospital get back on their feet when they return home.  Our health professionals will conduct home visits to help members get the services they need to remain healthy and avoid having to go back to the hospital. Part of this program may include home delivered meals for those members that are not able to get or prepare meals right after being discharged from the hospital. This is an extra benefit offered to make sure members have their basic needs met so they can focus on getting healthy.
  • Housing Placement: This program is for members that are at risk of losing their home or do not have a place to live. A group of specialized professionals will visit members where they are and work with other organizations in the community to help them obtain housing. With the shortage of housing in our city and the many steps that need to be taken to get housing, members in housing crisis can benefit from having our team on their side. If you have any questions, please call our Care Management Department at 1.800.579.9798, Monday through Saturday, from 9:00 AM to 5:00 PM.
MetroPlus has over 120 Urgent Care Centers in our service area to further assist our members with access to urgent care.  In 2018, we added CityMD one of the largest urgent care providers in the NYC area.  Giving members access to quality care when they need it is a MetroPlus priority. MetroPlus has employed multiple strategies to ensure that our provider directory is as accurate as possible.  The Plan is consistently auditing and educating providers to notify the plan of any changes in address, telephone number or demographics important to our members.  

Clinical and Service Initiatives
The 2018 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.
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 are as follows:
Annual Dental Visit
Annual visits to the dentist are recommended for children to promote healthy oral hygiene and to prevent tooth decay and gum disease.  Oftentimes, MetroPlus members do not realize they have covered dental benefits or may not have detailed knowledge of what their dental benefits include.  Another issue may be a lack of access to convenient dental providers or awareness of where dental providers are located.  To resolve some of these barriers to dental care, MetroPlus works with its dental partner, HealthPlex, to provide education and outreach to members through mailings, calls, text messages, and website/social media postings. In 2018 we had 1,996 dental screenings in communities where our members live making it as convenient as possible for MetroPlus children and adolescents to have a dental screening. The MetroPlus Member Rewards Program (metroplusrewards.org) offers points for completed dental screenings which can be redeemed for prizes.
  HEDIS 2016 HEDIS 2017 HEDIS 2018 NYS QARR 2017
  (MY 2015) (MY 2016) (MY 2017) 50th Percentile 75th Percentile 90th Percentile
MEDICAID 60 62 62 62 67 69
Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life
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 good 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 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 are offered to members who complete their well visits through the MetroPlus Member 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.
Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents 
MetroPlus encourages children and adolescents to have an annual well-visit.  During these visits, providers assess body mass index (BMI) and counsel members regarding physical activity and nutrition. MetroPlus also promotes healthy BMI through education about the importance of regular exercise and diet.  Health education provided by text and posted to online newsletter and website/social media to reach our busy members who are always on the go.  Member Reward points can be earned for completing a well-visit.  MetroPlus partners with our providers to conduct community events for convenient access to health screenings for children and adolescents. The table below shows rates of members receiving BMI assessment and counseling for nutrition and physical activity.
  HEDIS 2016 HEDIS 2017 HEDIS 2018 NYS QARR 2017
  (MY 2015) (MY 2016) (MY 2017) 50th Percentile 75th Percentile 90th Percentile
Body Mass Index 62 73 86 83.70 91.30 93.67
Nutrition 80 73 80 84.67 90.28 92.21
Physical Activity 76 62 63 77.96 84.78 88.10
Body Mass Index 82 86 93 80.54 86.63 90.51
Nutrition 87 80 90 81.51 84.91 86.98
Physical Activity 78 69 78 71.78 79.77 80.90
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 member throughout the year to educate and help members address personal issues and barriers to care. Providers are notified of members who are overdue for diabetic screenings. Furthermore, incentives are offered to members who complete their comprehensive diabetes care through our MetroPlus Member Rewards Program (metroplusrewards.org). The table below captures the percentage of adults who completed comprehensive diabetes care, which includes hemoglobin A1c testing, A1c under control (<8), and diabetic retinal eye exam.
  HEDIS 2016 HEDIS 2017 HEDIS 2018 NYS QARR 2017
  (MY 2015) (MY 2016) (MY 2017) 50th Percentile 75th Percentile 90th Percentile
HbA1c Testing 95 94 95 91.31 91.71 93.37
HbA1c < 8 56 46 55 65.21 67.70 69.72
Eye Exam 46 47 57 60.80 63.99 65.74
HbA1c Testing 93 93 94 90.75 91.97 92.94
HbA1c < 8 60 51 59 55.07 57.42 61.07
Eye Exam 59 62 66 64.52 65.69 67.40
  (MY 2015) (MY 2016) (MY 2017) 3 STAR 4 STAR 5 STAR
HbA1c Testing 95 97 97 68 77 90
HbA1c < 8 97 97 96 87 95 97
Eye Exam 63 70 90 62 75 82
Controlling High Blood Pressure
MetroPlus endeavors to support members with a hypertension diagnosis in keeping their blood pressure in control.  Healthy lifestyle tips are disseminated through educational materials which are mailed, texted, and posted to online newsletter and website/social media to reach as many members as possible. Members can also earn reward points for drinking water and tracking their daily steps.  The reward points can be redeemed for prizes at www.metroplusrewards.org. Targeted coaching calls are made by a registered nurse to members with multiple chronic conditions, including hypertension.  For members’ convenience, 90-day prescriptions of anti-hypertensive medication are encouraged.  The table below indicates rates of members with blood pressure in control.
  HEDIS 2016 HEDIS 2017 HEDIS 2018 NYS QARR 2017
  (MY 2015) (MY 2016) (MY 2017) 50th Percentile 75th Percentile 90th Percentile
EXCHANGE 40 34 58 71.65 73.44 77.81
MEDICAID 61 60 72 62.84 65.21 70.80
  (MY 2015) (MY 2016) (MY 2017) 3 STAR 4 STAR 5 STAR
MEDICARE 72 76 90 62 75 82
Breast Cancer Screening (BCS)
Breast cancer is the second leading cause of cancer-related death 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 are offered to members who complete their breast cancer screening through the MetroPlus Member 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.
  HEDIS 2016 HEDIS 2017 HEDIS 2018 NYS QARR 2017
  (MY 2015) (MY 2016) (MY 2017) 50th Percentile 75th Percentile 90th Percentile
EXCHANGE 77 68 74 75.87 76.38 79.68
MEDICAID 73 73 74 68.04 70.80 73.10
  (MY 2015) (MY 2016) (MY 2017) 3 STAR 4 STAR 5 STAR
MEDICARE 84 83 82 68 76 82
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 are 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 on the member website. Providers are notified of members who are due for cervical cancer screening. The MetroPlus Member Rewards Program (metroplusrewards.org) provides incentives to members who complete their cervical cancer screening. The table below captures cervical cancer screening rates.
  HEDIS 2016 HEDIS 2017 HEDIS 2018 NYS QARR 2017
  (MY 2015) (MY 2016) (MY 2017) 50th Percentile 75th Percentile 90th Percentile
EXCHANGE 60 51 63 80.90 82.25 84.75
MEDICAID 70 77 74 71.63 75.99 77.87
Prenatal and Postpartum Care 
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. Women should also have follow-up care within 21 to 56 days after delivery where the health care provider will assess both physical and emotional health and discuss topics such as contraception and birth spacing.    

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, offers tips on having a healthy pregnancy, and postpartum care.  Educational materials and newsletters on the importance of prenatal visits for a healthy pregnancy are posted on the website. Providers are notified of pregnant members to ensure members complete their prenatal and postpartum visits. The MetroPlus Member Rewards Program (metroplusrewards.org) provides incentives to pregnant members for prenatal and postpartum visits completed. The table below captures postpartum care rates.
Prenatal and Postpartum Care 
  HEDIS 2016 HEDIS 2017 HEDIS 2018 NYS QARR 2017
  (MY 2015) (MY 2016) (MY 2017) 50th Percentile 75th Percentile 90th Percentile
Postpartum Care
59 64 69 89.08 90.04 90.57
Postpartum Care
75 74 71 68.86 72.25 73.72
Medication Therapy Management 
Medication Therapy Management 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 several chronic health conditions (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 with their 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.
  HEDIS 2016 HEDIS 2017 HEDIS 2018 Medicare Star Benchmarks
  (MY 2015) (MY 2016) (MY 2017) 3 Star 4 Star 5 Star
Medicare 36 65 80 51 59 75

Care of Older Adults 
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.
Medicare Star Benchmarks
  (MY 2015) (MY 2016) (MY 2017) 3 Star 4 Star 5 Star
Functional Status Assessment 70 92 94 68 77 90
Pain Screening 91 91 95 73 89 97
Medication Review  90 91 95 54 83 92
Service Initiatives
At every point of contact, MetroPlus strives to improve the customer experience.

MetroPlus knows that a good experience with customer services is very important to our members. As part of continually improving this experience, the following were accomplished in 2018:
  • We restructured the Customer Call Center so that dedicated staff now separately handle member and provider calls. This redesign minimizes the amount of time our members now have to wait to speak to us.
  • Our outbound Customer Service teams outreach all new members within their first 30 days of enrollment to help them schedule an appointment with their PCP and answer any questions they have about their health care benefits. 
  • We started an aftercall survey to measure caller satisfaction with their interaction with Customer Service. Majority of callers surveyed (98%) are very satisfied with how their call was handled.
For Medicaid
Contact our Customer Services Department at 1.800.303.9626, 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.

For Qualified Health Plan (QHP) members, please call our Customer Services Department at 1.855.809.4073 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.