ADDING VALUE. Efforts to Control Costs, Improve Quality, and Drive Innovation annual report

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1 2012 annual report ADDING VALUE Efforts to Control Costs, Improve Quality, and Drive Innovation The Nation s Best Health Plans Working for Affordable Care

2 table of contents where does the premium dollar go? 2 where do massachusetts residents get care? 3 who s making money? 4 the country s best health plans: right here in massachusetts 6 what are mahp member plans doing to add value? 7 harvard pilgrim health care 8 tufts health plan 10 neighborhood health plan 12 bmc healthnet plan 14 network health 16 fallon community health plan 18 health new england 20 unicare 22 unitedhealthcare 24 celticare health plan of massachusetts 26 senior whole health 28 unitedhealthcare community and state, massachusetts health plan 30 targeting health care cost control 32 the myths and facts about health plans 34 highlights from mahp s annual health policy conference 35 about mahp 36 mahp board of directors and staff 37

3 dear friends: The past year had a profound impact on the future of the health care system. The June 2012 decision by the U.S. Supreme Court and the reelection of President Obama along with a Democratic majority in the U.S. Senate cleared the way for implementation of the Affordable Care Act and universal access to health care for citizens across the nation. Meanwhile, Massachusetts took another important step in ensuring that our achievements around access are sustained by addressing the long-term affordability of health care with the passage of the landmark payment reform law (Chapter 224 of the Acts of 2012). Chapter 224 encourages a transition away from the current fee-for-service system, which emphasizes volume over value, to a system that rewards high-quality and costeffective health care and includes a number of important tools to make health care more affordable. Among them: a system-wide target for health care spending; greater transparency around costs; annual cost hearings; and statewide planning of health resources. The law recognizes that cost control is a shared responsibility. No single part of the health care sector can be made solely responsible for containing costs. Instead, we all have a role in improving the quality of health care and making it more affordable. MAHP member health plans have been pioneers in efforts to control costs, improve quality, and drive innovation, and this year s annual report, Adding Value, highlights our members contributions to the health care system. Yet how you define value depends on who you ask. For employers, it may mean having a broad range of options to help them manage their health care costs. For consumers, it may mean having a choice of providers and coverage offerings that best meet their needs, while also having the tools to engage them in their care. For physicians, hospitals, and other providers, it may mean having the necessary supports to help them as they start to change how they deliver care under new payment methods. Our member health plans recognize these differences and have been leading efforts in transforming the health care system. One of the reasons MAHP member health plans are routinely rated the country s best for quality and member satisfaction is that they have been developing new and innovative programs to improve quality and lower costs. While the approaches each takes may vary, the goal is the same: to promote measures that make health care better, more affordable, and easier to understand. The following pages provide examples of the innovative approaches MAHP members already are taking to meet the state s cost containment targets and to fulfill the vision of Chapter 224, established by Governor Patrick, Senate President Murray, House Speaker DeLeo, Chairmen Moore and Walsh, and the entire legislature, of a health care system that rewards value over volume. We hope you enjoy reading this year s annual report and discovering how MAHP member health plans are making the promise of payment reform a reality. Sincerely, lora m. pellegrini President & CEO mahp 2012 Annual Report 1

4 where does the premium dollar go? Any serious discussion about keeping health care affordable needs to start with what we pay for medical care and why it costs so much, because an increasing portion of the premium dollar is directed to medical care, such as doctor visits, diagnostic tests, prescription drugs, and hospital stays. Beginning in 2012, Massachusetts required that a minimum of 90 percent of the premium dollar must be spent on medical care in the small and non-group markets, requiring that any amount below that level be returned to individuals and small businesses. This is the most stringent standard in the nation and well above the 80 percent level in the Affordable Care Act. Additionally, state law restricts the amount of funds that may be allocated to administrative expenses and limits health plan profits to no more than 1.9 percent in the small and non-group markets. Further, health plans must provide rebates to employers and consumers if the percentage of the premium spent on medical care does not meet state minimum standards. The charts below provide a snapshot of where the premium dollar is spent by all insured business (nongroup, small group, and medium and large companies). massachusetts health plans: the nation s most efficient health plan revenues and expenses Medical Costs 88.99% Administrative Costs 10.06% Surplus 0.94% Medical Costs 90.90% Administrative Costs 9.73% Surplus -0.63% Medical Costs 89.79% Administrative Costs 9.74% Surplus 0.47% Medical Costs 87.79% Administrative Costs 10.07% Surplus 2.18% source: Data is based on statements filed by plans with the MA Division of Insurance for the five Massachusetts-based MAHP member commercial health plans. Due to rounding, the percentages may not add up to 100%. 2 mahp 2012 Annual Report

5 where do massachusetts residents get care? The high concentration of physicians in academic medical centers compared to national averages is one of the major drivers of premium increases over the last several years. According to 2010 state reports, admissions to academic medical centers are more than double the national average, and a higher proportion of outpatient care in Massachusetts is delivered in academic medical centers when compared with the rest of the U.S. admissions to academic medical centers: 19% national average 45% massachusetts source: Commonwealth of Massachusetts, Division of Health Care Finance and Policy, Cost Trends Final Report, According to a November 2012 report by the Commonwealth s Center for Health Information and Analysis, payments from commercial payers were more concentrated in higher-priced acute hospitals and physician groups, and higherpriced providers accounted for about four out of every five dollars paid. The Center s analysis mirrored similar findings by the state s former Division of Health Care Finance and the Office of the Attorney General. hospitals with higher relative prices tended to be academic medical centers, teaching hospitals, specialty hospitals, and geographically isolated hospitals. a majority of the hospitals that had lower relative prices were disproportionate share hospitals. higher-priced hospitals and physician groups all other hospitals and physician groups source: Commonwealth of Massachusetts, Center for Health Information and Analysis, Health Care Provider Price Variation in the Massachusetts Commercial Market, November mahp 2012 Annual Report 3

6 who s making money? Making health care affordable starts with understanding where the health care dollar goes and where care is delivered. Roughly 80 percent of the money spent on doctors and hospitals goes to higher-priced providers, with admissions to academic medical centers in Massachusetts more than double the national average. The following charts provide a snapshot of where the health care dollar goes, comparing the profit margins that hospitals report with the margins of MAHP member health plans and other health plans in the state. However, profit margins tell only part of the story. In addition to the country s most stringent requirements on the level of how the premium dollar is spent, the Commonwealth requires health plans to report a significant amount of financial, membership, and utilization data. To increase transparency around the 2011 total margins: top 10 teaching hospitals lahey clinic mount auburn hospital 7.90% massachusetts general hospital 7.40% 8.60% massachusetts eye and ear infirmary 7.30% berkshire medical center 6.20% children s hospital boston 6.10% brigham and women s hospital 5.20% beth israel deaconess medical center 4.50% baystate medical center 3.50% umass memorial medical center 3.10% 4 mahp 2012 Annual Report

7 true cost of health care and to provide a more complete picture of how the health care dollar is spent, hospitals should be subject to similar reporting requirements, including providing information on operating margin by payer. This will allow for greater transparency around the costs associated with various populations and payer types, as well as differentials between commercial, state, and federal programs as it relates to cost shifting. Further, hospitals that report an operating margin in excess of 5 percent would be subject to a public hearing held by the Center for Health Information and Analysis on the continued need for the surplus, on the impact of the surplus on the organization s ability to meet the state s cost growth benchmark, and on how it will dedicate any portion of that surplus to reduce the cost of health care coverage, improve patient safety, and make quality improvement efforts total margins: top 10 community hospitals 2011 total margins: massachuestts health plans sturdy memorial hospital falmouth hospital 9.20% 9.70% unitedhealthcare of ne 7.21% fallon community health plan 3.41% steward saint anne s hospital 7.70% harvard pilgrim health care 3.17% cape cod hospital 7.60% tufts health plan 3.06% signature healthcare brockton hospital 7.30% harrington memorial hospital 7.20% hallmark health 7.00% milford regional medical center 5.90% fairview hospital % health new england 2.19% blue cross blue shield of ma 2.14% neighborhood health plan 0.31% celticare health plan of massachusetts network health 5.70% % health alliance hospital 5.50% sources: Health Plan Data: Mark Farrah Associates, Massachusetts Health Plan Report Enrollment Trends & Financial Performance, May Hospital Data: Commonwealth of Massachusetts, Center for Health Information and Analysis, Massachusetts Acute Hospital Financial Performance Fiscal Year 2011, August mahp 2012 Annual Report 5

8 the country s best health plans: right here in massachusetts In its annual report card ranking the quality and member satisfaction of health plans, the National Committee for Quality Assurance (NCQA) recognized the high performance of Massachusetts commercial and Medicaid health plans. The rankings were based on data evaluating 538 private health plans, ranking 474 of those based on clinical performance, member satisfaction, and NCQA accreditation. Additionally, NCQA evaluated over 200 Medicaid health plans and ranked 115 of those based on the same criteria. in 2012, massachusetts was again home to the country s top health plans with the #1 hmo, ppo, and medicaid plans. rated hmo rated ppo rated medicaid plan, as well as four of the country s top 10 medicaid health plans 6 mahp 2012 Annual Report

9 what are mahp member plans doing to add value to the health care system for employers, consumers, and providers? mahp 2012 Annual Report 7

10 Trevor Singleton Assistant Vice President Global Benefits & Wellness, John Hancock harvard pilgrim health care: john hancock wellness partnership 8 mahp 2012 Annual Report

11 For more than a decade, Harvard Pilgrim Health Care and John Hancock have been engaged in a strategic partnership aimed at improving the health and wellbeing of the John Hancock employee population while stemming the tide of rising health care costs. At the heart of the partnership is a multidisciplinary team of senior John Hancock and Harvard Pilgrim staff with expertise in human resources/benefits management, medical management, health education, member and account services, communication, technology, and health reporting and data analysis. Their aim is to identify and address health care cost drivers, medical management needs, and health education gaps specific to the John Hancock employee population through a variety of targeted programs that generate results. We re continually looking for ways to provide even greater value, identify new opportunities based on data analysis, cultivate full engagement, and ensure Harvard Pilgrim s efforts are tightly aligned with John Hancock s overall strategic goals, says Michael Sherman, M.D., Harvard Pilgrim s Chief Medical Officer. According to Trevor Singleton, John Hancock s Assistant Vice President, Global Benefits & Wellness, the collaboration with Harvard Pilgrim has been a key element in the success of HealthMatters, a comprehensive initiative through which the company aims to improve, encourage, and promote employee health and productivity. For example, Harvard Pilgrim offers Healthy Returns, a program that includes convenient, quarterly on-site biometric screenings for John Hancock employees working in Massachusetts and New Hampshire. The biometric data collection focuses on key health risk indicators related to lifestyle-driven chronic conditions weight, body mass index, blood pressure, cholesterol level, and smoking status. Participants in the screening sessions can establish health improvement goals, and earn financial incentives for participating in Harvard Pilgrim s lifestyle education/ personal health coaching and for attaining their goals. John Hancock offers employees a Stay Fit reimbursement in addition to Harvard Pilgrim s member fitness benefit, so employees incur little or no cost for classes, programs, based on the four healthy returns on-site events that occurred in 2012, harvard pilgrim and john hancock report: 38% participation and memberships that help them meet their goals. We believe that the most effective way to control health care costs is by building health awareness, helping employees manage their health, and keeping them out of the health care system, rather than cost-shifting and benefit reduction, Singleton says. Avoiding the need for care related to lifestyle-driven illnesses has helped reduce our costs, but it requires employee education, awareness, engagement, and behavior change. The partnership with Harvard Pilgrim has been a critical component of the strong results achieved through HealthMatters and it s helped keep wellness front and center for employees. Singleton listed some of the most valuable lessons from Hancock s commitment to HealthMatters and its decadelong partnership with Harvard Pilgrim. Don t try to go it alone; collaborate with other public and private stakeholders. Be clear about the cost drivers and lifestyle issues that are priorities. Track key metrics such as participation levels, goal attainment, and clinical outcomes in aggregate. Drop what doesn t work and improve what does, try new ideas. Establish strong branding, consistent communications, and visible leadership support. Tap into your culture John Hancock drives engagement through friendly competition and by linking wellness to community involvement. Integrate your wellness strategy with your benefit design strategy to get people thinking about controlling their health and their health care costs. 52% of participants sustained engagement for multiple sessions 51% lost weight: 2,439 lbs. total 78% lowered blood pressure 87% improved cholesterol levels Singleton stresses that John Hancock is not operating on intuition; its programs are evidence-based and data-driven. Harvard Pilgrim developed a Value of Wellness tool to measure the financial impact of Healthy Returns and calculated that between 2010 and 2012, participants annual costs averaged $190 less than those of their nonparticipant peers, saving more than $150,000. Overall, John Hancock invests about one percent of its health care spending in its broader HealthMatters strategy, Singleton says, and calculates its aggregate return on investment at a very healthy 3 to 1. mahp 2012 Annual Report 9

12 Barbara Tripp Vice President of Human Resources, BayCoast Bank tufts health plan: behind the care - innovative approaches to wellness 10 mahp 2012 Annual Report

13 Tufts Health Plan s comprehensive approach to workplace wellness is built on a strong foundation of data and analysis, as well as thoughtful planning, ongoing measurement, and plenty of support. It is definitely not one-size-fits-all. According to Chief Medical Officer Paul Kasuba, M.D., Tufts Health Plan has collaborated with more than 200 of its clients, and a common ingredient for success is understanding each employer s goals and expectations. We initially try to make sure that senior management and human resources understand the value of creating a culture of wellness and a healthy workforce. Then we get to know the company and its employees so we can assess where they are on the continuum of commitment and readiness, he says. A case in point is BayCoast Bank. Says Vice President of Human Resources Barbara Tripp, We understand the importance of encouraging wellness in our organization to not only help lower our health care costs, but also benefit from a more energized and productive workforce. Our wellness strategy focuses on what we can do to help our employees live a healthier lifestyle. To get started, BayCoast Bank formed a Wellness Committee made up of employees from throughout the organization. Tufts Health Plan advised us to keep it simple at the beginning, so we decided to begin with a walking program, Tripp says. They provided us with pedometers and ideas on how to encourage employees, and now it is an annual event with more than half of our employees participating each year. And once you see the enthusiasm build for your first program, it s easy to take on the next challenge in other areas where you want to promote wellness. With Tufts Health Plan, the process for determining what the next wellness challenge should be is focused not on individual programs but on the needs of the company and its employees. We take a broad-based, integrated approach to health and wellness, Kasuba says. We make sure we understand our clients risk concerns and help them apply whatever approach will reduce those risks. The options range from coupons and other simple incentives that get employees engaged, to online tools and health coaching, to intensive care management. The programs are closely coordinated, and, Kasuba adds, Tufts Health Plan continuously develops and integrates new initiatives, based on evolving industry standards and evidence of clinical value. Tufts Health Plan recently became the first health plan in the Northeast and one of only 20 organizations in the U.S. to receive the Wellness & Health Promotion Accreditation from the National Committee for Quality Assurance (NCQA). The accreditation is based on a rigorous assessment of how well an organization implements wellness programs in the workplace, provides services such as coaching to help participants develop skills needed to make healthy choices, and properly safeguards individual health information. With its commitment to workplace wellness firmly established, BayCoast Bank is now participating in a pilot program that is aimed at reducing future premium costs. Tufts Health Plan provided us with an online Personal Health Assessment for our employees to complete. They also provided screeners who met with employees to determine their biometric measures, Tripp explains. To complete the program, employees will also participate in an online healthy living or health coaching program. Tufts Health Plan provided us with an online Personal Health Assessment... {and} screeners who met with employees... - Barbara Tripp To make it easier for employees to meet their health and wellness goals, BayCoast Bank has established a gym facility at its Operations Center and offers fitness classes with a personal trainer, as well as weekly yoga and Zumba classes. The company has also given its employees the opportunity to participate in WeightWatchers at Work and a smoking cessation program that was provided by Tufts Health Plan. While it is too early to measure results, Tripp says there is a clear sense that a culture of wellness is taking hold. Employees are enthusiastic, and it is apparent that investing in employees health has improved morale, she reveals. The first success story I heard concerned an employee who enrolled in our WeightWatchers at Work program. She had been taking multiple blood pressure medications for a number of years. After several months of losing weight, she told me she was off every medication. I remember thinking to myself that this is exactly what we are trying to accomplish! mahp 2012 Annual Report 11

14 Sylvia Ferrell-Jones President & CEO, YWCA Boston neighborhood health plan: mammography communications campaign 12 mahp 2012 Annual Report

15 With the principles of health equity and affordable care embedded in its mission, Neighborhood Health Plan (NHP) has made an exceptional commitment to addressing the root causes of health disparities. In recent years, for example, NHP has led a highly successful campaign to reduce the disproportionate breast cancer risks faced by African American women in some Boston neighborhoods. The goals of the campaign are to encourage African American women 40 years of age and older to get an annual mammogram and to educate them about the importance of mammography screening as a critical first step in the early detection and treatment of breast cancer. Pam Siren, NHP s Vice President of Quality and Compliance, explains that a key to determining the focus of the campaign was the health plan s close, longstanding relationship with the state s community health centers. Federally qualified health centers are required to collect data on health disparities, and about 65 percent of our Boston members get their care at health centers, she says. When we matched their clinical and demographic data with our claims-based quality measures, we found significant disparities in mammography screening among African American women, especially in Boston s Roxbury, Dorchester, and Mattapan neighborhoods. The NHP breast health campaign was designed to reach as many women in the target population as possible through a diverse and integrated mix of media and communication opportunities. Using media that includes brochures, posters, advertisements, and presentations, NHP has spread the message at community health centers, churches, hair and nail salons, transit stations, bus stops, and health fairs, as well as through its website. Two key partners in the campaign are Dana-Farber Cancer Institute and YWCA Boston. Founded in 1866 as the nation s first YWCA, the Boston nonprofit is no longer a facilities-based organization. Rather, its focus is on community outreach and education, and its initiatives reach an estimated 3,000 Boston residents each year. Part of our mission is to reduce the health disparities that affect the well-being of so many lowerincome women and women of color, says YWCA Boston President and Chief Executive Officer Sylvia Ferrell- Jones. Neighborhood Health Plan is a wonderful partner in this effort. Each year, NHP and YWCA Boston team up for a phone-a-thon during which employee volunteers from the two organizations connect with local women in their native language, educating them on the importance of breast health and exams, answering questions, and providing details about mammography and screenings. The callers can also arrange for screening appointments as Dana-Farber s mammography van makes the rounds of community health centers throughout the city. In another example of the three-way collaboration, YWCA Boston s health educators have been integrated into the van program. NHP provides its call center facilities and equipment for the evening calls, and YWCA Boston supplies training and protocols to maximize the effectiveness of each call. Both organizations draw upon their databases for names and phone numbers NHP identifies its members in the target communities who have had a lapse in Part of our mission is to reduce the health disparities that affect the well-being of so many lower-income women and women of color. - Sylvia Ferrell-Jones recommended screenings for two or more years, and YWCA Boston draws from its lists of women who have used their services. The calls are a very effective way to overcome fears and misinformation about mammography, says NHP s Siren. Many women don t know that mammography screening is fully covered by their insurance and that they don t need a referral. At the same time, some women don t have, or don t know they have, a primary care provider we can send the results to, so we need to follow up and make that connection. In addition, NHP sends reminder cards to its members who are due for a mammography and notifies members doctors when there has been a lapse in recommended screenings. NHP s data shows that the program is working, Siren reports. With three years of targeted interventions in Roxbury, Mattapan, and Dorchester, we and our community partners have been able to bring mammography screening rates among black/african American women up to the same levels as their white counterparts. mahp 2012 Annual Report 13

16 Karen Boudreau, M.D. Chief Medical Officer, BMC HealthNet Plan bmc healthnet plan: transition to home program 14 mahp 2012 Annual Report

17 One of the biggest challenges facing the health care system is to help people with multiple chronic conditions stay out of the hospital. Costs, quality, and patient safety are all at stake. BMC HealthNet Plan has made significant headway in addressing this complex issue, says Chief Medical Officer Karen Boudreau, M.D. We developed a Transition to Home (TTH) program that provides members with a variety of medical, behavioral health, and social services during the weeks and months after they have been discharged from a hospital stay, when the risk of readmission is especially high. A hypothetical case illustrates how the goals of the Transition to Home program are achieved. Jane is a 50-year-old BMC HealthNet Plan member who has been hospitalized for treatment of COPD and uncontrolled diabetes. Her diagnoses indicate she is at high risk for readmission, so she is designated for outreach by the TTH team. Cheryl Laneve, RN, is one of the three nurses and three coordinators who manage active TTH cases. Based in Springfield, she makes between 20 and 25 calls per day to members who are either eligible for or participating in the TTH program. post-discharge assessment and review of hospital discharge instructions Jane agrees to talk with Cheryl by phone, and since English is not Jane s primary language, an interpreter joins the call. Cheryl conducts an in-depth assessment of Jane s current situation, and learns that Jane is obese, is a heavy smoker, and has trouble walking. Her discharge instructions from the hospital recommended an appointment with her primary care provider in two weeks, monitoring of her blood sugar levels, daily use of an inhaler, and resumption of her medications. However, Jane s glucose meter is broken and, at this point, she is not taking her medications. She has not scheduled her followup appointment, in part because she does not drive and has no family support to help with transportation. She has not had regular eye or foot exams as recommended for people with diabetes, and she does not know why she should. education and agreement on a care plan Cheryl counsels Jane about the importance of taking her medications and explains the need for blood sugar monitoring. Jane agrees to have a new glucose meter and testing supplies delivered to her home. She also agrees to have a VNA nurse make a home visit to evaluate her mobility problems and her medication compliance. In addition, educational information on COPD, diabetes, smoking cessation, and weight loss programs will be mailed to Jane in her native language. Told that free transportation is available from MassHealth, Jane agrees to make a follow-up appointment with her doctor. coordination of care Cheryl orders a glucose meter and other supplies and asks the vendor s representative to instruct Jane on how to use them. She calls Jane s doctor s office to confirm that an appointment has been scheduled and confirms that Early results...showed a reduction in readmissions during a nine-month period...with annualized savings of $1.1 million. - Karen Boudreau, M.D. free transportation has been arranged. She also confirms that the doctor s office has arranged for Jane s VNA visit and evaluation. A nurse and physical therapist conduct the evaluation and show Jane how to use her inhaler and pill organizer, and they report to Cheryl that Jane would benefit from a walker. During their second weekly call, Jane confirms that she has received her new glucose meter and knows how to use it. Her blood sugar levels are elevated, so Cheryl recommends that she bring the discharge plans written by the hospital, a list of her current medications, and a list of any concerns or questions she has to her doctor s appointment. self-management of chronic conditions In subsequent calls, Jane reports that she is getting around better with the help of her new walker. Her blood sugar levels improved after her doctor adjusted her insulin doses. She has scheduled another appointment with her doctor, along with eye and foot exams. She is not yet ready to quit smoking or start a weight loss regimen, but she is being more careful about what she eats. After six weeks, Jane has completed the Transition to Home program without being readmitted to the hospital. She has what she needs to comply with her care plan, and she understands what she can do to maintain her own health. According to Dr. Boudreau, Early results from Transition to Home showed a reduction in readmissions during a nine-month period, from a baseline readmission rate of 18.5% to an intervention readmission rate of 16.9%, with annualized savings of $1.1 million. mahp 2012 Annual Report 15

18 Julie Gutowski Member, Network Health network health: integrated care management 16 mahp 2012 Annual Report

19 Shortly after Julie Gutowski and her husband joined Network Health in the spring of 2012, she received a phone call that both surprised and delighted her. It was Ann Mutharia, calling on behalf of Network Health, to ask simply, How can we help you? Julie has lived for many years with severe chronic conditions that put her at high risk for a medical crisis and hospitalization. Her ongoing treatment includes oxygen therapy and multiple medications, and her mobility is limited. Today, with assistance from Network Health s Integrated Care Management program, Julie has gained far more control over her health, and she could not be more grateful. Network Health s Integrated Care Management program offers members like Julie an innovative, multidisciplinary approach to managing complex care issues by bringing together a team of nurses, social workers, community health workers, and behavioral health clinicians to holistically evaluate members care needs and develop customized care plans. Julie says her care has been enhanced both through her phone contact with Ann and from visits by a Network Health Integrated Care Management nurse. He suggested a way I might be able to use my inhaler more effectively. Then he contacted my PCP, and I was using it within 24 hours, she says. And after seeing how I lived, he came up with more ideas to help and passed all this information back to Ann, who continued to follow up and monitor my progress. I can t say enough about how wonderful and knowledgeable they are. Jean O Malley, Network Health s Director of Integrated Care Management, says that, at any one time, 1,200 to 1,400 Network Health members are involved in some level of Integrated Care Management, with the degree of involvement based on an assessment of each patient s situation and needs. The health plan has developed a predictive tool that helps identify members who could significantly benefit from engagement with a Network Health clinical community outreach coordinator, care manager, or complex care manager. Once these members are identified, the Integrated Care Management team is available to talk with them about their overall care needs, determine whether they have a PCP they like and are seeing regularly, and connect them with support services in their local communities, including transportation. In addition, the team makes every effort to ensure that members understand their benefits and know how and where to get appropriate care when different needs arise. Increasing engagement among our high-risk members has notably decreased overall admissions, medical readmissions, and emergency department utilization, O Malley says, and based on feedback we receive from members, we ve also been able to enhance the member experience. That has certainly been the case for Julie. My attitude toward life is, Don t worry about your problem, find the solution. So when I leave the house, I put my oxygen tank in a backpack, looking more like a Ninja Turtle, but it means I can get around better. And that s how Network Health operates; they adapt to whatever your needs are. Network Health members or their families can request the services of the Integrated Care Management team, or be connected through a variety of referral sources primary care providers, hospital clinicians, discharge planners, home care nurses, social service providers, and others. They probably contacted me because they saw how many medical issues I have and they wanted to help me stay out of the hospital, Julie says, but it s not just financial. What really comes through is how caring and professional they are. They offer me the full package and I feel very well looked after. the network health integrated care management program seeks out potential candidates through a monthly review of data on members use of the health care system. for example: Emergency Department use: Members who are frequent ED users are contacted to find out if they have a primary care physician and whether they tried to get an appointment before seeking emergency care. High-cost cases: Members who incur very high, ongoing medical costs are automatically enrolled in case management, although they can opt out. The Integrated Care Management team conducts an extensive assessment of how well the member s needs are being met, both at home and within the health care system, and can provide or arrange for a broad spectrum of coordinated care services, as well as help with self-management. Members at risk: Factors considered include the lack of a primary care provider, frequent ED use, or failure to schedule appropriate preventive screenings. The team seeks out members who don t have, or don t know they have, a PCP; educates them on the role of the PCP; and helps connect them with their PCP, as well as with benefits and programs that can improve their health and well-being. mahp 2012 Annual Report 17

20 fallon community health plan: city of worcester advantage plans 18 mahp 2012 Annual Report

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