Quality Management Program

MetroPlusHealth’s mission is to provide every New Yorker equitable access to quality health care. Our purpose goes beyond offering insurance. We take on the City’s most complex health challenges. Our work connects us to what every New Yorker needs. Our vision is to be the number one plan of choice for the communities we serve.

MetroPlusHealth’s Values:

• Real: Transparency and trust go hand in hand. MetroPlus focuses on the needs of our members first. Clear, comprehensive care is our top priority.
• Welcoming: MetroPlus treats every person with dignity. Race, religion, and cultural backgrounds should not impact someone’s health outcomes. Neither should gender expression, sexuality, citizenship, or economic standing.
• Diverse: MetroPlus embraces the differences and common values of all New Yorkers. Our doctors, health plans, community partnerships, and staff all reflect the City we serve.
• Focused: MetroPlus anticipates what tomorrow will bring. MetroPlus uses the latest research to design our plans and programs.
• Loyal: Good health is a journey, not a destination. MetroPlusHealth sticks with our members through it all. Our practical, research-based tools and programs bring out the best in everyone.

The goals and objectives of the Quality Management Program Description (QMP) are to support MetroPlus Health Plan in realizing its mission.  The QMP provides a framework and processes that will facilitate 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 is 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:

• Health Promotion
• Continuity and Coordination of Care
• Chronic Care Improvement Program (CCIP) for Medicare, MAP and SNP Members
• Quality Improvement Projects and Studies for Medicaid/CHP, HIV SNP, MLTC, Essential Plan, QHP, MAP and HARP members
• Care Management
• Pharmacy Management
• Behavioral Health
• Partnership in Care
• Quality of Care
• Quality of Service
• Patient Safety
• Utilization Management
• Member and Provider Satisfaction
• Provider Availability and Accessibility
• Delegation
• Member Complaints, Grievances, and Appeals
• Human Resources
• Social Determinants of Health
• Health Equity

Member Resource Support Tools:

The Plan’s website, Metroplus.org contains an array of support tools to assist members with understanding and managing their benefits and health care needs. The website is available in several languages, including, but not limited to, English, Spanish, Chinese, Hmong, Japanese, Korean, Punjabi, Russian, Tagalog, and Vietnamese. Tools include but are not limited to the following:

• On-line comprehensive Provider Search Directory.  Includes search capabilities to find a PCP, Specialist, Pharmacy, Dentist, Hospital, and a robust list of other Health Care Providers.  Searchable criteria include gender, location, zip code, languages, etc.
• Link to MetroPlusHealth Member Rewards program where members in designated lines of business can earn incentives for making healthy choices.
• Link to the New York State Smokers Quitline and free downloadable material to support smoking cessation.
• Links to Health-Related Events hosted by our business and community partners.  Events include wellness and chronic disease seminars, health fairs, holiday, and community events.
• Link to important COVID-19 updates, information, and testing sites
• Resources for members living with HIV/AIDS including general information, HIV counseling and testing and HIV Clinical Trials.
• Information about the Health Home Program.
• LGBTQ Resource Guide that compiles resources that are specifically committed to assisting the LGBTQ community. Included is information on assistance with primary care services, health, and legal support as well as information on marriage, family planning and where to find substance abuse help and more.
• Links to social services programs addressing the social determinants of health for seniors, people with disabilities and/or low income.  Links to Medicare Savings Programs, Elderly Pharmaceutical Insurance Coverage (EPIC), SSI, Food Stamps, Reduced MTA fares, Senior Centers, America the Beautiful are some examples of resources provided.
• A comprehensive health library, featuring health information on extensive topics, healthy recipes, educational videos, and much more.
• Self-service capabilities are also available.  Members have 24/7 access to the following:
  • Ordering a new ID card
  • Changing a PCP
  • Reviewing claim history
  • Viewing benefit summaries
  • Renewing coverage
  • Paying premiums
  • Scheduling a Virtual Visit with a Provider.

Cultural Diversity:

• The Plan endeavors to provide clinical and non-clinical services in a culturally competent manner to accommodate members who have limited English proficiency in speaking and/or understanding languages other than or in addition to English, diverse cultural and ethnic background, race, gender, or health literacy.

• The Plan makes available provider gender and languages spoken in its Provider Directories and on the website.  Customer Service is also available to assist members find PCPs or other health care providers that meet their linguistic/gender needs.

• The Plan monitors the language needs of non-English speaking members through usage patterns of the language line. Customer Service and Medical Management hire staff with multilingual skills to assist non-English speaking members.

• Member Newsletters and other written materials are routinely provided in English, Spanish, Chinese, Bengali, Urdu, and Haitian Creole.  The website is available in several languages.

• The Plan analyzes healthcare quality metrics by race, ethnicity, and language. Results are used to address the unique needs of racial and ethnic subpopulations through culturally competent member communications, clinical and service quality improvement activities, assist members in provider selection or to “match” members with specific health professionals who can best meet their linguistic and cultural needs and thus enhance the quality of care and improve patient outcomes.

• The Plan collects language data to support communication of important plan information including but not limited to health benefits, health services and health education materials. Additionally, MetroPlus uses language data to hire and match members to Plan resources such as case managers, peers and customer services staff ensuring a high level of service and understanding.
• MetroPlus Health Plan’s Community offices are based in all five boroughs and offer community-based services to members.  The Plan’s Community offices offer access to information and administrative services as well as health services and are offered by culturally diverse Plan employees.
  • Bronx Community Office: MetroPlus held a series of Holiday and Community Events, such as Easter, Mother’s Day and Father’s Day, Summer Jam Ticket Raid, Community Blitzes, Thanksgiving Holiday Celebrations, etc. in the Bronx Community Office on Southern Blvd. We also joined organizations such as the Bronx Borough President’s Office to launch the “MetroPlusHealth Back to School” events to distribute backpacks and essential school supplies. In 2022, we enhanced our direct relationships within the Muslim/ African Communities nearby the office. We partnered with Muslim organizations who are dedicated to serving the newly arriving immigrants approaching the mosques, and other African establishments such as, Union Fouta, Aljaned & Futa Islamic Centers, GadInterprises, Ramatoulaye Sow Immigration Services and Ivore Car Services.
  • Brooklyn Community Office: The Church Ave. Community Office in Brooklyn hosted a series of “Books For Tots” events with Councilwoman Rita Joseph. In addition, we partnered with “Public Health Solutions” (Navigator CBO) in the Brooklyn, Queens, and Staten Island Community Offices to provide SNAP (Food Stamps) benefits. We partnered with the “Pakistani American Youth Organization (PAYO) & Councilwomen Rita Joseph” to provide food to undeserved communities (Pop Up Food Pantries) at the Brooklyn Community Office. We held several “Back to School” events distributing bookbags, notebooks and pencil kits to kids in need. On September 7th, we held a “Child/Adolescent Dental Screening” event with HealthPlex at the Brooklyn Community Office. We held a number of “Caribbean Flag Celebrations” for Haiti, Guyana, Trinidad, and Jamaica.

We also participated in “Life is Sweet Friday’s,” Child Health Plus Initiative providing ice treats to communities on Summer Fridays and Pop-up Food Pantry in partnership with Community Conversation Collaboration. We worked directly with FQHC Morris Heights Health Center with on-site marketing days at BCO to assist with clinic outreach to communities.

• • Manhattan Community Office: In 2022 we opened a brand-new Manhattan Community Office located on Adam Clayton Powell Jr. Blvd. at 125th Street in the heart of Harlem. We partnered with Borinquen Health Clinic every other Friday to offer screenings for Diabetes, High Blood Pressure, and COVID testing. We hosted two Thanksgiving events providing MetroPlusHealth grocery bags in partnership with Borinquen Health & Harlem Hospital. Additionally, we partnered with Harlem Hospital Public Affairs & our Partnership in Care Department to offer screenings for genetic testing & HIV testing.
  • Queens Community Office: MetroPlus conducted a series of events at both the Flushing and Jackson Heights Community Office to raise awareness of the services offered. We partnered with ACS, WIC, CommonPoint to coordinate joint quarterly Baby Showers. These baby showers offered mothers pertinent information regarding their journey before delivery and post-delivery. The goal of these events was to improve the overall infant mortality rate in Queens. We conducted holiday events such as Lunar New Year Celebrations, Easter, Mother’s Day, Father’s Day, and Thanksgiving Grocery giveaways. We conducted back to school events in partnership with the local BIDS (Flushing, Corona/82nd Street). We partnered with HungerFree NYC each week at both Community Offices to provide food snap services to consumers and with the Mayor’s Public Engagement Unit, GetCovered  to help with health insurance.
  • Staten Island Community Office: At the Port Richmond Ave. Community Office we are partnering with Public Health Solutions to provide SNAP benefits enrollment and renewals in our office every Tuesday and Wednesday. We did two pop-up IDNYC events with MOIA in the summer, and another event in December to provide on the spot ID cards. We hosted a number of “Back to School” events distributing school supplies. With Health and Hospitals support we were able to have a year-long distribution of PPE to our community. Book distribution for Kids (Spanish and English) partnering with Literacy Inc. In collaboration with Staten Island Community Partnerships (SICP), we are providing 130 jackets, from toddler to adult sizes to the community.
• The Plan provides training for clinical and non-clinical staff in cultural competency, disparities in healthcare, health literacy and other relevant topics.

• MetroPlus Health Plan is in full compliance with the requirements under 45 CFR 92 that implements Section 1557 of the Affordable Care Act. Appropriate Plan publications and communications include a non-discrimination statement and taglines that are published in 15 languages other than English.

MetroPlusHealth’s Quality Management Department strives to offer important information and support to our members. We are extremely proud to continue to be a Plan that receives high “quality measure” scores from the Center for Medicare and Medicaid Services (CMS) and New York State Department of Health for our work in helping our members get the preventive and chronic care needed to stay healthy.

The Plan’s consistently high quality results reflect the investment MetroPlusHealth makes in keeping its members healthy. The MetroPlusHealth staff works closely with members and providers throughout the year to ensure that members get the care they need.  This includes reminder notices and arranging for doctors’ appointments and helping members adhere to their medication schedules to improve their health.

Listed below are some of the initiatives that were conducted in 2022 and that will continue in 2023:

• MetroPlusHealth Member Website: MetroPlusHealth continuously updates the member website where you can find important information and resources. Click here to see the member website.
• Flu Vaccination: Ever since the COVID-19 pandemic, getting the influenza vaccination is even more important to protect oneself and loved ones.  Preventing influenza helps decrease the number of people who may get sick and need to be hospitalized which will lower the burden on healthcare providers and the public health system.  MetroPlusHealth has increased communications to both members and providers through texting, mailings, website postings, and newsletters to get the message out about how important the flu shot is, especially in the cooler months of the year and how safe it is to get a flu vaccine and a COVID-19 vaccine at the same visit. MetroPlusHealth members can get the flu shot for free at CVS stores, any in-network pharmacy, CityMD Urgent Care, or doctor’s office. Members are also informed that they can receive Member Rewards for receiving a flu shot.
• Coronavirus (COVID 19): We know that our members have questions about this virus, and we continuously update our website to reflect updates and changes in knowledge. Information is provided here.
• MetroPlusHealth Member Rewards Program: The Member Rewards Program is now in its fifth 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 rewards upon completing a healthy activity. Since the program started over 121,877 members have registered for the Member Rewards Program. Member satisfaction with the services they receive, the overall program, online and phone program satisfaction and whether the program has helped them make healthy choices and improve their health is at 96%. Over 26,329 members have participated in the Step-Up Challenge and have taken over 3.5 billion steps towards better health.  Members can earn rewards for preventive screenings such as mammography, cervical and colon cancer screening as well as for visiting their PCP. In 2022, we added many enhancements to the Member Rewards Program including but not limited to the following:
  • Adult PCP Check-Up Reward: This reward is for members ages 22+ attending an annual checkup with the primary care physician (PCP).
  • Game-On Challenge: The Game-On Challenge is a 3-week challenge for ages 18+. To complete the challenge members do 30 minutes of physical exercise, 5 days a week for 3 weeks.  After successfully meeting the 3-week challenge goals, members can earn rewards.
  • Member Portal Registration Reward: Members can earn rewards when they register for the MetroPlusHealth Member Portal at members.metroplus.org

In addition, the Member Rewards Program included the following:

• Updated the Colon Cancer screening reward to include members 45-75 years of age.
• Expanded the COVID vaccine reward to defined, eligible populations.
• Completed the Healthy Snack Pack Initiative to select Essential Plan members.
• Developed and delivered a consolidated provider postcard solution with rewards information as a tool for providers that is easy to use in the office with patients.

Most members are eligible for the program and can register anytime at metroplusrewards.org and start earning points immediately.

• MetroPlusHealth Member Texting Program.  Campaigns include but are not limited to encouraging Future Appointment Reminders, Controlling High Blood Pressure, Post-Emergency Department/Inpatient Stay, Medication Adherence, Children &Adolescent Well Visits, Annual Dental Visit, Asthma Care, Breast Cancer Screening, Cervical Cancer Screening, Colorectal Cancer Screening, Flu Vaccine Reminders, Medication Refill Reminders, Follow Up Care for Children Prescribed ADHD Medication, Smoking Cessation, Prenatal and Postpartum Care, and Diabetes Care. Many texting programs are interactive allowing MetroPlusHealth another way to communicate with our members! In 2022 we also used text messaging to remind members about the importance of getting the COVID-19 vaccine and provided updated needed information throughout the year..

• Health Education: MetroPlusHealth works closely with our members and 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, chronic care management, quality measures, etc.) through a wide array of media (direct mailings, website, provider & member portals, social media, texting, public health advertisements, posters, webinars, community events, site visits, telephonic and face-to-face encounters, etc.).

• Pharmacy:
  • MetroPlus members can go to any NYS enrolled Caremark network pharmacy to fill prescriptions, which includes many large pharmacy chains such as CVS Pharmacy, Rite Aid and Walmart. MetroPlusHealth partners with various pharmacies that offer programs such as pre-packaged multiple medications that are sent directly to our member’s home for no additional cost.
  • MetroPlus members can also fill a 90-day supply of most maintenance medications at any in-network pharmacy. These are medications members take 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 and maintain their health!  Members can also get medications mailed right to their home if their pharmacy offers delivery service or through our mail-order pharmacy partner, CVS Caremark. Setting up home delivery service is easy.  For assistance members can contact MetroPlus Health Plan Customer Service.
  • We have partnered with CVS Pharmacies to offer same-day or next-day delivery for medications. Members can contact their local CVS retail pharmacy to find out more information on how to access this benefit.
  • For more information about pharmacy benefits visit Find a Pharmacy.

Virtual Visit: Access to a doctor—whenever and wherever you need it!
With MetroPlusHealth Virtual Visit, doctors are available 24/7 — Members can login on a smart phone, tablet or computer and connect to board-certified, experienced medical providers. Now, more than ever, online, or telephonic doctor visits are recommended by the CDC as a safe way to access care. Virtual Visit, online therapy, and initial online psychiatry visits and follow up visits are free.

It is easy to get started with the MetroPlusHealth Virtual Visit app. Visit here.

• New York State Smokers Quitline (NYSSQL): The NYSSQL is a service of the New York State Department of Health Tobacco Control Program which is a free and confidential program providing services to New York State residents who want to stop vaping,  smoking or using other forms of tobacco.  The NYSSQL provides the following services:
  • Talk to a Quit Coach. Chat, text, or call a coach.
  • Free patches and more. Enroll online or by phone.
  • Texting program. Build the skills needed to quit any tobacco product.
  • Savings calculator. Help you find out how much money you can save by quitting.
  • Addiction quiz. Teach about levels of nicotine addiction and steps to take.
  • Information to quit. Extensive information to quit at any stage of the journey
  • Social media. Get the latest and talk with a Coach.
  • Local programs. Online, local, and in-person group support in your area.
  • Printed materials. Brochures, cards, posters, handouts, reports, and more.
  • Family and Friends. How to support someone looking to quit.
  • To learn more about the NYS Quitline visit https://www.nysmokefree.com/
  • To find local resources visit https://www.nysmokefree.com/ToolsAndResources/LocalResources

• NYC Health + Hospitals Smoking Cessation Program: NYC Health + Hospitals understands that everyone requires a personalized plan to stop smoking. This program provides comprehensive and affordable treatment choices for New Yorkers who use tobacco or vaping products and works with smokers who are willing to quit to find effective, individualized treatment, including nicotine replacement therapy (NRT), counseling services, and other available resources. To find a smoking cessation program visit: https://www1.nyc.gov/assets/doh/downloads/pdf/csi/cessation-guide.pdf or Smoking Cessation Resources – MetroPlusHealth

• Integrated Care Management (ICM) Program: The Integrated Care Management (ICM) program, is a collaborative process that assesses, plans, implements, coordinates, monitors and evaluates the services and options available to meet the health and human service needs of members with complex care needs and are at increased risk for hospital admissions and emergency room visits. The ICM program serves eligible members in the 5 boroughs of New York City.  Care Managers complete a comprehensive assessment, identify/prioritize goals, coordinate based on member need and available resources and work with the primary care provider, specialist, and other members of the health care team to develop and implement a plan of care. Our ICM program has two components, Transition of Care for members admitted to the hospital and who are at risk for readmission and Comprehensive Care Management for members identified as having high complexity and morbidity factors.

• Transition of Care (TOC) Program: This program provides coordination and continuity of care for members transitioning from an inpatient facility setting to other care settings. A Care Manager will support the member through the transition process by providing discharge support and coordination including self-management skills, medication reconciliation and medication adherence, enhanced care coordination of care for all member needs, and facilitation of follow up appointments. Members are offered TOC management for up to 90 days after hospitalization or subacute/rehab admissions. Members that continue to have needs after the 90-day period continue to receive comprehensive care management.

• Comprehensive Care Management: Members who have graduated from TOC, have ongoing needs, and are identified as having complex needs receive comprehensive care management.  Type of services provided, and duration of those services are based on the member’s risk and need.

• Medicaid High Risk Care Coordination: The High-Risk Medicaid Team care manages members enrolled into MetroPlusHealth managed Medicaid plan who have complex care needs.  These members are holistically care managed by a team that includes Registered Nurses, Social Workers, Health and Wellness Advisors, along with collaboration with members’ providers, internal providers and other departments as needed to meet the members’ needs. The team works collaboratively to assist members with their gaps in care, connection to community resources, and healthcare providers. Care Managers address members’ needs, conduct assessments, develop individualized goals and interventions to improve quality outcomes, prevent potential readmissions, reduce avoidable hospitalizations, and ensure members remain safe in the community.

• Medicare Care Coordination: Every Medicare member receives and is encouraged to actively participate in a timely comprehensive Health Risk Assessment (HRA) of their medical, behavioral health, long-term services and supports (LTSS), and social needs.  This activity helps to identify members that would benefit from care management.

• Personal Care Services (PCS) Management: MetroPlusHealth identifies members receiving PCS that need care management and develops and implements a care plan for managing both simple and complex medical and/or behavioral health issues to meet the member’s specific needs. The Person-Centered Service Plan (PCSP) is created from information provided by the member/caregiver on the Uniform Assessment System (UAS-NY) and is developed with the member and/or caregiver and input from the provider and other members of the healthcare team as appropriate.

• High-Risk OB Care Management: MetroPlusHealth’ High Risk OB Program focuses on attaining positive health outcomes for both mother and newborn. The Care Management Program partners with obstetrical providers to promote early entry into prenatal care for members identified with a High-Risk diagnosis. Once a member has been stratified as having a High-Risk pregnancy a RN Care Manager (CM) ensures that the pregnant member’s needs are met through a complete initial assessment, telephonic follow-up, and postpartum assessment. Education is provided to the member to increase understanding about pregnancy risks and necessary interventions allowing the member to develop a realistic pregnancy and delivery plan.

• Social Determinants of Health: MetroPlusHealth addresses the importance of identifying ways to create social and physical environments that promote good health for our members. The Plan has taken steps to address food insecurity, social isolation, health literacy and homelessness in conjunction with the medical management services offered through the Plan. As Case Management staff encounter members with social needs, referrals are initiated to Community Based Organizations (CBOs) and social service agencies to assist members with closing identified needs. In addition, MetroPlusHealth has partnered with community-based organizations to provide tailored assistance, including home delivered meals, housing and even assistance with pet care.

• God’s Love We Deliver (GLWD) Program: MetroPlus Health continues to partner with “God’s Love We Deliver” GLWD to have medically tailored home-delivered meals to members with chronic illness and food insecurity.   This meal service is made available to members who could use temporary supplemental nutrition, particularly those who have been recently discharged from acute care settings (Discharge Meals benefit) and for whom nutrition is paramount to achieving optimal health care, including wound healing, malnutrition, and diabetes control.

• HealthBucks 2022: HealthBucks is a supplemental Medicare Advantage benefit. Eligible members with chronic illness are eligible to receive $64 worth of HealthBucks per quarter redeemable for fresh fruits and vegetables at NYCDOH farmers markets throughout all 5 boroughs including all 11 Health and Hospital locations. Members must commit to and complete agreed upon healthy tasks per quarter, including watching nutritional videos, attending nutrition appointments with network dieticians, or sharing 7 diaries with their Case Manager.

• In Lieu of Services (ILS) Medically Tailored Meals (MTM) Program: will allow 6 months of up to 3 MTM daily to be delivered to members who qualify by either having been determined to need aid Personal Care Service hours for assistance with meal prep or meal shopping or members with high ED or inpatient utilization with diagnosis of cancer, diabetes, heart failure or HIV/AIDS. Members need to be 18 years of age or older. This program is for Medicaid, HARP, HIV SNP members.

• 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 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.  Questions can be referred to the Care Management Department at 800-579-9798, Monday through Friday from 9:00 AM to 5:00 PM.

• Children with Special Health Care Needs: Children with special health care needs (chronic debilitating conditions; disabilities; behavioral, developmental and/or emotional conditions) may require health and related services to maintain or improve their health status and to prevent deterioration of their health.  In addition to providing care coordination activities, where applicable Care Managers interact with school districts, pre-school services, early intervention officials, behavioral health, and developmental disabilities service organizations to coordinate and assure appropriate delivery of needed services.

• Care Coordination in the MAP (UltraCare) Plan: The MAP is designed to provide increased patient-centered care coordination and encourages better communication among providers, caregivers, and patients. All UltraCare members are assigned a primary Care Manager (a nurse) who is responsible for care plan development, implementation and ongoing monitoring and coordination of services. The Care Manager is the primary point of contact for the member and his/her caregivers and will coordinate all services on the member’s behalf including medical and behavioral health services.

• Patient Safety: MetroPlusHealth addresses patient safety through a variety of mechanisms and participates in improving safety by working within the local and regional health care community.  Safety is promoted by the following activities, including but not limited to:
  • Educating members and physicians about medical safety issues.
  • Making performance data available publicly for members, providers, and consumers.
  • Working with community agencies to develop and promote safety initiatives.
  • Promoting reporting of issues affecting member safety.
  • Analyzing events within organizations to evaluate the need for process improvement.

• MetroPlusHealth has over 137 Urgent Care Centers in our service area to further assist members with access to urgent care.  MetroPlusHealth 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 change in address, telephone number or demographics important to our members.

Clinical and Service Initiatives

Measures

The 2022 Quality Program targeted many clinical and service measures for improvement. Below are short descriptions of the work we did in 2022 along with MetroPlusHealth’ most recent results. Results are compared to national and state-wide benchmarks.

Interpreting the Tables Below:

To gauge performance MetroPlusHealth 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 challenging work; MetroPlusHealth has a team of dedicated health care professionals who work every day toward improving health services for MetroPlus members.

Clinical Initiatives

MetroPlusHealth sends personalized health communications to make members aware of 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:

Well-Child Visits and Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents

MetroPlusHealth encourages children and adolescents to have an annual well-child visit to promote good health and monitor appropriate development.  MetroPlusHealth sends educational mailings and text messages to inform parents/guardians about the importance of visiting the pediatrician yearly and reminds them to take their child for a complete well visit for needed immunizations, screenings, and counseling. Incentives are offered for children who complete their well visits through the MetroPlusHealth Member Rewards Program (metroplusrewards.org).

During well-visits, providers also assess body mass index (BMI) and educate parents about the importance of physical activity and nutrition.  Health education about the importance of regular exercise and diet is provided by MetroPlusHealth through text and posted to the online newsletter and website/social media to reach our busy members.  MetroPlusHealth also sends providers gap in care reports detailing children who need preventive care.  The tables below show rates of members attending a well-child visit and rates of members receiving BMI assessment and counseling for nutrition and physical activity.

*Not a measure in HEDIS 2019      ** Note:  COVID-19 pandemic impacted all MY2020 and MY 2021 rates. Therefore, MY2020 and MY2021 rates are not trendable year over year and comparable to benchmarks.

Please note provider offices are safe to return to and are taking the needed precautions to stop the spread of COVID, flu, etc. Children/adolescents should see their provider every year.

Note: COVID-19 pandemic impacted all MY2020 and MY 2021 rates. Therefore, MY2020 and MY2021 rates are not trendable year over year and comparable to benchmarks.

Immunizations for Adolescents

Vaccinations for older children are also very important to prevent diseases such as meningococcal, tetanus, diphtheria toxoids, acellular pertussis, and human papillomavirus.  MetroPlusHealth provides member education by sending out letters and texts to inform caregivers about vaccinations and remind them that their child is due for a vaccination.  MetroPlusHealth also provides tips to providers through in-person and virtual provider meetings such as taking the opportunity to vaccinate during sports physicals so that busy parents do not have to make another appointment and reminding providers to input vaccination information into the Citywide Immunization Registration so that both members and public health officials can keep track of vaccinations for infectious diseases.

Note: COVID-19 pandemic impacted all MY2020 and MY 2021 rates. Therefore, MY2020 and MY2021 rates are not trendable year over year and comparable to benchmarks.

Please note provider offices are safe to return to and are taking the needed precautions to stop the spread of COVID, flu, etc. Adolescents should not fall behind on needed immunizations and should see their provider every year.

Breast Cancer Screening

Breast cancer is the second most common cancer among women in the United States. Each year in New York City, about 970 women die from breast cancer and about 6,300 women are newly diagnosed. Regular checkups and screenings can find breast cancer at an earlier stage when treatment is most effective. MetroPlusHealth sends educational materials and reminders, through mail, email and text messaging to women who are due for a mammogram. Educational materials and newsletters on the importance of early detection are posted on the member portal.  Gap in care reports are sent to providers so that they can follow up with members who are due for mammograms during routine visits. The MetroPlusHealth Member Rewards Program (metroplusrewards.org) offers Member Rewards for members who complete their breast cancer screening.  The table below captures the percentage of women screened for breast cancer.

*2023 Medicare Star Ratings3, 4 and 5 star cut points are displayed for Medicare product line benchmarks.

Note: COVID-19 pandemic impacted all MY2020 and MY 2021 rates. Therefore, MY2020 and MY2021 rates are not trendable year over year and comparable to benchmarks.

Cervical Cancer Screening

An average of 120 women die from cervical cancer and 430 women are newly diagnosed annually in New York City.  Women ages 21 to 64 should have a cervical cancer screening (Pap test) every 3 years.  Alternatively, women ages 30 to 64 can rely on human papillomavirus (HPV) testing instead of, or in addition to, a Pap test. Women in this age group should get HPV testing every five years, a Pap test every three years, or a combination of the two tests every five years.  MetroPlusHealth endeavors to notify members who are missing a cervical cancer screening that one is due through texting or automated calls.  The MetroPlusHealth Rewards Program offers Member incentives once a cervical cancer screening is completed.  List of members who are due for a cervical cancer screening are shared with primary care providers so they can assist their patients to get cervical cancer screening.

Note: COVID-19 pandemic impacted all MY2020 and MY 2021 rates. Therefore, MY2020 and MY2021 rates are not trendable year over year and comparable to benchmarks.

Chlamydia Screening in Women

Chlamydia is a common sexually transmitted disease (STD), especially among young people. Approximately 1 in 20 sexually active women aged 14-24 has chlamydia. As chlamydia is usually has no symptoms, screening is necessary to identify most infections. The Centers for Disease Control and Prevention (CDC) recommends chlamydia screening every year for all sexually active women younger than 25. If not treated, chlamydia can cause severe pain and infertility (inability to have children).  Educational materials and newsletters on the importance of chlamydia screening are posted on the member portal. A social media campaign is conducted during STD Awareness Month. The goal is to educate members about the importance of screening and early detection. Additionally, MetroPlusHealth shares information with providers on members who may need screening. The table below captures the percentage of women screened for chlamydia.

Note: COVID-19 pandemic impacted all MY2020 rates. Therefore, MY2020 rates may not be trendable year over year and comparable to benchmarks.

Prenatal and Postpartum Care

MetroPlusHealth supports the health of new mothers and their babies by offering resources and education through mailings, texting, telephonic outreach, and posting of materials on the MetroPlusHealth website.  These communications include contact information for MetroPlusHealth High-Risk OB/GYN Case Management, community-based organizations that provide services for expecting and new mothers and stop smoking and getting the flu and Tdap immunization reminders.  The MetroPlus Healthy Rewards Program offers incentives for completing a postpartum visit and well-baby check-ups.  To assist expecting and new mothers to monitor their emotional health, MetroPlusHealth provides a Patient Health Questionnaire that members can fill out and take with them to their next doctor’s appointment as a prompt to start a discussion about how members are coping with motherhood.  Calls are conducted to new mothers as a reminder to attend their postpartum visit for important follow-up care after delivery.

Note: COVID-19 pandemic impacted all MY2020 and MY 2021 rates. Therefore, MY2020 and MY2021 rates are not trendable year over year and comparable to benchmarks.

Please note provider offices are safe to return to and are taking the needed precautions to stop the spread of COVID, flu, etc.

Colorectal Cancer Screening

Colorectal cancer is the third most common cancer diagnosed in both men and women in the United States with an estimated 106,180 new cases of colon cancer and 44,850 new cases of rectal cancer in 2022. Regular screening, beginning at age 45, is the key to preventing colorectal cancer and finding it early. The U.S. Preventive Services Task Force recommends that adults aged 45 to 75 be screened for colorectal cancer. The Task Force recommends that adults aged 76 to 85 talk to their doctor about screening. MetroPlusHealth texts, sends postcards, and calls members to educate them about the importance of colorectal cancer screening and the different options available such as easy and fast stool-based screening tests. During Colon Cancer Awareness Month, MetroPlusHealth conducts a social media campaign to encourage members to get their colorectal cancer screening. Members can also earn Member Rewards for completing their colorectal cancer screening. Providers are informed of members who need screening and are provided with educational resources.

*2023 Medicare Star Ratings 3, 4 and 5 star cut points are displayed for Medicare product line benchmarks.

Note: COVID-19 pandemic impacted all MY2020 and MY 2021 rates. Therefore, MY2020 and MY2021 rates are not trendable year over year and comparable to benchmarks.

Controlling High Blood Pressure

Hypertension is a risk factor for cardiovascular disease that may go unnoticed due to being a largely asymptomatic condition. As of 2019, a third of people with hypertension are undiagnosed and of those diagnosed, around half are not taking antihypertensive medications. The World Health Organization (WHO) estimates that high blood pressure directly or indirectly causes deaths of at least nine million people globally every year.

MetroPlusHealth endeavors to support members with a hypertension diagnosis in keeping their blood pressure under control.  Healthy lifestyle tips are disseminated through educational materials which are text messaged and posted on the MetroPlusHealth website to reach as many members as possible. Members can also earn rewards through completion of healthy activities which encourage walking in the “Step-Up Challenge.”  For members’ convenience, 90-day prescriptions of anti-hypertensive medications are also encouraged.  The table below indicates rates of hypertensive members with blood pressure in control.

*2023 Medicare Star Ratings 3, 4 and 5 star cut points are displayed for Medicare product line benchmarks.

¹ Not included in CMS’ Star Ratings program due to specification changes.

Note: COVID-19 pandemic impacted all MY2020 and MY 2021 rates. Therefore, MY2020 and MY2021 rates are not trendable year over year and comparable to benchmarks.

Asthma Medication Ratio

Approximately 25 million people in the U.S. have asthma, roughly 1 in 13. Many people with asthma need to take long-term controller medications daily, even when they don’t have symptoms, to control their condition. Clinical guidelines (GINA) advise patients to continue taking their prescribed asthma medications, particularly inhaled corticosteroids which are long-acting asthma medications.

MetroPlus Health encourages and supports members to maintain a 50%-75% ratio of long-acting controller medications to all their asthma medications to effectively manage their condition. Asthma management tips are shared through educational materials in text messages and newsletters on the website. Members can also earn rewards by refilling long-term controller asthma medication prescriptions.  For members’ convenience, 90-day prescriptions of asthma medications are also encouraged for members who are stable with asthma medication management.  The table below indicates rates of members with asthma medication management in control.

Note: COVID-19 pandemic impacted all MY2020 and MY 2021 rates. Therefore, MY2020 and MY2021 rates are not trendable year over year and comparable to benchmarks.

Comprehensive Diabetes Care

According to the Centers for Disease Control & Prevention (CDC) more than 30 million people in the United States have diabetes, and 1 in 4 of them do not know they have it. Diabetes is the 7th leading cause of death in the United States. In the last 20 years, the number of adults diagnosed with diabetes has more than doubled as the American population has aged and become more overweight or obese. Much of the burden of illness and cost of diabetes is related to potentially preventable long-term complications that includes heart disease, blindness, kidney disease and stroke. Timely screenings and careful treatment can significantly reduce and delay the onset of complications diabetes can cause.

MetroPlusHealth has effective mechanisms to ensure members are getting the care and support they need to manage their diabetes. This includes texts campaigns to provide tips on how to manage diabetes and reminders to complete the following checkups: retinal eye screening, HbA1c testing, kidney health evaluation, and frequent blood pressure readings. Educational materials and community resources are also posted on the member portal. For Medicare members, home visits are offered to complete diabetic screenings such as the retinal eye exam. Care Managers also provide education and help members address barriers to care. A peer mentoring program is offered to MetroPlusHealth Medicaid members for support to better manage their diabetes. Providers are notified of members who are overdue for diabetic screenings. An incentive is offered to members who complete their diabetic eye exam through the MetroPlusHealth Member Rewards Program (metroplusrewards.org). The table below captures the percentage of diabetic adults who completed components of diabetes care.

*2023 Medicare Star Ratings3, 4 and 5 star cut points are displayed for Medicare product line benchmarks.

Note 1: COVID-19 pandemic impacted all MY2020 and MY 2021 rates. Therefore, MY2020 and MY2021 rates are not trendable year over year and comparable to benchmarks.

Note 2: HbA1c Testing is a CDC legacy measure that is no longer in place as of 2022.

Statin Adherence for Patients with Cardiovascular Disease

Cardiovascular disease remains the number one cause of death in the United States. According to the CDC, nearly 700,000 people have died from heart disease in 2020 in the United States. People with unhealthy cholesterol levels have a greater risk of developing Atherosclerotic Cardiovascular Disease (ASCVD). Additionally, for adults diagnosed with diabetes, 69% had high blood pressure and 44% had high cholesterol. Medications that help control cholesterol levels belong to a class called statins. The American College of Cardiology and American Heart Association (ACC/AHA) guidelines state that statins of moderate or high intensity are recommended for adults with established clinical ASCVD. Additionally, moderate or high intensity statin therapy reduces the risk of developing ASCVD for adults with diabetes. MetroPlusHealth conducts telephonic outreach with members to discuss the importance of adhering to their statin medication and relay information about pharmacy benefits such as 90-day refills, mail order and home delivery programs such as PillPack, Capsule, and CVS Home Delivery. The table below captures the percentage of members who are dispensed at least one statin medication of any intensity and members who were 80% adherent to their statin therapy during the measurement year.

*2023 Medicare Star Ratings3, 4 and 5 star cut points are displayed for Medicare product line benchmarks.

Note:  COVID-19 pandemic impacted all MY2020 rates. Therefore, MY2020 rates may not be trendable year over year and comparable to benchmarks.

Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment (IET)

MetroPlus encourages and supports all members who have recently been diagnosed with Alcohol or Drug Abuse Dependence to engage in ongoing substance use treatment. Multiple treatment options are available including Inpatient Rehabilitation, Inpatient Detox, Outpatient Detox, Residential Treatment, Outpatient Clinic Care and Medication Assisted Treatment. MetroPlus makes use of various data sources to outreach members who have been diagnosed with substance use disorders for intervention. The Plan contacts members via telephone outreach to assist them in securing treatment. The Plan meets regularly with Inpatient Substance Abuse Rehab facilities to address adequate aftercare planning for all members discharged from their facilities.

The Plan also surveys providers to assess their practices related to the diagnosis and treatment of substance use disorders and makes available screening tools and treatment resources for their patients with substance use disorders. The Plan website also has information available regarding the diagnosis and treatment available to members with substance use disorders.

Note: COVID-19 pandemic impacted all MY2020 and MY2021 rates. Therefore, MY2020 and MY2021 rates are not trendable year over year and comparable to benchmarks.

Antidepressant Medication Management (AMM)

The onset of depression has increased in recent years, making depression one of the most common mental illnesses in the United States. The signs of depression vary from mild to severe and symptoms are different from person to person. If someone experiences at least two of the following symptoms for longer than two weeks, it might mean that they are depressed: deep sadness; lethargy; loss of interest in the things they usually care about.

MetroPlus utilizes claims and other data to identify members prescribed antidepressant medication and encourages members to participate in psychotherapy and psychotropic treatment. The Plan utilizes text messages, mail, phone calls and other communication methods to remind members to remain adherent to their medication regiment and inform them of services available to them.  Also, MetroPlus works in collaboration with members to schedule needed follow up appointments to connect them with network providers. Additionally, we work with the member’s pharmacies to ensure timely medication refill processing. Members can find information regarding the diagnosis and treatment available to members struggling with depression on the MetroPlus website. The table below captures the percentage of adults filling antidepressants who were adherent to their medication regiment during the acute (remained on treatment for 3 months) and continuation phases (remained on treatment for 6 months) of their treatment.

Note: COVID-19 pandemic impacted all MY2020 and MY2021 rates. Therefore, MY2020 and MY2021 rates are not trendable year over year and comparable to benchmarks.

Medication Therapy Management (MTM)

The Medication Therapy Management (MTM) program helps Medicare members, and their doctors monitor the efficacy/side-effects of being on multiple medications. Members qualify for the 2023 program if they are in a Medicare drug plan, have several chronic health conditions (such as asthma, diabetes, and hypertension), take several different medications for these conditions and the medications cost are greater than or equal to $4,935 for the program year. MetroPlusHealth partners 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
• Over the counter (OTC) medications, vitamins, and supplements and how they interact with their prescribed medications

Members are given a printed written summary of their discussion, including an action plan with best use recommendations of their medications. Additionally, texting and IVR messaging are used to educate members on the value of participating in the MTM program. The table below captures medication review completion rates.

Note: COVID-19 pandemic impacted all MY2020 and MY2021 rates. Therefore, MY2020 and MY2021 rates are not trendable year over year and comparable to benchmarks.

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 the medication, find potential drug-drug and drug-disease interactions, and discuss 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. MetroPlusHealth has built these assessments/screenings into the Health Risk Assessment (HRA), thus members targeted for HRA completion will also have their COA needs addressed. Results are integrated into the member’s Plan of Care (POC), which is shared with both the member and their PCP. MetroPlusHealth also utilizes in-home providers to conduct home visits to complete these assessments and screenings.  In addition, targeted outbound calls are conducted by MetroPlusHealth 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 rates for Care for the Older Adult measure that are applicable to the CMS Medicare Star’s Program.