Quality Management Program

Quality Management Program Description

MetroPlusHealths’ mission is to provide a caring, high quality customer experience to preserve and improve the health and lives of New Yorkers. 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 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 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
  • Quality Improvement Projects
  • Chronic Care Improvement Program (CCIP) for Medicare, MAP and SNP Members
  • Quality Improvement Projects/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
  • Availability and Accessibility
  • Delegation
  • Member Complaints, Grievances, and Appeals
  • Human Resources

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 (Traditional and Simplified), Bengali, Urdu, French, Haitian Creole, and Russian. 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 important COVID-19 updates and information.
  • Link to free COVID-19 testing sites.
  • Link to MetroPlusHealth Member Rewards program where members in designated lines of business can earn reward points for making certain 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.
  • Resources for members living with HIV/AIDS including general information, HIV counseling and testing.
  • Information about the Health Home Program.
  • LGBTQIA+ Resource Guide that compiles resources that are specifically committed to assisting the LGBTQIA+ 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 use 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.

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, birth gender, gender identity 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. Facilitated enrollers can be found by gender, language, and location on the website.
  • The Plan monitors the language needs of non-English speaking members through usage patterns of the language line. Additionally, 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 numerous languages.
  • 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 that are offered by culturally diverse Plan employees. MetroPlusHealth provides recertification, documentation collection, premium payment collection and customer service at the Community Offices. In addition, we partner with various Community Based Organizations to provide Social Service and Entitlement Programs to consumers such as SNAP, WIC, Food Stamp, and other programs.
  • 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’ Quality Management Department strives to offer important information and support to our members. We are extremely proud to continue to receive the highest “quality measures” score being ranked number 1 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.

MetroPlusHealth’ 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 MetroPlusHealth scored particularly high include antidepressant medication management, colorectal cancer screening, comprehensive diabetes care (HbA1c poor control), controlling high blood pressure, immunizations for adolescents, weight assessment and counseling for nutrition and physical activity for children/adolescents, diabetes screening for people with schizophrenia or bipolar disorder using antipsychotic medications, follow up after emergency department visit for alcohol and other drug abuse or dependence within 7 days and postpartum care. These 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 2021 and that will continue in 2022:

  • MetroPlusHealth Member Website: MetroPlusHealth continuously updates the member website. You can find important information and resources here.
  • Coronavirus (COVID 19): Coronavirus (COVID-19) has dramatically altered life around the globe and has had a tremendous impact here in New York City. 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.
    Furthermore, MetroPlusHealth conducts ongoing text message campaigns to keep members informed of new developments such as when younger members are eligible for the COVID-19 vaccination, when new incentives are available for getting the COVID-19 vaccination, and locations of mobile vaccination clinics.MetroPlusHealth is also supporting providers with additional incentive and data to educate those members who may need counseling about the COVID-19 vaccination.
  • Flu Vaccination: During the COVID-19 pandemic, getting the influenza vaccination is even more important to protect oneself and loved ones. Preventing influenza helps to 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 2021. In addition to informing MetroPlusHealth members that they can get the flu shot for free at CVS stores, any in-network pharmacy, CityMD Urgent Care, or doctor’s office, MetroPlusHealth is resuming community events where flu shots are provided..Members are also informed that they can receive Member Reward points for receiving a flu shot.
  • MetroPlusHealth Member Rewards Program: The Member Rewards Program is now in its sixth 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. Since the program started over 107,302 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 23,729 members have participated in the Step-Up Challenge and have taken over 2.9 million steps towards better health. Members can earn rewards for preventive screenings such as mammography and colonoscopy as well as for participating in wellness challenges such as the Step-Up Challenge. In 2021 we added many enhancements to the Member Rewards Program including but not limited to the following:
    • Star Student Challenge: The Star Student Challenge is a 4-week wellness challenge that encourages students ages 5-17 to meet academic goals that will help them succeed in school. This Challenge realizes the high correlation between health and education. After successfully meeting the challenge goals, the account owner earns 150 reward points ($15 value), which can be used to shop for healthy items in the MetroPlus Rewards catalog.
    • New Member Onboarding Module: Innovative web experience that is designed to orient members to MetroPlus and their healthcare benefits. Members earn reward points ($5 value) for completing the onboarding activity within 30 days of enrolling with MetroPlusHealth.
    • New Member PCP Checkup Reward: Members can earn reward points ($20 value) when they complete a checkup with their PCP within 90 days of enrollment.
    • Member Portal Registration Reward: Members can earn reward points ($5 value) when they register for the MetroPlusHealth Member Portal at members.metroplus.org
    • COVID Vaccination Reward: Launched in November 2021 members in MetroPlusHealth Medicaid, HARP and HIV SNP products can earn reward points ($100 value) for becoming fully immunized.

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 Adolescent Well Visits, Annual Dental Visit, Asthma Care, Breast Cancer Screening, Cervical Cancer Screening, Colorectal Cancer Screening, Flu Reminders, Medication Refill Reminders, Prenatal and Postpartum Care, and Diabetes Care. Many texting programs are interactive allowing MetroPlusHealth another way to communicate with our members! In 2021 we also used text messaging to remind members about the importance of getting the COVID-19 vaccine with a link to find a vaccine site near them and information on how to schedule an appointment to get the vaccine at home, text messages encouraging members to get back to care for preventive services and immunizations were also delivered to our members.
  • Community Screening Events:. Due to the COVID pandemic community events were suspended in March 2020. MetroPlusHealth did conduct a dental event in the fall of 2021 and a flu event in the winter of 2021 to test members’ interest in receiving health services at community events. MetroPlusHealth continues to gauge members’ interest in attending community events as the pandemic evolves. In the meantime, MetroPlusHealth offers online educational webinars to provide health information, topics have included dental care and diabetes care as well as updates on benefits and the Member Rewards Program.
  • 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 CVS Caremark in-network pharmacy to fill prescriptions as well as many other in-network pharmacies. MetroPlusHealth partners with programs such as Amazon PillPack to allow members to get multiple medications pre-packaged and sent to their home for no additional cost. To sign up, members can contact PillPack directly at 855-745-5725.
    • 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 the MetroPlus Health Plan Customer Service.
    • We have partnered with CVS Retail 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 our Pharmacy page.
  • Peer to Peer Program: MetroPlusHealth partnered with InquisitHealth to provide peer-to-peer mentoring to Medicaid members who need to better control their diabetes. This program pairs MetroPlusHealth members who have diabetes with trained peer mentors who are successfully managing their diabetes. The mentor/mentee relationship enables members to work closely to set goals towards better health.
  • MyChart: Members who receive care at NYC Health +Hospital facilities have access to MyChart which is a free, secure member portal where members can manage their health information. Members can message their doctors, request medication refills, access test results, and schedule appointments.
  • Virtual Visit: Access to a doctor—whenever and wherever you need it! MetroPlusHealth Virtual Visit is the fast, easy way for our members to see a provider for common physical, mental, emotional, and behavioral health issues that are not emergencies. MetroPlusHealth Virtual Visit is available anytime, from anywhere in New York State, 24/7 – and in your language. Click here to learn more or to access care.
  • Medication Assistance with Smoking and Tobacco Use Cessation:
    New York City Housing Authority (NYCHA): NYCHA’s smoke-free initiative, Smoke-Free NYCHA, is designed to create healthier homes for members residing in NYCHA housing who smoke and want to quit. The program offers the following services:

    • 1:1 coaching
    • Telephonic/virtual outreach
    • FREE support to cut back or quit smoking
    • Connect residents to local resources for cessation
    • Help residents access health insurance benefits for cessation
    • Refer to NYS Quitline
    • Support resident volunteers

 

For more information about Smoke-Free NYCHA visit https://www1.nyc.gov/site/nycha/residents/smoke-free.page.

  • 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 smoking or using other forms of tobacco. The NYSSQL provides the following services:
    • Telephonic and web-based cessation services for tobacco users
    • Free Coaching: up to 2 coaching sessions and unlimited calls
    • Free Nicotine Replacement Therapy (NRT) and self-help materials. Eligible members (age, residence, no contraindication) can receive supply of NRT two times in 12 months with 3-month interval
    • Information about other cessation services (e.g., health plan, local or healthcare program)
    • Moderate and heavy smokers receive a combination of nicotine patch and gum or lozenge (combination therapy)
    • Teens and Adolescent Texting: For help with quitting vaping, teens, and young adults (ages 13-24) can text “DROPTHEVAPE” to 88709 to join the free texting support program
    • Parents can also text “QUIT” to 202-899-7550 to receive daily advice to help youth 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
  • 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 includes the following components:
    • Transition of Care (TOC) Program: This program helps members that were in the hospital get back on their feet when they return home. MetroPlus health professionals will conduct home visits to help members get the services they need to remain healthy and avoid re-hospitalization. Members are offered TOC management for up to 90 days. 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.
    • High-Risk OB Care Management: Partnering with the member and obstetrical provider, the High-Risk OB Care Manager helps to promote early entry into prenatal care for members identified with a high- risk diagnosis. The goal is to attain positive health outcomes for both mother & newborn and to reduce the number of newborns that need care in a Neonatal Intensive Care Unit.
    • Medicare Care Coordination: Every Medicare member receives and is encouraged to actively participate in a new member and annually thereafter 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.
    • 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.
    • God’s Love We Deliver (GLWD) Program: High-risk Medicaid members, including those recently discharged from the hospital, who indicate they need help with food/meal preparation will be further assessed for medically tailored, home-delivered meals provided by GLWD.
    • 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.
    • 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 120 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 2021 Quality Program targeted many clinical and service measures for improvement. Below are short descriptions of the work we did in 2021 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 hard 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-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 shots, tests, screenings, and counseling. Incentives are offered for children who complete their well visits through the MetroPlusHealth Member Rewards Program (metroplusrewards.org).

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 receiving BMI assessment and counseling for nutrition and physical activity.

 

WEIGHT ASSESSMENT & COUNSELING FOR NUTRITION & PHYSICAL ACTIVITY FOR CHILDREN/ADOLESCENTS
HEDIS 2019HEDIS 2020HEDIS 2021NYS QARR 2020
BENCHMARKS
(MY 2018)(MY 2019)(MY 2020)50th Percentile75th Percentile90th Percentile
EXCHANGE
Body Mass Index71788090.0096.1197.50
Nutrition78818288.0895.0096.60
Physical ActivityN/A608080.0592.5095.24
 

MEDICAID

Body Mass Index94939287.8394.1694.40
Nutrition93929085.4089.1791.48
Physical Activity85868580.0584.1885.64

 

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

 

Childhood Immunization Status
Children up to age two should receive important immunizations to prevent the spread of communicable diseases such as measles, mumps, rubella, polio, hepatitis A and B, rotavirus, diphtheria, tetanus, and whooping cough. Infants and babies do not have the immunity to fight these infections without these essential vaccinations. MetroPlusHealth sends out timely notifications to providers to alert them of any member who is missing vaccinations. MetroPlusHealth sends texts and calls caregivers who are missing well-child visits to remind them to take their children in for preventive services such as immunizations and educate caregivers about why immunizations are necessary.

HEDIS  2019HEDIS  2020HEDIS  2021NYS QARR 2020
BENCHMARKS
(MY 2018)(MY 2019)(MY 2020)50th Percentile75th Percentile90th Percentile
MEDICAID83818179.8182.9784.91

Note: COVID-19 pandemic impacted all MY2020 rates. Therefore, MY2020 rates may not be 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 with 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.

HEDIS  2019HEDIS  2020HEDIS  2021NYS QARR 2020
BENCHMARKS
(MY 2018)(MY 2019)(MY 2020)50th Percentile75th Percentile90th Percentile
MEDICAID61625940.1544.2856.20

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

 

Annual Dental Visit

To promote healthy oral hygiene and to prevent tooth decay and gum disease, annual visits to the dentist are highly recommended for children. Two dental screenings per year are free and covered benefits for children. Oftentimes, MetroPlusHealth members do not realize they have dental benefits or may not have detailed knowledge of what their dental benefits include. To resolve some of the barriers to dental care, MetroPlusHealth works with its dental partner, HealthPlex, to provide education and outreach to members through mailings, calls, text messages, social media, and website postings. Dental webinars were held in lieu of community events during 2021. Towards the end of 2021, community dental screening events began again and will continue. The MetroPlusHealth Member Rewards Program (metroplusrewards.org) offers reward points for completed dental screenings which can be used to shop in the Member Rewards catalog.

HEDIS  2019HEDIS  2020HEDIS  2021NYS QARR 2020
BENCHMARKS
(MY 2018)(MY 2019)(MY 2020)50th Percentile75th Percentile90th Percentile
MEDICAID59634462.7665.1767.90
EXCHANGE24211230.7546.6655.20

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

 

Breast Cancer Screening

Breast cancer is the second most common cancer among women in the United States. Regular checkups and screenings can find breast cancer at an earlier stage when treatment is most effective. MetroPlusHealth 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 are posted on the member portal. Gaps in care reports are sent to providers so that they can follow up with members who are due for mammograms during routine visits. Reminders are emailed to providers of members who are due for a mammogram to remind the provider to speak with members about the importance of breast cancer screening at their next appointment. Incentives are offered to members who complete their breast cancer screening through the MetroPlusHealth Member Rewards Program (metroplusrewards.org). The table below captures the percentage of women screened for breast cancer.

HEDIS  2019HEDIS  2020HEDIS  2021NYS QARR 2020
BENCHMARKS
(MY 2018)(MY 2019)(MY 2020)50th Percentile75th Percentile90th Percentile
EXCHANGE74767069.7973.2078.76
HARP59565161.0065.0468.37
HIVSNP79777065.3977.1477.14
MEDICAID75736869.5571.8872.63
ESSENTIAL PLAN77757172.3775.0776.92
 

 

HEDIS 2019HEDIS 2020HEDIS 2021MEDICARE STAR 2021 BENCHMARKS
(MY 2018)(MY 2019)(MY 2020)3 Star4 Star5 Star
MEDICARE838378667683

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

 

Colorectal Cancer Screening

Colorectal cancer is the third most common cancer diagnosed in both men and women in the United States with an estimated 104,710 new cases of colon cancer and 43,230 new cases of rectal cancer in 2021. However, the death rate from colorectal cancer has been dropping for several decades. Reasons are that colorectal polyps are now being found more often by screening and removed before they can develop into cancers, or cancers are being found earlier when they are easier to treat. MetroPlusHealth texts, sends postcards, and calls members to educate them about the importance of colorectal cancer screening and the different options available such as colonoscopies and stool test kits. 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 Reward points for completing their colorectal cancer screening and use the points to go shopping in the Member Rewards catalogue. Medicare members who are eligible can have a clinician home visit who will leave behind a stool test kit for the members’ convenience. Providers are informed of members who need screening and are provided with educational resources.

HEDIS  2019HEDIS  2020HEDIS  2021NYS QARR 2020
BENCHMARKS
(MY 2018)(MY 2019)(MY 2020)50th Percentile75th Percentile90th Percentile
EXCHANGE62605755.2363.0469.13
HARP48504460.8362.1163.02
HIVSNP72706465.8271.5371.53
MEDICAID67595759.1764.2966.67
ESSENTIAL PLAN62576060.8262.0765.36
 

 

HEDIS 2019HEDIS 2020HEDIS 2021MEDICARE STAR 2021 BENCHMARKS
(MY 2018)(MY 2019)(MY 2020)3 Star4 Star5 Star
MEDICARE808280627380

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

 

Chlamydia Screening in Women

Among young people, chlamydia is a common sexually transmitted disease (STD). Approximately 1 in 20 sexually active young women aged 14-24 has chlamydia. As chlamydia is usually asymptomatic, 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. 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.

HEDIS  2019HEDIS  2020HEDIS  2021NYS QARR 2020
BENCHMARKS
(MY 2018)(MY 2019)(MY 2020)50th Percentile75th Percentile90th Percentile
EXCHANGE74806947.3355.4367.35
MEDICAID82807971.8179.8782.02
ESSENTIAL PLAN78827672.4577.3980.73
HARP89788277.9681.8884.47
HIVSNP80838768.1868.1868.18

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 the MetroPlus Healthy Rewards Program where members can earn points for 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.

HEDIS  2019HEDIS  2020HEDIS  2021NYS QARR 2020
BENCHMARKS
(MY 2018)(MY 2019)(MY 2020)50th Percentile75th Percentile90th Percentile
MEDICAID Prenatal Care89959388.3090.0292.53
MEDICAID Postpartum Care70848680.2982.4884.43
ESSENTIAL PLAN
Prenatal Care
84888584.0388.5390.17
ESSENTIAL PLAN Postpartum Care75848978.3580.7784.67
EXCHANGE Prenatal Care67858184.9691.1495.20
EXCHANGE Postpartum Care69677873.8982.1487.63
HARP Prenatal Care80868281.1289.7492.46
HARP Postpartum Care42615660.2066.1866.18

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

 

Comprehensive Diabetes Care
According to the Centers for Disease Control & Prevention (CDC) more than30 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 include heart disease, blindness, kidney disease and stroke. Timely screening and careful treatment can significantly reduce and delay the onset of complications from diabetes. MetroPlusHealth texts members with diabetes to provide tips on how to manage diabetes and reminds them to get regular screenings, such as retinal eye screening, HbA1c testing, kidney health evaluation, blood pressure check, and medication review. Educational materials and community resources are posted on the member portal. Online informational webinars are offered on topics such as “Intuitive Eating” and “Plant-Based Diet.” 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 members in participating lines of business 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.

DIABETES CARE
HEDIS  2019HEDIS  2020HEDIS  2021NYS QARR 2020
BENCHMARKS
(MY 2018)(MY 2019)(MY 2020)50th Percentile75th Percentile90th Percentile
 

EXCHANGE

HbA1c < 859586358.3563.7567.51
Eye Exam57596048.9156.1166.42
 

MEDICAID

HbA1c Testing91938691.7393.6795.13
HbA1c < =970766369.5974.1874.94
Eye Exam69696065.3369.4472.75
HbA1c < 857645457.4260.5863.75
 

ESSENTIAL PLAN

HbA1c Testing92938993.1993.9295.71
HbA1c < 861596060.5862.0463.99
Eye Exam70686461.1264.4869.83
HbA1c < =977747072.1376.2874.44
 

HIVSNP

HbA1c < =966787568.6178.3578.35
Eye Exam62625157.4261.8061.80
HbA1c Testing95979495.8696.8496.84
HbA1c < 866716762.5370.8070.80
HEDIS 2019HEDIS 2020HEDIS 2021MEDICARE STAR 2021 BENCHMARKS
(MY 2018)(MY 2019)(MY 2020)3 Star4 Star5 Star
MEDICARE
HbA1c Testing979788949597
HbA1c < 9828273392815
Eye Exam797974697378
HbA1c < 8706963687478

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

 

Controlling High Blood Pressure

According to the CDC about 75 million people in the United States have high blood pressure also known as hypertension, and only about 1 in 4 (24%) have their hypertension under control. 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 and posted on the MetroPlusHealth website to reach as many members as possible. Members can also earn reward points through completion of healthy activities which encourage walking in the Step-Up Challenge. The reward points can be used to shop in the Member Rewards catalogue at www.metroplusrewards.org. For members’ convenience, 90-day prescriptions of anti-hypertensive medications are also encouraged. The table below indicates rates of members with blood pressure in control.

HEDIS 2019HEDIS 2020HEDIS 2021NYS QARR 2020
BENCHMARKS
(MY 2018)(MY 2019)(MY 2020)50th Percentile75th Percentile90th Percentile
EXCHANGE63686362.0469.8375.43
MEDICAID75766865.6968.6175.43
ESSENTIAL PLAN69686968.4971.5672.81
HIVSNP76857561.1885.4085.40
HEDIS 2019HEDIS 2020HEDIS 2021MEDICARE STAR 2021 BENCHMARKS
(MY 2018)(MY 2019)(MY 2020)3 Star4 Star5 Star
MEDICARE818178627582

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

 

Statin Adherence for Patients with Cardiovascular Disease

Cardiovascular disease remains the leading cause of death in the United States. It is estimated that 121.5 million American adults have one or more types of cardiovascular disease. Having unhealthy cholesterol levels places people at significant risk for developing atherosclerotic cardiovascular disease (ASCVD). Statins are a class of drugs that lower blood cholesterol. 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. 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 adherent with their statin therapy medication.

HEDIS 2019HEDIS 2020HEDIS 2021NYS QARR 2020
BENCHMARKS
(MY 2018)(MY 2019)(MY 2020)50th Percentile75th Percentile90th Percentile
MEDICAID72747670.9474.1278.12
ESSENTIAL PLAN76737472.0176.5879.49
HIVSNP79799579.0789.7189.71

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

 

Medication Therapy Management (MTM)

Medication Therapy Management helps Medicare 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 an amount that is established by the federal government. MetroPlusHealth 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
  • Over the counter (OTC) medications, vitamins, and supplements and how they interact with their prescribed 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. Additionally, texting and IVR messaging are used to outreach members about the importance of participating in the MTM program. The table below captures medication review completion rates.

StarsStarsStarsMedicare Star Benchmarks 2021
(MY 2018)(MY 2019)(MY 2020)1 Star2 Star3 Star4 Star5 Star
Medicare828594<3054728289

Note: COVID-19 pandemic impacted all MY2020 rates. Therefore, MY2020 rates may not be 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 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.

CARE OF OLDER ADULTS
HEDIS 2018HEDIS 20191HEDIS 20202Medicare Star Benchmarks4
(MY 2018)(MY 2019)(MY 2020)3 Star4 Star5 Star
Medicare
Functional Status Assessment9292N/A3718593
Pain Screening969696768796
Medication Review959595718495

1 CMS suspended the regulatory requirement to submit HEDIS data for MY 2019 as a result of the COVID-19 Public Health Emergency (PHE) and used MY 2018 performance in the 2021 (MY 2019) Star program.
For the 2022 (MY 2020) Medicare Star’s program, CMS used the measure-level better of 2018 or 2020 star score in the calculation of HEDIS metrics.
Functional Status Assessment was not included in the 2022 (MY 2020) program.
Displayed benchmarks are reflective of MY 2020 performance for Medication Review and Pain and MY 2018 performance for functional status assessment.
Note: COVID-19 pandemic impacted all MY2020 rates. Therefore, MY2020 rates may not be trendable year over year and comparable to benchmarks.

Service Initiatives

We strive to provide the best first and lasting experience for our members. As part of our continuous improvement efforts, in 2021 we implemented the following service enhancements:

  • Established an email box for members to reach MetroPlusHealth regarding any issues that need resolution [email protected]
  • Enhanced multichannel messaging to meet members in their preferred mode of communication.
  • Call quality training (LEARN) and assessment implemented for member experience operations representatives.
  • New member online onboarding portal developed and implemented.
  • New member portal app was launched in 2021. Improved features to find and change PCP’s and other providers.
  • Member experience operations team trained to troubleshoot issues on the new member portal and can help members with registering and using the services.

Customer Services is available Monday through Friday from 8:00AM to 8:00PM and Saturday from 9:00AM to 5:00PM. After hours, Sundays and Holidays, members are connected to our 24/7 Customer Service Hotline. TTY users have access through 711.

 

Medicaid, Child Health Plus, Partnership in Care (SNP), MetroPlusHealth Enhanced, Qualified Health Plans (QHP) and Essential Plan
1-800-303-9626

MetroPlusHealth Gold & GoldCare I and GoldCare II
1-877-475-3795

Medicare Plans
1-866-986-0356

Managed Long-Term Care (MLTC)
1-855-355-6582

last updated: May 27, 2022

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