Overview

The Monroe Plan for Medical Care, a managed care plan, is working to improve the quality of care of its members. New York State's Medicaid incentive program has rewarded these efforts and enabled the plan to invest in new quality initiatives.

Issue: Taking the lead from corporate purchasers, state Medicaid agencies began in the late 1990s to incorporate pay-for-performance and other financial and non-financial quality incentives into their agreements with managed care organizations. Typically, these incentive programs rely on measures adopted from the National Committee for Quality Assurance's Health Plan Employer Data and Information Set, or HEDIS, and other standardized measures of plan performance. Their aim is to improve performance in specific areas and thus create better value for the states [1]. A handful of managed care organizations are, in turn, providing quality incentives directly to hospitals, physicians, and even to their enrollees [2].

Objective and Intervention: New York State's Medicaid incentive program offers financial and other incentives to Medicaid managed care programs that perform well on a number of measures. As part of its commitment to quality, the Monroe Plan for Medical Care initiated programs to improve prenatal care, asthma care, and rates of cancer screening. The success of these initiatives has earned Monroe quality rewards from the state, which the plan is reinvesting in further quality improvement efforts.

Organization: The Monroe Plan for Medical Care is a not-for-profit health care organization that manages the Blue Choice Option, Child Health Plus, and Family Health Plus programs for low-income residents in New York's Monroe County and 12 neighboring rural counties. Founded in 1970, it currently provides health care for about 85,000 members through contracts with more than 4,500 medical professionals. It has been in partnership with the BlueCross BlueShield of the Rochester Area division of Excellus Health Plan since 1987.

Implementation Milestones: The New York State Department of Health began collecting quality of care information, called the Quality Assurance Reporting Requirements (QARR), from the state's Medicaid managed care and other managed care plans in 1994. Since 2000, the QARR data, which include HEDIS, Consumer Assessment of Health Plans Survey (CAHPS), and state-specific measures, have been published on the department's Web site. New York State began rewarding plans for quality in 2000, when it implemented an auto-assignment method that enrolls patients who fail to select their own plans in higher-performing plans. (Because these enrollees typically use fewer resources, they are considered profitable members to attract.) Then, in 2002, the state incorporated a quality incentive into the Medicaid managed care capitation rate whereby plans can receive an additional 0.25, 0.5, 0.75, or 1 percent of their monthly premiums for meeting certain goals. For the fiscal year September 2003 to August 2004, plans received bonuses ranging from $54,000 to $1,356,000, totaling more than $7 million statewide. Monroe Plan for Medical Care has developed various performance improvement initiatives since the late 1990s and has participated in the incentives as offered by the state.

Key Measures: In 2004, New York State's QARR assessed plan performance in six areas: provider network, child and adolescent health, women's health, adults living with illness, behavioral health, and access and service. In 2005, the QARR measures include:

• percent of children who had five or more well-child and preventive health visits in the first 15 months of life;
• percent of children between the ages of three and six years who had a well-child and preventive health visit;
• percent of adolescents who had a well-care, preventive care, or OB/GYN visit;
• percent of women between the ages of 50 and 69 who had a mammogram in the past two years;
• percent of sexually active women ages 16 through 25 who had at least one test for Chlamydia;
• percent of women who had a postpartum care visit between 21 and 56 days after they gave birth;
• percent of members ages 46 to 85 who have hypertension and who have controlled their blood pressure (at or below 140/90);
• percent of adults ages 18 to 56 years identified as having serious and persistent asthma who received appropriate medications to control their condition;
• percent of diabetics receiving necessary components of diabetes care including hemoglobin (HbA1c) test within the past year, retinal screening exam over the last two years, cholesterol test over the last two years, and kidney damage screening; and
• percent of plan members hospitalized for treatment for selected mental health disorders (such as depression or bipolar disorder) who were seen on an ambulatory basis or were in day/night treatment with a mental health provider within seven days of discharge and again within 30 days of discharge.

In addition to these measures of clinical quality, CAHPS measures take into account patient reports of problems in getting needed care and patient ratings of their personal doctors, nurses, and health plans.

Process of Change and Results: The Monroe Plan for Medical Care's quality improvement program aims to make organizational changes to ensure adherence to appropriate practice guidelines through care coordination. This case study focuses on a prenatal care initiative and summarizes two other initiatives on asthma care and cancer screenings.

Neonatal Care
Poor birth outcomes are frequent among Medicaid beneficiaries, and delivery claims and neonatal intensive care unit (NICU) expenses can consume a large portion of Medicaid budgets. Monroe Plan for Medical Care implemented a prenatal care program called "Healthy Beginnings" in late 1997 [3]. Healthy Beginnings called for the use of learning cycles, referred to as Plan-Do-Study-Act (PDSA) cycles, to guide improvement teams through a systematic analysis and improvement process. The objectives were to reduce NICU admission rates from baseline in 1998 by at least 15 percent over the subsequent three years and to maintain that reduction in the following years. As part of this process, Monroe Plan developed a prenatal registration form that notifies program administrators when an enrollee becomes pregnant. The form is used to assess a woman's social risk factors, maternal medical and obstetrical history, and psychoneurological history. In addition, it takes into account whether a woman has previously delivered an infant that was stillborn, preterm, or low or high birth weight. This information provides a health risk assessment for each woman. When the program was first rolled out, practices were reimbursed $30 for completing the health risk assessment and could lose prenatal care reimbursement for failing to do so.

The submission rate reached 85 percent in 1998, but providers often submitted forms when their patients were well into their third trimester, when the ability to mitigate risk is limited. As part of a PDSA cycle to encourage earlier submissions, a tiered payment system was adopted in April 2001. Practitioners now receive $50 for a submission in the first trimester, $30 in the second trimester, and $20 in the third trimester, resulting in an increase in first trimester submission rates of more than 60 percent.

Based on the prenatal assessment, a perinatal nurse coordinator identifies all pregnant enrollees at moderate to high risk and manages their care through communication with practitioners, outreach programs, and a social work program. Since early 2002, those identified at high risk because of psychosocial problems have been referred to BabyLove, a community-based program that offers home visits, arranges transportation to health visits, and provides links to support and social work services. In 2003, Monroe introduced a BabyLove outreach worker to address depression during pregnancy and a social worker to help Healthy Beginnings clinical staff address social problems.

Monroe Plan's NICU admission rates have progressively decreased from a 1998 baseline rate of 107.6 per 1,000 live births to 56.7 per 1,000 live births in 2003. By comparison, NICU admission rates for the general Upstate New York Medicaid population remained in the range of 110 to 115 per 1,000 live births from 1998 to 2002. In addition, Monroe Plan's rate of births at a gestational age below 32 weeks decreased from 2.9 percent in 2001 to 0.9 percent in 2003, and the rate of births with a birth weight less than 1,900 grams decreased from 6.1 percent in 2001 to 1.6 percent in 2003. The number of women beginning prenatal care during their third trimester decreased from 13.0 percent in 2001 to 7.7 percent in 2003. Initial data indicate that the percentage of women beginning prenatal care during their first trimester has increased from approximately 13 percent in 2001 to 21 percent in 2004 and 24 percent so far in 2005.

Asthma Care for Children
Asthma is the primary cause for hospitalization and emergency department visits among children covered under Medicaid. Nearly 5 million of the 12 million Americans who suffer from asthma are under age 18. In an effort to better address the needs of this population, Monroe Plan for Medical Care participated in the Improving Asthma Care for Children program funded by the Robert Wood Johnson Foundation. This Best Clinical and Administrative Practices (BCAP) pilot project seeks to improve the identification and diagnosis of children with moderate to severe asthma, help patients and their families better manage asthma, and coordinate their care in primary care, specialty, and school settings. Since the pilot project was implemented in the winter of 2003, five aspects of health and quality of life for children with asthma have been measured every six months using the Integrated Therapeutics Group (ITG) Asthma for Children Survey [4]. Based on the ITG survey scale from 1 to 100, with the higher score indicating higher quality of life and functionality, the Monroe Plan found that statistically significant improvements have occurred in five domains from winter 2003 to summer 2003:

• daytime symptoms improved from 62 to 66;
• nighttime symptoms improved from 59 to 68;
• functional limitations improved from 73 to 78;
• inhaler interference improved from 77 to 79; and
• family-life adjustment improved from 66 to 71.

Based on these results, Monroe Plan will now expand the pilot program to the rest of its population. In addition to this program, Monroe Plan has worked with other health plans to reach out to high-volume practices that together treat 60 percent of the targeted asthma population. The program coordinator, a certified asthma educator, holds free, five-hour asthma training courses for eligible health professionals. Once they have completed the training and passed a test, they can begin to bill for providing asthma education to plan members.

Cancer Screening
As another quality improvement goal, the Monroe Plan chose to encourage women to have breast cancer screenings. The plan identified women who lacked up-to-date test results and contacted them to set up screening appointments, arranging transportation when necessary. These initial efforts resulted in an overall breast cancer screening rate of about 60 percent. To attain higher screening levels, the plan engaged outreach workers from various racial and ethnic groups to help target enrollees in their communities. By doing so, its breast cancer screening rate increased an additional 12 to 15 percentage points. Monroe Plan has developed other quality initiatives to enhance the plan's approach to care for diabetes patients, coordinate the care of mental health patients after discharge, and encourage enrollees to attend postpartum visits.

Next Steps: The Monroe Plan began rolling out a Practice/Plan Partnership Program at the beginning of this year. About 60 percent of its enrollees currently are patients of 16 physician practices. By assessing and supporting the infrastructural needs of these high-volume practices, the plan hopes to find new ways to enhance the care provided to its members. "It's not a cookie-cutter approach," says Joseph A. Stankaitis, M.D., M.P.H., chief medical officer, but an individualized assessment and strategy for each of these practices.

 Lessons Learned: What does it take to improve care for the Medicaid population? "The approach has got to be patient-centered, number one. You want to empower the patient," explains Stankaitis. "Number two, you've really got to work with the practices as a partner, otherwise you're viewed as an interloper. Outreach is critical." He also credits the improved partnership that New York State cultivated with its contracted plans for the success of the quality incentive program. The leadership of the New York State Department of Health's Managed Care Department has taken an approach where plans, as a group, can sit down and have a productive dialogue about common problems and discuss possible solutions. "They've essentially changed the whole dynamic. They're still a regulator but they're much more collaborative with the plan," says Stankaitis. Monroe Plan has found that its focused quality initiatives improve plan performance and, most important, the health status of their members. Medicaid patients "do care about themselves and about their health," Stankaitis says, citing their high response rates on plan surveys. "The problem you run into is they have many other life challenges they have to deal with and health care might not be at the top of that list." I

mplications: Monroe Plan for Medical Care's quality improvement efforts appear to be paying off. Excellus, which holds the plan's managed care license, has been recognized by the National Committee for Quality Assurance as one of the top 10 Medicaid managed care plans for quality. Last year the program qualified for an additional 1 percent premium through the New York State quality incentive program, an amount that totaled nearly $900,000. This amount is in addition to any cost savings from the programs. For example, the reduction in NICU admissions has produced substantial cost savings, estimated at more than $1.8 million, relative to a program investment of $924,300 through 2003. This represents a return on investment of more than $2 per $1 expended. "The quality bonuses are a significant amount of money and it means that you can do more innovative things," Stankaitis says. The plan's board of directors chose to reinvest these funds in enhanced quality initiatives, a decision that enabled it to roll out the Practice/Plan Partnership Program this year. "New York's Quality Incentive program is probably one of the best things the state could do in terms of incenting organizations to do the right thing," he says. "In our situation, it's been a wonderful thing for us to get additional funds to improve health outcomes and try to eliminate health care disparities."

 For more information: Contact Joseph A. Stankaitis, M.D., M.P.H., chief medical officer, at jstankaitis@monroeplan.com.

References
[1] M. B. Dyer et al. Are Incentives Effective in Improving the Performance of Managed Care Plans? Center for Health Care Strategies Inc., July 2004. [2] J. Verdier et al. Quality-Related Provider and Member Incentives in Medicaid Managed Care Organizations. Center for Health Care Strategies Inc., July 2004. [3] J. A. Stankaitis et al. (2005) Reduction in Neonatal Intensive Care Unit Admission Rates in a Medicaid Managed Care Program. The American Journal of Managed Care 11, 166–172. [4] D. A. Bukstein et al. (2000) Evaluation of a Short Form for Measuring Health Related Quality of Life Among Pediatric Asthmatic Patients. Journal of Allergy and Clinical Immunology 105, 245–251.

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This study was based on publicly available information and self-reported data provided by the case study institution(s). The aim of Fund-sponsored case studies of this type is to identify institutions that have achieved results indicating high performance in a particular area, have undertaken innovations designed to reach higher performance, or exemplify attributes that can foster high performance. The studies are intended to enable other institutions to draw lessons from the studied organizations' experiences in ways that may aid their own efforts to become high performers. The Commonwealth Fund is not an accreditor of health care organizations or systems, and the inclusion of an institution in the Fund's case studies series is not an endorsement by the Fund for receipt of health care from the institution.