By Susan Beane, MD
Healthfirst is a provider of Medicaid Managed Care plans in downstate New York and, in concert with our sponsor hospitals and medical centers in New York City, has been at the forefront of value-based care models since we were founded 25 years ago. As a Medicaid plan provider, people with a variety of complex health needs trust us on their care journey, so we care about health inequities and the impact on our communities. It can be difficult for health plans to focus on public health urgencies such as disparities and equity at a time when we are expending significant energy and resources on the transformation of the health care delivery system, but our unique expertise, and our design of value-based payment models, enables us to be a partner with others who are seeking innovative and evidence-based programs to address inequities in health care and outcomes.
At Healthfirst, we engage in three major approaches to improving health outcomes for our members. First, we promote access through outreach programs that inform, promote and invite individual members to meet key health prevention and chronic disease outcomes. The second is our Partnership and Spectrum of Health programming, that centers on close collaboration with our provider community to improve outcomes for the patients that they serve. The third approach is at the population-level, with collaboration and initiatives that often reach beyond our managed care organization to test innovative approaches to reach our most vulnerable members. We are constantly tracking, trending and stratifying our data to see where we’re succeeding and what we still need to work on to encourage better health across the population. It is this collaboration with a range of community-based and care-delivery systems that helps us target initiatives to the settings where our support and incentives can be most useful—for example, inpatient versus ambulatory care versus community-based care.
Given our approach to process and performance improvement, it was an obvious decision for us to join the Mount Sinai Health System in piloting an integrated value-based payment and health care delivery reform intervention to improve postpartum care for high-risk mothers. The intervention involved a cost-sharing arrangement between Healthfirst and Mount Sinai to hire a care coordinator/community health worker and social worker, small financial incentives from Healthfirst to Mount Sinai’s affiliate ob/gyn providers, and patient and provider education about postpartum care. You can read more about how it worked here.
For this intervention, we used as our main outcome metric the percentage of Healthfirst plan patients who had a timely postpartum visit — a HEDIS measure that is also used by the New York State Department of Health to assign star ratings to Medicaid programs, and which was important to Mount Sinai as it has a long history of serving New Yorkers for women’s health and obstetrical services. In addition, New York State has recently focused on improving postpartum care outcomes, making it a good time to look at designing an integrated payment and health care delivery reform program to address this issue.
From the Healthfirst perspective, we want to be part of the solution for birth equity, not only for our members, but for all New Yorkers. In particular, access to postpartum care provides women an opportunity to connect to ongoing care and services, especially if one or more co-morbidities are found during the perinatal period. It is one of the few opportunities physicians have to check in with them and catch important health issues that might otherwise go unaddressed.
This intervention enabled us to focus on a group of women who are at higher risk for long-term poor health, but who are least likely to access the postpartum visit. Preliminary results indicate that we significantly increased the percentage of timely postpartum visits in the population of women living in high-risk zip codes with higher risks of screening positive for diabetes, hypertension or depression.
I was especially impressed by the number of patients who stayed engaged with their providers. According to preliminary data, 74 percent of patients who started the intervention while in the hospital to give birth completed multiple contacts with the care coordinator/community health worker and social worker, all the way through to their postpartum visit. This has the potential to translate into long-term health benefits and engagement. Throughout the intervention, women had several points of contact with the care coordinator/community health worker, and some even trusted her so much they reached out to her on their own. I believe these multiple touchpoints were partly responsible for the high engagement levels. A prior initiative that Healthfirst conducted in Brooklyn also suggested that multiple touchpoints were essential to engage women in prenatal care. These vulnerable women may feel isolated and their needs neglected, and having someone care about their welfare was encouraging to them. For this reason, I believe our cost-sharing arrangement with Mount Sinai to pay for a care coordinator/community health worker and social worker was a smart investment.
Designing interventions that address the needs of the most vulnerable populations in our communities and managed care plans are a challenge. Questions that we discussed as we framed this intervention included: Will the obstetrics practice have funds for the initial hire of the coordinator/worker for this intervention? Does the plan’s incentive program provide funding at the practice level to sustain this worker? How does the obstetric practice provide a warm handoff to other providers in the delivery system in a manner acceptable to the women in the study? Will other managed care plans provide similar funding so that the program is available regardless of insurer?
In order to allow for future such efforts, though, we need to deal with a few challenges. Right now the Medicaid program in New York is beginning to consider how to transform usual care processes to include and reimburse community health workers and other peer-based services. Health plans will need the outcomes from studies like this to create the business case to justify future and ongoing investments in transforming practice processes through innovative interventions. For example: Do the impressive patient engagement levels translate to longer-term efficient and effective use of care by the women and families touched by the intervention? Does it lead to better long-term health? We also have much more to learn about setting the proper level of financial incentives for care team members, and which team members to incentivize.
We look forward to seeing the results of other work in this area, and hope that this and other interventions can help payers build the business case for pursuing initiatives and programs that are part of the solution for health equity.
Susan Beane, MD, is Vice President and Medical Director of Healthfirst.