Claremont Village rests just south of the Cross Bronx Expressway. It’s home to about 13,000 people living in one of the largest public housing projects in New York City. Residents are among the poorest in the country. It is just one of the 12 high-crime, low-income neighborhoods that is served by Healthfirst, an insurer that last year scored a 4 in CMS’s 5-Star Quality Rating System for Medicare Advantage Plans.
That’s quite a feat, because many of Healthfirst’s members have the serious health problems associated with low socioeconomic status. More than half of Healthfirst’s approximately 120,000 Medicare Advantage members are dual eligibles, and 80% qualify for a low-income subsidy for prescription medications. It’s also a diverse population that is 46% Hispanic and 36% African-American.
Private and public hospitals in the region sponsor Healthfirst, which serves Medicare beneficiaries in New York City’s five boroughs and in Nassau and Westchester counties. It’s the providers who fund the pay-for-performance incentive programs “that form the foundation of our ability to perform well in all of the various domains of the stars program,” says Susan J. Beane, MD, Healthfirst’s vice president and medical director. In the Medicare stars system, one additional star can be worth millions of dollars in bonuses for a health plan.
A provider-funded P4P program lays the foundation of Healthfirst’s good performance, says Susan J. Beane, MD, the plan’s medical director.
Provider-sponsored health plans (PSHPs) like Healthfirst aren’t new, but they may become more common as long as the ACA stays relatively intact. A white paper by the Advisory Board Company says that the health insurance exchanges give unprecedented opportunities for provider-sponsored health plans to compete with traditional health plans.
PSHPs collect insurance premiums directly from employers and individuals, giving hospitals and the physician groups affiliated with them more financial control then they have in other payment systems.
Healthfirst knows it can’t eradicate poverty, but it strives through one of its programs, Healthy Villages, to address the health problems that may arise from it. According to the New York City Department of Health, many of the residents in the neighborhoods where Healthfirst’s members live don’t have a primary care physician and go to the emergency department (ED) when they are sick. To partially fill the void, Healthy Villages holds health fairs, free diabetes screenings, and counseling sessions on medications.
Healthy Villages was launched in 2012, so outcome measurements are still inconclusive. Preliminary results suggest that engagement with the program is associated with lower HbA1C levels and a 5% reduction in ED visits.
All insurers can replicate Healthfirst’s success by forging better relations with providers, says Joyce Chan, who oversees the plan’s clinical performance efforts.
Healthy Villages borrows much of its approach from the Camden Coalition of Healthcare Providers, a nationally recognized effort spearheaded by Jeffrey Brenner, MD, that focuses on the 1% of patients who account for 21% of costs by bringing care into tough neighborhoods.
Forging deep partnerships with providers is something all insurers should consider doing, says Joyce Chan, who oversees Heathfirst’s clinical performance efforts. “Because we’re provider sponsored, we have a special relationship with many of our providers. But we aren’t an integrated system, so we have many of the same challenges that most health plans have,” she says.
Chan says Healthfirst works actively with its providers, many of whom are highly engaged and eager to receive and understand quality data. “It’s important to us because it affects quality scores like our Medicare Star Rating, and it’s important to them because it affects their own quality scores,” she notes.