Partnership with providers is key to good care

Health plan reaches out to hospitals, physicians

When Philip Bonaparte, MD, joined Horizon Mercy as chief medical officer, his vision was for the health plan to be a partner with the local health care providers.

"Although we are a health plan, we do not provide direct health care for the members. Our role is coordination, and we can do that more effectively by forming a close working relationship with the doctors, the hospitals, and other clinicians who are touching the members and providing the care," he says.

One of his initiatives in improving health plan-provider relations was to create a dedicated hospital liaison who is dedicated to helping the hospitals decrease denial rates.

Another involved putting Horizon/Mercy case managers on-site at some of the area's largest hospitals, working with members who need complex assessment and care plans. One goal is to cut hospitalizations and emergency department (ED) usage among this population.

The on-site case managers collaborate with the hospital case managers and social workers to make sure the patients know their primary care provider and they coordinate transportation and other social needs. They work with the Horizon/Mercy members to encourage them to see a primary care physician rather than using the ED for their routine medical needs.

Negotiating to expand

Before the program was implemented, Bonaparte; Pamela Persichilli, RNC, the ­director of utilization management; the health plan's hospital liaison; and director of social case management liaison met with representatives of the case management department, social work department, and medical leader-ship in all the hospitals.

The hospital representatives asked a lot of questions before the program began and three of the 10 initially approached declined to participate.

"Every hospital has social workers. We did not want them to feel threatened that we were coming in to take over their job. Once they recognized that we wanted a true partnership with them, they embraced the idea," Bonaparte says.

The project is in place at seven of the largest hospitals with which Horizon/Mercy contracts. The health plan is negotiating to expand the program to other hospitals.

A matter of access

Hospitals are pleased with the program because it has cut down on the patient load at their busy EDs.

"We know that the inner-city hospitals are so overwhelmed with emergency room utilization. The waits are long and it's not the most conducive way to get medical care," Persichilli says.

Bonaparte has been working with physicians whose patients have a high rate of ED visits.

"Mostly, it is just a matter of access. The doctors have office hours from 10 a.m. to 4 p.m. These members don't have the luxury of going to the doctor during regular hours because they cannot get off work," Bonaparte says.

He's persuaded many of the physicians to increase their office hours to accommodate working parents.

"When people have a true emergency, they should be in the emergency room. When you have members who do not need to be there, it slows the treatment process. It wastes everybody's time and money to have people visit the emergency room for routine care," Bonaparte says.

Pilot projects

The plan has begun a social work pilot project in the emergency department of one of the large hospitals. The hospital gives the Horizon Mercy social worker space to meet with the members in the ED.

"One of the biggest obstacles with Medicaid members is changing their behavior so they do not seek care from the emergency room," Bonaparte says.

As many as 80% of ED visits by Horizon/ Mercy's Medicaid population are not for true emergencies, he adds.

"They might have been urgent but they should have occurred in an ambulatory setting," he says.

The social worker meets with Horizon Mercy's Medicaid population who come to the ED and helps them develop a relationship with a primary care physician or specialist provider. She teaches them to use the ED only if there's a life-threatening situation.

"Many times, these members will sit there for hours for something as simple as a child's runny nose. They are afraid they will lose another day of work if they do not stay," he adds.