New VNS CHOICE Medicare Helps People Who Are Eligible for Medicare/Medicaid Get Better Care
Maria S., 67, is diabetic and has high blood pressure and circulation problems. "She came to us because she believed we could make a difference in improving her health," says Mazin Farraj. "She thought we'd be able to listen to her needs and help her prepare for her future."
Maria was not looking for a health care provider; she was looking for a health insurance plan that she could rely on if she needed it. "Maria says that being part of VNS CHOICE Medicare is the best thing that has happened to her, because we have shown her we do really care and will always be there to support her," says Mazin, the director of sales for VNSNY's Medicare Advantage plan, called VNS CHOICE Medicare.
Like Maria, Betty, 80, has several chronic conditions. She was having trouble getting all of the health care she needed despite being eligible for both Medicaid and Medicare, and the plan in which she was enrolled did not cover all of her prescription drugs. Betty's son, James, desperately needed someone to assist and guide his efforts to oversee his mother's care.
VNS CHOICE Medicare was designed specifically for people like Maria, who require coordinated care plans to manage their chronic conditions, and for people like Betty, who face significant barriers to access, do not have Internet service, and may rely heavily on son or daughter for help with their health care.
"We're trying to break down those barriers and connect these participants with good health care," says Christopher Palmieri, executive director of VNS CHOICE Medicare. "Our plan goes well beyond providing full health coverage."
The managed care plan was tailor made by the Visiting Nurse Service of New York (VNSNY), which draws on more than a century of expertise providing nursing care in the New York City area as well as an extensive knowledge of the local resources that are available to people who need supportive services in their homes and community. In addition to all of the standard Medicare-covered services, such as physician and hospitalization services with no co-pays, VNS CHOICE Medicare provides rides to medical appointments, enhanced vision benefits, specialist visits without a referral, and an innovative nurse ambassador program that allows any participant to receive a visit from one of VNSNY's highly qualified nurses up to four times a year.
Ensuring Essential Care
In its 113 years of providing health care to vulnerable New Yorkers based on their clinical needs, VNSNY has long recognized that a significant barrier to quality care is its patients own fragmented health coverage. It is not uncommon for health insurance companies to be overly rigid, withholding authorization for care that VNSNY nurses consider essential. On October 1, 2006, the agency launched its first health insurance package for "dual-eligibles"—people eligible for Medicare and Medicaid in all five boroughs of the city—so that it could provide even better care to its patients as well as the citizens of New York City.
"Offering a health plan is a way for VNSNY to introduce itself to members of the community who have no clinical need other than a good health plan, as well as to assist a large portion of our home care patients," says Mr. Palmieri. Forty percent of the people served by VNS who have Medicare are also "dual-eligibles," and the organization participates in a dozen managed care plans, so it has acquired much expertise in this area.
What makes the new health plan unusual is its case-management approach and easy access to the nursing resources of VNSNY. Nurses—not bureaucrats—who work closely with the patient's own health care providers, make the determination of what kind of heath care is needed. "We really put care first," Mr. Palmieri says.
In addition, says Karl Dehm, director of compliance and regulatory affairs, nurses look at the whole person with the goal of combining the community-based services that he or she needs and for which he or she is entitled.
"Many people who receive Medicaid are entitled to food stamps, heating assistance, and other forms help of which they may not be aware," says Mr. Dehm. "People may know that these benefits are out there but don't know how to get them, and some are too sick to go running around trying to make their way through the bureaucracies in order to apply. We can help," says Mr. Dehm.
Getting Through on the Phone
As with any insurance plan, the main access point to VNS CHOICE Medicare is through the telephone. For participants who are used to getting caught up in an endless voicemail cycle, VNS CHOICE will be a refreshing alternative, with nurses standing by to help.
The plan's biggest plus is the set of resources that VNSNY has to offer. According to Mr. Palmieri, VNS CHOICE Medicare staffing ratios are the lowest in the industry. Whereas larger companies may often have one registered nurse for every 10,000 customers, VNS CHOICE Medicare has one RN for every 250 people who enroll. That allows nurses to spend an adequate amount of time determining care needs and coordinating primary care and home- and community based services. If a member wants to talk to a nurse about her care, she can at any time.
"We have a close relationship with the 2,500 RNs of VNSNY, and we have contracts with ourselves," says Mr. Palmieri. "The response time and availability of staff are guaranteed. This is our philosophy, but it is not highly recognized within the insurance arena."
VNS CHOICE Medicare has a strong emphasis on providing health education to patients who have specific diseases, helping them manage those diseases, coordinating care with primary care physicians, and getting them to the right specialists. By focusing on education, self-care, and primary care, the VNS CHOICE Medicare goal is to avoid unneeded hospital admissions.
"If we authorize a test or get someone primary care, it will cost more up front, but in the long run people will be healthier or at least maintain their health," says Mr. Palmieri.
In addition, VNS CHOICE Medicare will reduce the bureaucratic hurdles—such as the need to obtain referrals to specialists—that health plans often impose on their members when they need to obtain services. The plan's prescription drug coverage includes a broad formulary that includes all of the drugs most frequently prescribed for an elderly population, and it excludes requirements for "step-therapies" and most of the need for prior authorizations.
"We want people to take the medications that they need to remain healthy and believe that giving people easier access is an important way to achieve this goal," says Mr. Dehm.
VNS CHOICE Medicare is a federally funded Medicare Advantage Special Needs plan. These plans were established by the Medicare Prescription Drug, Improvement and Modernization Act of 2003 to encourage managed care for people in the Medicare program. The plan covers all Medicare Part A, B, and D services—physicians, hospitalization, skilled nursing facilities, and prescription drugs. Although such plans can be geared to cover specific populations, like those with diabetes, VNSNY chose to focus on its own population, which includes many people with multiple chronic illnesses. There are eight licensed sales representatives marketing the insurance product in senior centers, in physician offices, and on the street—wherever older patients may be. In addition, a community-based marketing campaign is under way.
Mr. Dehm emphasizes that the insurance plan is more than a product; it is a piece of VNSNY's larger goal of improving public health, very much in keeping with its mission. That mission particularly guided the organization's choice to serve low-income, older people because they are not necessarily served well thought traditional managed care.
"We're a place where people with chronic illnesses, functional deficits, and other real health problems get care," he says. "We don't view ourselves as a big player in the HMO world but are making sure vulnerable populations are served well at home. As a local health plan, we know who cares for people here in New York, and our care mangers can link local people to local services. We help them navigate the system."
To find out more about VNS CHOICE Medicare, please call 1-866-867-0047 or visit the VNS CHOICE Medicare part of our website: www.vnschoice.org
