Community and Connection Drive UPMC Health Plan’s Multifaceted Success

In September, The American Journal of Managed Care^® (AJMC^®) moderated an insightful discussion with 4 individuals whose involvement with UPMC Health Plan, offered by UPMC (University of Pittsburgh Medical Center) and a Strategic Alliance Partner of AJMC, has proved to be instrumental in furthering health equity and providing high-quality care not only in Pennsylvania, but Ohio, West Virginia, and Maryland.

Thomas Washington Jr, Program Director, UPMC Health Plan Neighborhood Center; Sally Kozak, MHA, RN, Deputy Secretary, Office of Medical Assistance Programs, and State Medicaid Director, Pennsylvania Department of Human Services (DHS); John Lovelace, President, UPMC for You, and President of Government Programs and Individual Advantage products, UPMC Health Plan; and Terri Shields, Founder/Executive Director, JADA House International, addressed on several fronts the challenges and successes each has faced while striving to serve the states’ diverse communities.

Optimizing member outcomes, quality of life, and community support are the common goals they are striving to accomplish through Medicaid offerings and health care equity, integrated care, and collaboration initiatives.

This interview has been edited for clarity and conciseness.

Thomas Washington, Jr

AJMC: Thomas, as a native of Pittsburgh, how has staying and working in your hometown helped to shape your sense of community and connection with the people here?

Washington: We’ve been able to serve a lot of individuals within the UPMC Health Plan Neighborhood Center and focus on multiple areas of need, based on the fact that we're using social determinants. We definitely like to express our excitement about that, about the love for our community that has come from not only working within the community, but from understanding the areas of need from the community members themselves. In the past, I’ve needed some of the same type services that we're providing today to a lot of neighboring neighborhoods.

I believe that it's very important to understand the baseline needs before you're able to say, “Hey, I'm in perfect health,” to understand the needs of the whole person. That is one of the major reasons I have worked so hard to provide our services and programs, because I understand there's no single solution to a problem when it comes to helping and developing yourself as an individual and understanding a lot of those dynamics.

AJMC: Please tell us more about the population that takes advantage of the Neighborhood Center’s wide-ranging services. Are there unique challenges and rewards that come with focusing on their needs?

Washington: That's kind of a loaded question. Due to the fact that we have such a diverse population coming to the center—everyone from refugees to seniors to youths—I can say with certainty that each need is different and each outcome is different. We offer not only citizenship classes, but courses on financial literacy and insurance assistance. There are also kiosks that UPMC Health Plan members can use for virtual clinic and telehealth visits. Even with these challenges, we're blessed to have so many amazing partners under one roof.

Sally Kozak, MHA, RN

AJMC: Sally, as a registered nurse, do you approach your role within the state’s Medical Assistance program through a different lens?

Kozak: I am actually the first nurse to have this position within the department. As a nurse, you’re trained in head-to-toe assessment, and so you bring that integrated system approach to the way you work and how the individuals that we serve receive health care. One of the things people have heard me say since I've come into this world is, “We need to talk about integrating.” Unfortunately, government is not set up that way. You have a behavioral health program over here, you have physical health programs over here, you have children and youth programs over there.

I think one of the things that nursing really allowed me to challenge is, why aren’t we all complementing each other? Why aren't we working together? Why aren’t we focusing everywhere improvement is needed? I think the other thing the nursing background brought is a broader sense of team. I spent years working in the [intensive care unit], where you really are a team. You needed a respiratory therapist, you needed housekeeping, you needed everybody.

So often we hear about team-based care, and so one of the things I've been doing is I've been expanding what we consider a vital member of the team. We're looking at, how do we use pharmacists to provide health care? How do we use community health workers? Is there a role for ambulance providers, paramedics? They all have to be part of that team, because all of health care is important. I think being a nurse has helped me to bring that perspective of my role.

AJMC: Ahead of the April 1 Medicaid redeterminations in Pennsylvania, how did the state’s DHS prepare to deal with potential fallout, particularly panic among those who may not have known they would lose coverage or about the financial implications?

Kozak: We had been planning for 2 years and then we get renewed plans. We work worked closely with all of our stakeholders, our various advocacy groups or managed care organizations, the individual committees that we have within the department, individuals receiving Medicaid services. We worked on what our targeted messaging needed to look like, what our mailings needed to look like. We partnered with the Department of Insurance on the insurance exchange. We had a hands-on process in place where somebody who is eligible that came in through the exchange, we knew how to hand them off. Also, if we had the opposite, if we found somebody that wasn’t eligible, we spent time trying to figure that out. If somebody wasn’t eligible, we gave them them 90 days to get back in.

So we didn't really spend a lot of worrying about what the messaging looked like, what materials looked like. We just really focused on getting the word out. Everywhere we go we talk about it. “Remember to fill in your application, if you get it in the mail. If you get an email from the Department of Human Services, open it.”

John Lovelace

AJMC: John, we know UPMC for You is UPMC Health Plan’s Medical Assistance/Medicare Advantage managed care plan, but we want to know more. Can you provide an overview?

Lovelace: UPMC for You started as a renaming of a product called Best Healthcare, which is how UPMC began as a Medicaid MCO [managed care organization]. It stayed Best Healthcare for about 3 years. UPMC for You has 3 lines of business. The Healthy Choices program encompasses physical health, Medicaid, and medical care. UPMC Community HealthChoices, which is Medicaid dual-eligible people—Medicare and Medicaid—includes long-term services and supports home-based services for people who are eligible or supports facility services. The third product is a Medicaid/Medicare special needs plan.

The idea is to align what Medicare services people get with the Medicaid services they get. This allows for more efficient and more effective health care. The goal is really to minimize the amount of time people spend in hospitals, to reduce the amount of time they spend there when they don’t want to and to make sure their stay is successful.

In the last 6 years of doing the program, we been able to change the amount of services from 50 to 170. People that used to go to nursing homes now stay in the community. People would rather stay home with their families and support than be in a facility. It’s an opportunity to really improve people's lives without spending unnecessary money on emergency rooms and hospitals.

AJMC: Are there any misconceptions or myths about Medicaid/Medical Assistance coverage that you would like to dispel, so that individuals who might benefit from these services are not afraid of asking for assistance or seeking more information?

Lovelace: The big myth probably is that Medicaid, because it's a mostly low income–based program that it's therefore second-class service, that you're getting bargain basement health care or mental health care. It’s actually a very robust program. There's really very little that hasn’t been covered by the Medicaid program. It's acute care, long-term care, medical care, nursing home care and home care. For some, it’s school-based services. There is a whole range of services, and it applies to many people.

People typically think of Medicaid as something for other people, but it could be your grandmother in a nursing home, it could be someone with an autism spectrum disorder in a middle-class family, young people with disabilities who want to continue to work. So, it’s wide range of people with a wide range of needs. And it's something to think about how to take advantage of because the price point is fantastic. It's really, basically free. It also has been expanded recently to product coverage for people who are employed. So you don't have to be unemployed to on Medicaid. It’s not just for poor people; it’s a program for a broad spectrum of people.

Terri Shields

AJMC: Terri, in the 2-plus decades you have been with UPMC Health Plan, what major changes have you witnessed in access to health care services?

Shields: From my experience working in the health plan, I have to say integration. As everyone else has mentioned, you're able to get access to different types of insurance plans without much costs. I have a daughter who works at UPMC Mercy who has Medicaid and she's been able to get the Medicaid for her 5 children. And she's able to do that through work. When I was working there, it was like, you had to have a certain amount of income to get that. So I've seen that change over the years.

AJMC: You are also the founder and executive director of JADA House International. Please tell us about this organization, how it collaborates with the Neighborhood Center, and the individuals who benefit from your services.

Shields: JADA House International started in my house by a group of women. They were sort of the key. And I decided to do something for everyone: the seniors, the teenagers, the middle ages in between. I collaborated with Thomas about the idea of where we would help seniors and caregivers get educated about dementia and Alzheimer disease, about cognitive thinking. It’s really about just educating their mind, trying to get them to think a lot.

I took care of my dad who suffered with dementia the last 3 years of his life, and it made me want to understand what it is and have people or caregivers understand what it is. So my job at JADA House is to educate the seniors, motivate them, give them more sustainable living while they're in their last stages of life. We have the opportunity to do that here by working with the Neighborhood Center.