A Part of the Community: Caring for Underserved Individuals in New York City

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Healthfirst's Medicare Advantage members are largely low income, and actually poorer than its Medicaid members. In order to reach these members and foster trust, Healthfirst makes itself a part of the fabric of the community.

As the third largest insurer in New York City, covering 1 in every 8 residents, Healthfirst’s Medicare Advantage members are largely low income, which presents challenges and allows for unique solutions, explained Pat Wang, CEO of Healthfirst, during a session at America’s Health Insurance Plans’ National Conference on Medicare.

Healthfirst’s beneficiaries are predominantly non-white and 53% speak a primary language other than English. According to Wang, there are dozens of other primary languages, so much so that the company will staff people who speak 7 to 8 different languages. In addition, Healthfirst relies on physicians who come from the communities in which its members reside.

Two-thirds of Healthfirst’s Medicare members live in a designated health professional shortage area, which is much higher than the 13% national rate. On average, 29% of Healthfirst members in the areas live in poverty compared with 15% nationally.

“Our Medicare members are very poor,” Wang said. “They are poorer, it seems, than our Medicaid members.”

Wang took the time to highlight what these underserved individuals look like:

They have low education levels, which means a lower health literacy and poor compliance. This can make it difficult to move the needle on this population’s health.
The population has cultural diversity, which can mean more traditional attitudes toward health, such as a reliance on botanicals and healers, and a suspicion of organized American medicine.
The members are clinically complex, which manifests as multiple comorbidities, plus behavioral health issues.
There is a low engagement rate, which is a result of a low contact rate. Wang explained it is difficult to reach these members because they move frequently, don’t have phones, or have housing instability.
Members reside in high-poverty, high-crime neighborhoods. As a result, they may not get a lot of physical activity because they are afraid to go for a walk, they may be reluctant to leave the house to pick up prescriptions, and they do not want prescriptions mailed to them because of crime.
Finally, they face economic challenges that trump healthcare. For example, it’s hard for a member to care about missing an appointment for a breast cancer screening if she is facing food insecurity, Wang said.

In order to reach these members, Healthfirst makes sure it is part of the fabric of the community it serves.

“We believe that trust is the key to engagement, not just for our members, but for the delivery system, as well,” Wang said. “And engagement is the key to better health.”

While Healthfirst does rely on data to stratify members for the purposes of care management, it tries to make workers available in other ways and really pushes to have “feet on the street.”

“Big data has not yet replaced the personal touch in our experience,” Wang said.

In order to prioritize how to invest its dollars, one of the most important questions Healthfirst considers is if this investment is going to foster trust with members in the community or undermine trust. Trust is important, Wang said, because many members remember the Tuskegee Syphilis Study, and have a mistrust of organized medicine and the ethics of what the medical system is doing.

Healthfirst has a number of changes and improvements it is striving for, including delivering relevant information to providers at the point of care, coordinating high-value care management activities, and strengthening provider capabilities to manage risk. In addition, Wang added that she would like to see the Medicare program align and reduce the number of quality metrics required of providers and further adjust for socioeconomic status in the quality bonus programs.

“I really thank CMS for the work that they have done to recognize the role of socioeconomic status in the quality rankings, but also more work needs to be done,” she said. “It’s a good first step, but in 2 particular areas—medication adherence and avoidable hospital care—more is definitely needed.”