Improving the Coordination of Care for Medicaid Beneficiaries in Pennsylvania

Bielaszka-DuVernay C
Source: Health Affairs
Publication Year: 2011
Patient Need Addressed: Care Coordination/Management
Population Focus: Complex care, Medicaid beneficiaries
Intervention Type: Service redesign
Study Design: Pre-post with Comparison Group
Type of Literature: White

Mercy Health System, a member of Catholic Health East, serves Philadelphia and southeastern Pennsylvania through four acute care hospitals, community and home care services, and affiliated physician practices. The system is also part owner of Keystone Mercy Health Plan, a Medicaid managed care organization serving more than 300,000 Medicaid recipients in the greater Philadelphia region.

The two organizations improved care coordination by placing Keystone Mercy care managers in provider settings affiliated with Mercy Health System, resulting in fewer hospitalizations, shorter stays, and fewer readmissions. But patients receiving care coordination were more likely to choose the Mercy Health System hospital that participated in the pilot program, increasing its admissions volume among this population.

COST SAVINGS: Unpublished data show that in the pilot, per member per month savings were $37.70 for the patient population that received improved care coordination.


RESULTS: Among the group receiving improved care coordination, the rate of hospital admissions per 1,000 members per year was reduced 17 %, and length-of-stay dropped 37 %.

CHALLENGES: These include misalignment between the two organizations’ respective performance and financial incentives; providing local “champions” with the support they need to sustain their own focus and enthusiasm during the hard work of change, as well as their colleagues’; and identifying appropriate metrics to evaluate care coordination outcomes.

Insights Results

Overview of article/program

  • This article describes the components and successes of a joint project that aim to improve care delivery for high-needs Medicaid patients in southeastern Pennsylvania
  • Mercy Health System, a Catholic healthcare provider, and Keystone Mercy Health Plan, a Medicaid managed care organization partnered to pilot a care coordination project, aiming to improve care delivery for the same high-needs southeastern Pennsylvania population that they serve
  • Before diving into program development, 3 points were identified in which change could be made to make the greatest impact: 1) Primary care setting (i.e., a medical home for patients); 2) Transition from hospital to community (i.e., tighter systems to prevent readmissions and reconnect patients back to the medical home); and 3) Community (i.e., supplemental healthcare services and resources)
  • The program began with 1 care manager, who added the value of being able to give providers a more complete picture of their patients, and ability to combine the system and plan’s data to identify care gaps (e.g., missed mammogram). Talking 1:1 with patients in person and on the phone also allowed the care manager to identify barriers
  • A transition care manager was also hired to help patients transition from hospital to ambulatory care
  • For community resources, the program partnered with a local nonprofit to help with follow-up coordination


    • Hospital admission rate dropped by 17% and average length-of-stay fell 37%, for a 48% decrease in inpatient days per 1,000 members. Hospital days per admission declined from 4.3 days to 2.7 days
    • Patients began to prefer Mercy if they needed hospitalization and were more likely to remain in the health plan
    • 36% of patients reported they went to the emergency department because they didn’t know what else to do. Another 20% said they wet because their primary care physician was not available

    Key takeaways/implications

    • Many benefits of the pilot stemmed from sharing and combining data. Partnership allowed for better care delivery and better efficiencies
    • Challenges faced in the pilot include lack of alignment between the 2 organization’s financial and performance incentives. Moving forward, the 2 are exploring policy changes that will align their respective incentives. Leadership commitment is also necessary for a larger scale pilot