About Gateway Health Plan^®

Gateway Health Plan^® (Gateway) was established in 1992 as an alternative to Pennsylvania’s Department of Public Welfare's Medical Assistance Program. Gateway Health Plan^® provides service to more than 250,000 members eligible for Medical Assistance. In January 2006, Gateway launched Gateway Health Plan Medicare Assured^SM, a Medicare approved Special Needs Plan in Pennsylvania for individuals who are eligible for both Medicare and Medicaid and live within Gateway’s service area. Gateway currently operates Gateway Health Plan Medicare Assured^SM in 27 Pennsylvania counties and 12 Ohio counties.

Gateway Health Plan Medicare Assured^SM is among the largest Medicare Special Needs Plan in the nation for the dually-eligible population with more than 24,000 members.

Innovative Leadership
Under the direction of Michael Blackwood, President and CEO, Gateway Health Plan^® has become a leader in innovation while remaining focused on ensuring access to quality care for our most needy citizens.

Top Honors
Gateway Health Plan^® is one of the nation’s top Medicaid health plans. For the past four consecutive years, U.S. News & World Report and the Committee for Quality Assurance (NCQA) placed Gateway Health Plan^® among the highest rated Medicaid health plans in the country. The 2007 report, National Committee for Quality Assurance “America’s Best Health Plans,” ranks Gateway Health Plan^® #12 among 196 Medicaid plans nationwide. It is the top-ranked Medicaid plan in Pennsylvania. In 2006, the National Committee for Quality Assurance (NCQA) awarded its highest, four-star accreditation status of “Excellent” to Gateway for its Medicaid HMO product. According to the NCQA, achieving excellent accreditation status is significant because it is only awarded to those plans that meet or exceed rigorous requirements for consumer protection and quality improvement. Further, Excellent accreditation status requires Health Plan Employer Data and Information Set (HEDIS) results in the highest range of national performance. Specifically, NCQA looked at how easy it is for Gateway members to get care and services, how well Gateway helps its members remain healthy and avoid illness, how well Gateway cares for its members when they are ill, and members with chronic illness, and how well Gateway rates doctor’s care provided to members. Gateway has one of the highest Health Plan HEDIS scores in the nation for Medicaid—in excess of 98 percent.

Quality
Making quality the basis of performance demonstrates Gateway’s underlying dedication to member satisfaction. Gateway’s 2004 Consumer Assessment of Health Plans (CAHPS) scores revealed a profound satisfaction among members by receiving a perfect score that equates to the Health Plan meeting or exceeding all established standardized measurements at the 90th percentile or above. As an independent agency, the NCQA results indicate the strength of Gateway Health Plan^®’s overall member services, from efficient and timely claims processing to assisting its members in receiving the care they need. While earning the NCQA “Excellent” level of distinction places Gateway in the highest tier of health insurers in America, at the same time, Gateway has reduced its administrative cost ratio to below eight percent.

Managing Care Compassionately
At Gateway, we prove that it is possible to be both compassionate and viable. Gateway’s priority has been to ensure that care is delivered in the most cost-effective manner commensurate with the individual member’s needs.

Gateway is working with providers and others involved with our members’ care to address specific health needs. Programs focused on managing diabetes, preventing and treating obesity, smoking cessation among pregnant mothers, controlling asthma, and a multitude of other initiatives are testimony to Gateway’s commitment to improving the quality of life and health status of our members and serve as a model for others to emulate.

Prospective Care Management (PCM^®) “Meeting Members Where They Are”

Innovatively Addressing the Needs of Those in Our Community
Over the past several years, Gateway Health Plan^® has designed and implemented an enhanced healthcare management model called Prospective Care Management (PCM^®). PCM^® addresses the unique challenges faced by our most vulnerable citizens in accessing medical and social support services. This approach uses cutting-edge techniques to examine the varied aspects of a person’s life – behavioral, environmental, economic, medical, social, and spiritual (BEEMSS^SM) – to understand and help overcome the barriers to care.

The goal of PCM^® is to improve the overall health status and maintain the well-being of each member. By “Meeting Members Where They Are” in their lives, PCM^® focuses on addressing issues that stand in the way of accessing the healthcare system and living healthier lives.

Going Beyond Traditional Disease and Care Management
PCM^® takes a proactive, holistic approach to design an individualized plan of care. Gateway’s care coordination staff provides disease specific education, instruction in self care, and helps locate referrals to community-based services. Gateway collaborates with physicians and community organizations to implement a treatment plan that addresses each member’s unique needs.

Building Invaluable Community Partnerships
Gateway recognizes the importance and value of partnering with physicians, providers and community agencies in the management of the medically and socially complex issues of our members. To improve member functional status and quality of life, we encourage and seek out the participation of these partners.

Actively Engaging Members and Their Caregivers
The PCM^® approach centers on actively engaging members and their caregivers to anticipate problems rather than simply react to them. Once interventions have been established, continuous feedback of information allows Gateway to comprehensively update the treatment plan.

The following case studies show how PCM^® can make a difference in the lives of our members:
Member Challenge #1

A 57-year-old woman is overwhelmed by the physical, social and financial difficulties of life. She has missed important doctor's appointments and has been forced to visit the emergency room several times for her diabetes, depression and asthma. The member's primary care physician (PCP) refers her to a Care Manager(CM) at Gateway Health Plan^® to address her poor adherence to the treatment plan.

PCM® Solution
In discussions with the member, the CM discovers that her financial situation has impacted her ability to get to appointments, purchase groceries and pick up much needed medications. Using the PCM^® approach, the CM takes immediate action to help and: 

- Identifies a utility support program to help pay the bills

- Works with the pharmacy to institute a mail order program that ensures the member will receive her medications on a regular basis

- Contacts the Medical Assistance Transportation Program to arrange transportation to physician visits and offers a food bank referral in the interim

- Arranges an appointment with behavioral health services for evaluation of the member's emotional need

Results
Within a few weeks, there are marked improvements in the member's medical and emotional health. Her asthma, diabetes, and mild depression are better managed.

Thanks to the innovative PCM^® approach to care, the member is enjoying a better quality of life and a positive feeling about the future.

A 69-year-old man with diabetes and loss of vision in one eye lives alone. His functional limitations have led to depression. He often sits at home smoking and not taking care of his health needs. The Gateway Care Manager (CM) also learns that that the member is not keeping appointments with his primary care physician, and it is questionable whether or not he is taking all of his medications as prescribed.

PCM^® Solution
Using the PCM^® approach, the CM takes immediate action to help and:

- Provides education, support and coaching to help the member stop smoking

 - Provides counseling to the member and educates him on the importance of keeping his appointments and taking his medications

- Explains the benefit of behavioral health support

During counseling, the member receives word that he can no longer live in his apartment; he must move within 60 days. The CM provides a helping hand and:

- Works closely with various community agencies to identify affordable housing for him 

- Discusses options to help the member to become less socially isolated, and the member agrees to try out a Day Program

- Works with the Area Agency on Aging to complete the necessary paperwork and coordinates with a local Day Program to facilitate the member's enrollment

Results
Through such help and guidance, the member is no longer sitting in his home alone all day. He is embracing a new way of life that actively involves others in his care, treatment and well-being.

A 64-year-old woman resides with her frail husband. While spending her time and energy caring for him, she overlooks some of her own healthcare needs, which include multiple sclerosis, hypertension, cellulitis, depression and an addiction to cigarettes. She also has financial and accessibility issues that stand in the way of a healthy life. She cannot afford simple things, like a shower chair that can help ensure she does not fall - a real possibility for someone who has been identified as high-risk for falls.

PCM^® Solution
Right away, the Gateway Care Manager (CM) applies the PCM^® approach and:

- Coordinates with the member's Primary Care Physician (PCP), and other Gateway departments to help the member obtain the durable medical equipment she needs. This includes nutritional supplements to help the member take in the adequate caloric intake needed to manage her cellulites

- To treat her depression and smoking issues, provides the member supportive counseling and education and encourages her to become involved with therapeutic services

- Connects the member to various community resources for financial assistance

- Educates the member's husband on the Social Security Disability processes

- Works with the member to secure in-home supports through the State Waiver program

Results
As a result of working with the CM, the member feels less overwhelmed. Having access to the supplements has resulted in her weight being stabilized, her cellulitis improving, and an increase in energy.

These and countless other stories showcase how PCM^® helps Gateway members take charge of their health and wellness. By targeting members who are at higher risk for developing serious health issues, PCM^® is critical to our ongoing efforts to foster a healthier member population.

Ensuring Quality Care
An 18-member Quality Improvement Committee strives to keep Gateway on the road to continuous improvement. Since Gateway’s inception, the Committee has played a critical role in the organization’s success. The QI Committee, which is made up of experts in a wide variety of medical fields, assesses all of Gateway’s efforts to ensure the delivery system results match the organization’s high standards for quality.

The Committee not only assesses Gateway’s ongoing efforts, it also works to assess new protocols and clinical guidelines to improve care. For example, the Committee members worked with a number of neonatal intensive care unit physicians across Western Pennsylvania to create guidelines for the proper care of premature infants. The guidelines are helping to reduce the rate of clinical complications for premature babies.

In 2007, the Committee worked with practicing physicians to introduce clinical guidelines designed to ensure the proper care for babies born to drug addicted mothers. In addition, a comprehensive training video was created to teach nurses how to remove drugs from babies’ systems and put them on the road to better health.

Gateway is dedicated to providing the best care to our members. That means making sure the provider and measurement systems are in place to ensure high quality care and making sure it actually reaches the member at the ground level.

Wellness and Education
Community wellness begins with awareness and prevention.

Gateway Health Plan^® brings a variety of educational outreach seminars and other support services designed to actually keep people out of the hospital. Gateway also participates in a number of programs to help train tomorrow’s health care professionals in many fields, strengthening our pool for future caregivers.

• Participation in community events
• Sponsorships
• Board and committee technical support
• Volunteer activities
• Health Education programs

Gateway Health Plan^® is committed to perpetuate that spirit of giving in the coming years, with a focus on providing access to the highest quality care.