Hello colleagues,
We are launching an informative series of articles that will tell you about EmblemHealth’s and ConnectiCare’s Medical Directors, what we do to ensure your patients receive the right care at the right time, as well as other “Hot Topics.”
To get started, let me introduce myself and tell you about our team. I’m Dr. Sandra Rivera-Luciano MD, MHSA, and I serve as one of the Senior Medical Directors for both EmblemHealth and ConnectiCare. My specialty is General Pediatrics. I have been with the companies since 2018. My primary role is to serve as a Senior Medical Director under the leadership of both doctors Indulekha Warrier, Vice President of Medical Affairs & Chief Medical Officer, ConnectiCare, and Richard Dal Col, SVP, Chief Medical Officer for the EmblemHealth family of companies.
I am part of a team of over 200 nurses and 11 physicians. All are licensed and hold utilization management certification by MCG, an organization that develops evidence-based review guidelines used by many provider communities and payers across the nation. In addition, our physicians are board certified in various fields of medicine including, but not limited to, Internal Medicine, Family Medicine, Pediatrics, OB-GYN, GYN Oncology, Palliative Care, Infectious Disease, and Occupational Medicine.
We also collaborate with organizations that conduct utilization management for their own members as part of value-based arrangements, and with others that provide specialty specific expertise to supplement our own. We work closely with our provider communities, members, and UM partners to ensure access to high-quality care for all our members.
Let’s look at one of the ways we ensure access to high-quality care: utilization management. Our UM program is guided by appropriate, evidence-based clinical criteria, as well as policies and procedures that ensure uniformity of UM processes.* We are committed to making this process both member- and clinician-friendly by establishing collaborative relationships with our provider partners.
Here are two of the ways we put this approach to UM into practice.
- Changes to ongoing maintenance infusions. Our data analysis showed hospital-based infusions cost our members much more than if they received the same infusions at home, at their doctor’s office, or in an ambulatory setting. Using this information, we set up a concierge program with New York Cancer & Blood Specialists offering an enhanced experience at convenient locations and at a lower cost. We also aligned our policies and workflows to account for site of service. Now, we proactively identify members who can benefit from a site of service change and have staff call the member and the provider to offer and broker a better option.
- EmblemHealth and ConnectiCare’s Case/Care Management programs. These programs offer a great way to partner with us. Our team-based approach not only facilitates our collaboration with you, but helps you coordinate with all other providers who are part of the effort to support members with complex care needs.
UM is only one way we help our members access quality care. We want to shift from fixing what is broken to preventing the damage in the first place, or catching it as early as possible. We can do this together by encouraging members to get needed care, including immunizations and screenings. For instance, now is the time to take advantage of the back-to-school season to bring students in for visits.
In next month’s article, we will share insights on preventive care.
Until next time!
Sandra
Sandra Rivera-Luciano MD, MHSA, FAAP
Sr. Medical Director/Utilization Management
*We believe that partnership includes transparency. We invite you to review our policies and guidelines so you can see what is informing our decisions.
EmblemHealth Resources: Medical Policies, Medical Technologies Database, Clinical Practice Guidelines, and 2022 Quality Measure Resource Guide.
ConnectiCare Resources: Medical Policies, Clinical Information.