Respiratory Health Management Program

A PUBLICATION OF UPMC HEALTH PLAN

Pages 5 & 6 Page 7

JULY

2008

UPMC HEALTHPLAN

One Chatham Center 112 Washington Place Pittsburgh, PA 15219

upmchealthplan.com

1-866-918-1595

1-800-361-2629

In This Issue

Cervical cancer screening . . . . 3 Medications for rheumatoid arthritis . . . 4 Proper use of Modifier 79 . . . 5 Always online . . . 6 Complex case management . . 7 Potentially harmful drug-disease interactions in the

elderly . . . 8 Because respiratory

diseases are a growing health problem in America, UPMC HEALTHPLANoffers a comprehensive Respiratory Health Management program to help our members with respiratory conditions. This program serves members with chronic obstructive pulmonary disease (COPD) as well as members with asthma. The program uses a team approach. A care manager, pharmacist, behavioral health specialist, and clinical account manager — one or all of them — may work in collaboration with physicians to help members with asthma and COPD manage their

condition. Our care managers are trained nurses who identify problems and work with the member’s physician to develop treatment plans based on specific medical needs.

Below are some goals of the Respiratory Health Manage-ment program They are based on guidelines established by the National Heart, Lung, and Blood Institute.

• Increase the number of patients who visit their PCPs, allergists, or pulmonologists • Increase long-term use of

controller medications

• Increase patient satisfaction and improve quality of life • Increase patients’ satisfaction

with their medical care • For patients with chronic

respiratory disease, improve their ability to comfortably participate in their daily activities

To refer patients to the Respiratory Health Manage-ment program, call 1-866-778-6073, or fax the Health Management Referral Form provided to you by your Network Management representative. If you would like more information about this program, you can call screening tests Page 2 To refer patients

to the

Respiratory Health

Management

1-866-778-6073

Respiratory Health

Management Program

Among women in the United States, breast cancer is the most commonly diagnosed cancer and the second leading cause of cancer-related deaths — after lung and bronchial

cancer. According to the CDC, 182,125 women had a diagnosis of breast cancer in 2002, and 41,514 died from the disease.

The most encouraging CDC report points out that screening mammography can reduce mortality from breast cancer by approximately 20 to 35 percent in women aged 50 to 69 and by approximately 20 percent in women aged 40 to 49. Despite this positive news, the 2007 Behavior Risk Factor Surveillance System (BRFSS) report indicates that mammography rates continually declined from 2000 through 2005. It is vital that you encourage all women in your practice to have an annual mammogram after age 40.

Breast cancer

screening

ACCOUNTABLE

PROVIDER

Encourage

women

to have important

screening tests

Many women do not feel comfortable talking openly to their doctors about private health matters. Physicians and their support staff, therefore, can be the key to preventive care by bringing three vital screenings—chlamydia and breast and cervical cancers—into the physician-patient dialogue.

Chlamydia —

Don’t be silent

about this “silent” disease

The Centers for Disease Control and Prevention (CDC) calls chlamydia a silent disease because three-quarters of infected women and half of infected men have no symptoms. According to the CDC, chlamydia is by far the most common and the most frequently reported bacterial sexually transmitted disease in the United States, ahead of gonorrhea and syphilis. In the United States, the CDC reported more than a million new infections for 2006.

Because chlamydia often comes with no telltale symptoms, the young women who most need to be screened are unlikely to bring it up to their physician or other health care staff. If you are treating a woman who is under 25 years old and has had sex, she’s in the most at-risk group and should be screened for chlamydia. Girls who are sexually active in their teens may be even more susceptible to infection because their cervix has not matured.

Cervical

cancer screening

Please make sure these young women hear the facts from you and your staff:

Even if they have what they think is “protected” sex using a condom, they can still be infected.

The threats of untreated chlamydia to a woman’s health include damage to reproductive organs and infertility. CDC reports indicate up to 40 percent of women with untreated chlamydia develop pelvic inflammatory disease.

Chlamydia is caused by a bacteria (chlamydia trachomatis), which means that it is curable and there are medicines that can cure chlamydia — sometimes in just one dose.

Women infected with chlamydia are five times more likely, if exposed, to become infected with HIV.

The CDC recommends an annual chlamydia screening for all women who may be at risk. The at-risk group includes sexually active

women who:

Are under 25 years old

Are pregnant

Don’t consistently use barrier contraceptives

Have signs of a possible cervical infection

Have previously had an STD

Are older women who have a new sexual

The National Cancer Institute (U.S. National Institutes of Health, www.cancer.gov) reports that cervical cancer affected more than 11,000 women in the United States in 2007. An early diagnosis increases a woman’s chance of being successfully treated.

The Pap test is simple, routine, and the best way to find abnormal cell changes in the cervix. Found early, chances for successful treatment increase for both breast and cervical cancer. Like the young women at risk for chlamydia, the women who most need cervical cancer screenings may not bring the subject up if they’re seeing you for another problem. Talk about chlamydia and breast and cervical cancer screening tests at

every opportunity you have with your patients who could benefit from

ACCOUNTABLE

PROVIDER

The Healthcare Effectiveness Data and Information Set (HEDIS), developed by the National Committee for Quality Assurance (NCQA), consists of 71 measures across 8 domains of care. Each health plan submits audited data, some of which is gathered through information taken directly from patient charts. Most information is taken from claims data. HEDIS measures address a broad range of important health issues. The following measures are for respiratory health: • Use of spirometry testing in the

assessment and diagnosis of COPD • Pharmacotherapy management of

COPD exacerbation

• Avoidance of antibiotic treatment in adults with acute bronchitis

• Use of appropriate medications for asthma

Controlling asthma through medication

More than 20 million Americans suffer from asthma. Long-term medication therapy, or asthma management, can greatly improve your patients’ quality of life. Ask your patients if they use controller medications every day to control their asthma. If not, make sure your patients understand the importance of taking a controller medication that reduces both airway inflammation and bronchocon-striction, long-term on a daily basis. Inhaled corticosteroids (ICS) are the most effective and the preferred long-acting controllers for mild, moderate, and severe persistent asthma. They are generally safe and well tolerated at moderate doses. Asthma that is not controlled with low to moderate doses of ICS may benefit from the addition of a

agents that may be added to ICS include leukotriene modifiers or theophyllines.

Spirometry test for diagnosing COPD

Chronic obstructive pulmonary disease (COPD) is a lung disease in which damaged lungs make it difficult to breathe. The airways — the tubes that carry air in and out of the lungs — are partly obstructed. This makes it difficult to breathe air in and out.

If a patient regularly experiences breathlessness, has difficulty breathing, or thinks he or she may have COPD, you should consider ordering a spirometry test. This test, a covered benefit under UPMC HEALTH

PLAN’Sbenefit programs, will help

you determine the best treatment plan for your patient.

Do you know the HEDIS measures for respiratory health?

Medications called disease-modifying antirheumatic drugs (DMARDs) that can slow or sometimes prevent joint destruction are now recommended early for rheumatoid arthritis. Anyone with rheumatoid arthritis is a candidate for DMARD treatment. DMARDs can help prevent the significant joint damage that may occur in the early stages of rheumatoid arthritis. DMARDs are also called immunosuppressive drugs or slow-acting antirheumatic drugs (SAARDs). Early treatment with DMARDs may significantly reduce disease severity. A separate study

recommended that DMARD treatment be continued for a prolonged period of time to sustain the benefit of disease control.

DMARDs can be divided into two general categories — oral and biological — based on how they work. Oral DMARDs are taken by mouth and are typically first line therapy. They interfere with the making or working of immune cells that cause joint inflammation. Biological DMARDs are given by injection or infusion. They are reserved for moderate to severe rheumatoid arthritis or for those who cannot tolerate the oral agents. The biological DMARDs act in several different ways to affect how immune cells work. Biological DMARDs decrease joint inflammation and damage.

You may prescribe DMARDs as part of a combination therapy which may reduce the risk of side effects that can occur with higher doses. Oral medications may be combined with each other or with biological DMARDs, but biological DMARDs cannot be used with each other because there is a higher risk of infection. Studies have shown that combination therapy may be an effective way to reduce symptoms of rheumatoid arthritis, control the disease, and prevent it from getting worse.

Medications for

Proper use

of Modifier 79

of coordinating care

People with behavioral health disorders are often at greater risk of developing physical illnesses, and people with physical illnesses often develop a behavioral health disorder. When this occurs, it is important that they receive treatment for both their physical and behavioral health illnesses. If both are not addressed, the disorders are likely to become more severe and lead to higher morbidity and mortality rates. For this and other reasons, we encourage medical practitioners to coordinate care with behavioral health specialists to promote overall better health for their patients.

Here are some facts about the connection between physical and behavioral health:

• Treating depression can help improve the prognosis of a co-occurring medical illness.

• Heart disease, stroke, cancer, HIV/AIDS, diabetes, and Parkinson’s are all associated with depression.

• Individuals with both congestive heart failure (CHF) and depression have a fourfold increase in mortality compared to individuals diagnosed solely with CHF.

• Individuals with both chronic obstructive pulmonary disease (COPD) and depression have a threefold increase in mortality compared to individuals diagnosed solely with COPD.

• People who have untreated mental health issues tend to use more medical services.

• People who have depression are more likely than others to develop diabetes.

• Anxiety disorders are linked with many physical health illnesses, including epilepsy, heart disease, asthma, and diabetes.

We strongly encourage you to coordinate care with other providers who are seeing your patients. As needed, please send a written report or call any other physician that you know is treating one of your patients. Coordination may help avoid duplicate assessments, procedures, or testing, and it could improve treatment outcomes as well as promote patient safety.

Current CPT coding guidelines stipulate that Modifier 79 should be used only to indicate when the same physician performs an unrelated procedure within the global postoperative period. Appropriate use of Modifier 79 includes:

• An unrelated procedure was performed during the global _{Inappropriate use of Modifier 79 includes the following:}

The following information is available through upmchealthplan.com.

PROVIDER MANUAL POLICIES AND PROCEDURES PHARMACY

• Formularies

• Prior Authorization Forms

NEWS AND INFORMATION

• Behavioral health confidentiality

• Behavioral health patient safety guidelines • Accountable Provider eNewsletters and Updates

FOR YOUR PATIENTS

• Health Management programs • Patient Education

• Healthy Living Resources

• UPMC for LifeMedicare Concierge Program • Special Needs Program

LINKS AND RESOURCES

• Domestic violence

MEDICAL MANAGEMENT

• Clinical guidelines*

• Preventive health guidelines for adults and children • Medical necessity statement

• Medical record documentation guidelines • Utilization management criteria

▼The UM decision making process

▼Accessing a medical director to discuss UM decisions • Physician Forms

QUALITY IMPROVEMENT

• Complaints and Grievances Process

• HIPAA (Health Insurance Portability and Accountability Act) privacy guidelines • Member Rights and Responsibilities

• Quality Improvement Program information • Physician-Patient Communication Guidelines • Provider Accessibility Standards

• Provider Satisfaction Results

• Quality and Safety (compare hospitals for quality and safety) • UPMC for LifeMedicare Concierge Program

• Special Needs Program

To request a hard copy of any of this information, call Provider Services at 1-866-918-1595.

Items with an asterisk (*) include recently updated information.

ALWAYS

ONLINE

6

Updated Beers Criteria for Potentially

Inappropriate Medication Use in Older

Adults,

Independent of Diagnoses or Conditions

Provider Satisfaction Survey

UPMC HEALTHPLANproviders were recently surveyed to measure how well the Health Plan is meeting their expectations and needs. The 2007 Provider Satisfaction survey was conducted between October 2007 and January 2008 by The Myers Group, a vendor certified by the National Committee for Quality Assurance (NCQA).

For the second year in a row, UPMC Health Plan outperformed its competitors in overall satisfaction. In addition, the Health Plan consistently scores above average in the areas of Network and Quality Management, as well as Customer Service.

We want you to know that we constantly strive to ensure your satisfaction. Remember that your Provider Services representative is available to answer your questions and concerns.

Complex

case management

UPMC HEALTHPLANmembers who have complex medical or behavioral health conditions may benefit from additional support. UPMC HEALTHPLANhas a complex case management program that can help. This program encourages collaboration among providers who are caring for the same member.

Our care managers coordinate health care services, support the physician’s treatment plan, and identify gaps in care. They will educate the member and caregivers on condition self-management. Care managers can connect your patients with supportive services in the community.

Care management staff will attempt to contact the members they feel could benefit from the complex case management program. Enrollment is voluntary and members can decide to opt out at any time.

If the member agrees to participate, the care manager will assess needs and work with the physician, member, and caregivers to develop a case management plan. The care manager will contact the physician, when needed, to clarify the plan.

If you would like to refer a UPMC HEALTHPLANmember to the complex case

management program, contact us at 1-866-918-1588. Representatives are available from 8 a.m. to 4:30 p.m. Monday through Friday.

The Clinical Guidelines below are available at upmchealthplan.com. Select “For Providers” on the homepage and then “Medical Management” from the menu on the left. Next select “Clinical Guidelines” from the list. To view the Preventive Guidelines for children and adults, follow the steps above but scroll down the list until you see “Preventive Health Guidelines.”

CARDIOLOGY

• Adult Cholesterol Management • Hypertension Management

• Heart Failure Guideline — Outpatient Management

• Cardiovascular Risk Factors and Coronary Artery Disease

DIABETES

• Adult Diabetes*

PHYSICAL/BEHAVIORAL HEALTH

• ADHD • Depression

• Substance Abuse and Dependence

RESPIRATORY

• Asthma • COPD

WOMEN’S HEALTH

• Prenatal Clinical Practice Guidelines

LOW BACK PAIN QUALITY INITIATIVE

• Program Booklet

• Frequently Asked Questions • Primary Care or First Contact

Physician Algorithm

• Physical Therapists and Chiropractors Algorithm

• Workers’ Compensation: Primary Care or First Contact Physician Algorithm • Workers’ Compensation: Physical

Therapy and Chiropractic Algorithm • Algorithm Legend

• Yellow Flags Form

Clinical Guidelines

on the web

Self-disclosing

POTENTIAL FRAUD

ACCOUNTABLE

PROVIDER

8

One Chatham Center 112 Washington Place Pittsburgh, PA 15219

upmchealthplan.com

©2008 UPMC Health Plan, Inc. All Rights Reserved.

ACCT PROV-Q2 C20080404-09 (RT) 7/8/08 9M XX

The Office of the Inspector General (OIG) is encouraging health care providers to participate voluntarily in the self-disclosure of potential fraud.

In an open letter to providers that is available on the website of the Department of Health and Human Services, the OIG outlines specific ways in which the self-disclosure process can be improved. According to the OIG, the initial self-disclosure submission should contain the following:

• A complete description of what is being disclosed.

• A description of the provider’s internal investigation or a commitment on when it will be completed.

• An estimate of damages to the federal health care programs.

• A statement of laws potentially violated. In 1998, the OIG established the Provider Self-Disclosure Protocol (SDP) to encourage voluntary disclosure by health care providers of self-discovered evidence

of potential fraud in order to “ensure the integrity of the federal health care programs.”

The open letter states that providers will be removed from participation in the SDP unless they respond in a timely fashion and in good faith to requests for information from OIG.

To view the entire open letter, you can follow this link: http://oig.hhs.gov/fraud/ docs/ openletters/OpenLetter4-15-08.pdf.

The elderly are at increased risk of adverse effects with certain drugs. Risk of an adverse effect increases exponentially with the number of drugs used, partly because multiple drug therapy reflects the presence of many diseases and increases the risk of drug-disease and drug-drug interactions. Three drug-disease interactions are particularly common:

• A history of falls and a prescription for

tricyclic antidepressants, antipsychotics, or sleep agents

• Dementia and a prescription for tricyclic antidepressants or anticholinergic agents

• Chronic renal failure and a prescription for nonaspirin NSAIDs or COX-2 selective NSAIDs

It is important that you regularly review the drugs prescribed to elderly patients. In addition, you should pay close attention to

post-hospital discharges or nursing home discharges and to patients who live alone or have a cognitive impairment. Electronic prescribing, limiting the number of physicians who are prescribing medications, and limiting (if possible) the number of medications for an elderly person can all help reduce drug-disease and drug-drug interactions.