Navigator. UnitedHealthcare Community Plan. Helping Our Members Live Healthier Lives.

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1 FALL 2012 the Navigator. Helping Our Members Live Healthier Lives. Rising to the challenges of performing in this dynamic health care industry is something we face every day. How we rise to these challenges defines us as leaders. During the summer, I established UnitedHealthcare Community Plan s Michigan Innovation Council not only to embrace the ever-changing health care landscape but also to create operationally sound solutions. The Innovation Council s members are United- Healthcare Community Plan employees who share the fundamental goal of making health care work for everyone. s commitment to innovation in Michigan is not limited to employee involvement. Throughout the history of this plan, our best practice has been our collaboration inside Message from UnitedHealthcare Community Plan President David Livingston: Innovative Solutions HEDIS Snapshot Milliman Care Guidelines Asthma Diagnosis and Care with our valued network of providers and community partners. This partnership leads us to be more responsive and realistic in developing end-to-end solutions even as health care policies continue to evolve. Together, we face complex issues in Michigan. We must bring compassion and innovation to everything we do, because access to and affordability of quality health care influence the quality of people s lives. Thank you for your continued support of as, together, we light the way for positive and meaningful change. Michigan Quality Improvement Consortium (MQIC) Updated Asthma Guidelines Updated Recommendations and Key Points Include: All Patients Develop written action plan in partnership with patient Update annually; more frequently if needed Follow-up care Schedule patient within one week, or sooner if acute exacerbation Two- to six-week intervals while gaining control One- to six-month intervals to monitor if sufficient control is maintained Three-month interval if a step-down therapy is anticipated MQIC Age-Specific Clinical Practice Guidelines/Recommendations: MQIC Management of Asthma in Children 0-4 Years asthma_in_children_0_to_4_years_cpg.pdf MQIC Management of Asthma in Children 5-11 Years asthma_in_children_5_to_11_years_cpg.pdf MQIC Management of Asthma in Youth 12 Years and Older and Adults asthma_in_youth_12_years_and_older_and_ adults_cpg.pdf

2 Healthcare and Effectiveness Data and Information Set Snapshot HEDIS Medicaid Measures and Specifications for Service Year Children s Health Well-Child Care Visits Ages 0-15 Months Recommend minimum of 6 well-child visits At least 1 well-child visit Ages well-care visit per calendar Childhood Immunizations Before Age 2 Completion of: 4 DTaP 3 IPV 1 MMR 4 HIB 3 Hep B 1 VZV 4 Pneumococcal 2 Hep A 2 or 3 Rotavirus 2 Influenza Chlamydia Screening Sexually Active Women Ages with a Claim Indicating Sexually Active At least 1 chlamydia test yearly Urine test or vaginal culture Prenatal Care 1 prenatal visit in first 12 weeks or 45 days of joining health plan Postpartum Care 1 visit between 21 and 56 days after delivery Asthma-Appropriate Medication Ages 5-64 with Persistent Asthma Systolic BP < 140 mm Hg Diastolic BP < 90 mm Hg High BP Controlling High BP Ages with HTN Systolic BP < 140 mm Hg Diastolic BP < 90 mm Hg Antidepressant Medication Management Ages 18 and Older with Depression Optimal PCP contacts: at least 3 Effective acute phase: on antidepressant medication for 84 calendar days Continuation phase: 180 days of medication Adolescent Well-Care Visits Ages Years 1 well-care visit per calendar year Adolescent Immunizations Before Age 13 Meningococcal Tdap, or Td Lead Testing Before Age 2 Medtox or state paper lead test Venous blood test Follow-Up for Children with ADHD Ages 6-12 Initiation phase of medication management 1 visit within 30 calendar days of an ADHD script Continuation and maintenance phase At least 2 additional visits while on ADHD meds for at least 210 calendar days within 9 months after initiation phase Preventive Health Breast Cancer Screening for Women Ages mammogram in previous 2 years Cervical Cancer Screening Ages Pap smear in current year or previous 2 years Medical Assistance with Smoking Cessation Ages 18 and Older (Current Smoker) Review treatment plan and implementation process Medications prescribed or discussed Acute and Chronic Care COPD Spirometry Testing Ages 40 and Older At least 1 spirometry test to confirm COPD Dx and 1 spirometry test per year Cholesterol Management Patients with Cardiovascular Conditions Ages with AMI, CABG, PCI, IVD LDL screen Diabetes Comprehensive Care Ages Hb A1c test LDL-C screen Retinal eye exam Microalbumin urine test annually BP control < 140/90 mm Hg Appropriate Testing for Children with Pharyngitis Ages 2-18 years Antibiotic Rx Had a group A strep test Appropriate Treatment for Children with URI Ages 3 months to 18 years Dx of URI Not dispensed an antibiotic Weight Assessment and Counseling Dated BMI percentage or BMI plotted on a percentile growth chart yearly Dated nutritional counseling yearly Dated physical activity counseling yearly Colorectal Cancer Screening Ages FOBT (3 sample tests) yearly or Flexible sigmoidoscopy in past 5 years or Colonoscopy in past 10 years ifobt (1 sample test) yearly Adult BMI Assessment Dated BMI documented in the medical record annually Height and weight must also be documented in addition to BMI ifobt (1 sample test) yearly Pharmacotherapy Management of COPD Exacerbation Ages 40 and Older Dispense systemic corticosteroid within 14 calendar days of event and dispense bronchodilator within 30 calendar days of event. Persistence of Beta-Blocker Treatment After AMI Ages 18 and older Receive beta-blocker Rx for 6 months after discharge from hospital Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis Ages Dx of acute bronchitis Not dispensed an antibiotic 2

3 HEDIS Medicare Measures and Specifications for Service Year Preventive Health Pneumonia Vaccine Ages 65 Years 1 dose pneumococcal vaccine Breast Cancer Screening for Women Ages mammogram every 2 years Osteoporosis Testing in Older Women Ages 67 Years Bone density test Flu Shots for Adults Ages 65 Years 1 flu shot every year Glaucoma Screening Ages 65 Years Without Prior Dx Glaucoma eye exam Medical Assistance with Smoking Cessation Ages 18 and Older (Current Smoker) Review treatment plan and implementation process Medications prescribed or discussed Fall Risk Management Ages 75 years or Ages with Balance or Walking Problems or a Fall in Last 12 Months Seen by PCP in last 12 months and received fall intervention from their PCP Colorectal Cancer Screening Ages FOBT (3 sample tests) yearly or Flexible sigmoidoscopy in past 5 years or Colonoscopy in past 10 years ifobt (1 sample test) yearly Physical Activity in Older Adults Ages 65 years Annual PCP visit Discuss exercise level and/or was advised to start, increase, or maintain exercise level Osteoporosis Management Ages 67 Years for Women with a Fx BMD (bone mineral density) test or Rx for a drug to treat or prevent osteoporosis within 6 months after date of Fx High BP Controlling High BP Ages with HTN Systolic BP < 140 mm Hg Diastolic BP < 90 mm Hg Antidepressant Medication Management Ages 18 and Older with Depression Optimal PCP contacts: at least 3 Effective acute phase: on antidepressant meds for 84 calendar days Continuation phase: 180 days of medication Potentially Harmful Drug-Disease Interactions in the Elderly Ages 65 Years with Underlying Disease, Condition, or Health Concern Dispensed an ambulatory Rx for a contraindicated medication, concurrent with or after the diagnosis Medication Reconciliation Post-Discharge Within 30 days of hospital discharge, a review of medications prescribed in the hospital or Within 30 days of hospital discharge, documentation of no medications prescribed Acute and Chronic Care COPD Spirometry Testing Ages 40 and Older At least 1 spirometry test to confirm COPD Dx Cholesterol Management for Patients with Cardiovascular Conditions Ages with AMI, CABG, PCI, IVD LDL screen Diabetes Comprehensive Care Ages Hb A1c test LDL-C screen Retinal eye exam Microalbumin urine test annually BP < 140/90 DMARD (Disease Modifying Anti-Rheumatic Drug) Therapy in Rheumatoid Arthritis Ages 18 and Older Diagnosis of RA with at least 1 DMARD Care for Older Adults Advance care planning Medication review Functional status assessment Pain screen Each area reviewed and documented yearly Pharmacotherapy Management of COPD Exacerbation Ages 40 and Older Dispense systemic corticosteroid within 14 calendar days of event and dispense bronchodilator within 30 calendar days of event. Persistence of Beta-Blocker Treatment After AMI Ages 18 and Older Receive beta-blocker Rx for 6 months after discharge from hospital Use of High-Risk Medications in the Elderly Ages 65 Years Assess members who may be receiving one or two potentially harmful drugs Annual Monitoring for Patients on Persistent Medication Ages 18 and Older Annual monitoring for members on these persistent medications: ACE/ARB, diuretics, Digoxin, anticonvulsants Adult BMI Assessment Dated BMI documented in the medical record annually Height and weight must also be documented in addition to BMI 3

4 UnitedHealthcare Community Plan uses Milliman Care Guidelines in the utilization management (UM) of both inpatient and outpatient services. The Care Guidelines are nationally recognized, evidence-based guidelines and are more than just a tool used by the payer community to guide care and services authorization. The key aspects of the Care Guidelines include: Clinical indications for decision making for admission, procedures, testing, and services A guide for optimal recovery (the Milliman Care Guidelines Optimal Recovery Course), Milliman Care Guidelines which reflects best practices in prescriptive care Discharge planning guidelines Patient education/teaching information Clinical documentation requirements Extended-stay criteria Common complications and conditions guidelines Hospital care planning Quality measures Opportunity to use guidelines to guide collaboration and consultation between payers and providers regarding patient care and management UM review decisions are based on criteria, the appropriateness of the care or service/item, the benefit coverage, and the provider s affiliation with the plan. We do not compensate UM review decision makers for denials of coverage or service. Financial incentives are designed to encourage, not discourage, the appropriate use of services. UM review guidelines are available at the request of the participating practitioner/provider by calling UnitedHealthcare Community Plan at Practitioners may discuss clinical review decisions with our Medical Director and physician advisers at Provider Manual The Provider Manual explains policies and procedures involving our provider partners and serves as a resource for the management of our plan. periodically updates our Provider Manual. The productspecific, up-to-date Provider Manual is available at Online, you can access not only the Provider Manual but also provider directories, newsletters, clinical practice guidelines, drug formularies, and more. For a hard copy of the UnitedHealthcare Community Plan Provider Manual, or if you are unable to find what you are looking for, please contact your Provider Relations Advocate. Your Provider Relations Advocate is your resource for on-demand training and orientation for your staff. 4

5 Asthma Diagnosis and Care Management More than 23 million adults and children have asthma in the U.S. Managing care for your patients with asthma can be challenging. encourages our members to work with their providers to manage this chronic disease. Listed below is the recommended approach for asthma care: Establish a Diagnosis of Asthma and Determine Asthma Severity Symptoms include dyspnea, cough, and/or wheezing, especially nocturnal, difficulty breathing, or chest tightness. Episodic and recurrent symptoms are present. Symptoms worsen in presence of exercise, viral infections, inhaled allergens, irritants, changes in weather, strong emotional expression, stress, or menstrual cycles. Perform spirometry measurement in all patients ages 5 and older to determine if airway obstruction is at least partially reversible. Prescribe Appropriate Pharmacological Therapy Using a Stepwise Approach Prescribe a daily preventive asthma medication if the patient is not currently taking one. Inhaled corticosteroids (ICS) are the most consistently effective antiinflammatory therapy for all age groups and the preferred first-line treatment that results in improved asthma control. Understand the difference between the following medications: Long-Term Control Medications: These medications prevent symptoms, often by reducing inflammation. They must be taken daily. Do not expect long-term control medications to give quick relief. Quick-Relief Medications (required for all patients): Short-acting beta- 2-agonists (SABAs) relax airway muscles to provide symptom relief. Do not expect long-term asthma control. Using SABAs on more than two days a week indicates the need for starting or increasing long-term control medications. Assess and Monitor Asthma Control and Adjust Therapy as Necessary Perform validated asthma questionnaires such as the Asthma Control Test (ACT) at or the Asthma Control Questionnaire (ACQ) at at every office visit. Step-up and step-down asthma treatment based on assessment of symptom control. Monitor for possible overuse of the quick-relief or rescue asthma medications. Refer to a specialist if patient has difficulty achieving or maintaining asthma control. Develop, Review, and Update Asthma Action/Treatment Plans at Each Visit Provide and Reinforce Patient Education/ Asthma Self-Management Identify and reduce factors contributing to severity. Emphasize medication adherence and medication administration techniques. Train on the use of a spacer device with metered-dose inhalers (MDI). Explain the difference between rescue and preventive medications. Schedule Follow-Up Care At two- to six-week intervals until asthma control is achieved or while asthma medication is being adjusted At one- to six-month intervals after control is achieved and to monitor whether asthma control is maintained Prior to predicted seasonal exacerbations Provide influenza vaccine for all patients older than ages 6 months annually, unless a vaccine contraindication exists. 5

6 PO Box 2127 Southfield, MI PRSRT STD U.S. Postage PAID UnitedHealthcare Community Plan Postmaster: Please deliver between October 29 and November 2. implemented our new Children s Special Health Care (CSHCS) Benefit Plan in response to the Michigan Department of Community Health (MDCH) mandate to enroll all CSHCS beneficiaries into a Medicaid health plan. CSHCS is a Medicaid program that the MDCH created to find, diagnose, and treat children in Michigan who have chronic illnesses or disabling conditions. Visit our website! Children s Special Health Care Benefit Plan Under the CSHCS Benefit Plan, United- Healthcare Community Plan covers the same Medicaid benefits and medically necessary services for CSHCS beneficiaries that we provide to all the Medicaid recipients on our health plan, including customer service, unlimited routine transportation, case management, and overall improved coordination of care. worked to ensure CSHCS members have access to our provider network and enjoy a seamless transition into this new plan. As a valued provider in our Medicaid network, you will find that your participation automatically extends to our new CSHCS Benefit Plan. Participating in the CSHCS Benefit Plan allows your practice to experience United- Healthcare Community Plan s high level of provider service, swift claims payment, coordination of benefits, paperless referral process, and extensive provider network, which will continue to alleviate administrative burden. From a patient care perspective, participation will ensure continuity of quality care and improved health outcomes through collaboration with our Case Managers. CSHCS will be imprinted on identification cards to help your office staff identify CSHCS members. Also, CSHCS eligibility can be found online on OSCR, our provider portal at Portal/Security/Login.aspx. Please remember that there are CSHCS benefits that UnitedHealthcare Community Plan will not administer. Respite, orthodontia, insurance premium payment, and certain pharmaceuticals are carved out to MDCH. Please see the MDCH Provider Manual for a complete list. Please direct any questions to your dedicated Provider Relations Advocate. Thank you for supporting UnitedHealthcare Community Plan s Children s Special Health Care (CSHCS) Benefit Plan. the NavigatOr David K. Livingston President Steven Stein, MD, MHS Medical Director Mary Beth Scherer Editor The Navigator is published by UnitedHealthcare Community Plan, a Michigan for-profit corporation, to provide general information. It is not intended to provide personal medical advice, which should be obtained directly from a physician All rights reserved. Printed in the U.S.A. Printed on Recyclable Paper 864M