From the Desk of the Chief Medical Officer

Transcription

1 September 2015 From the Desk of the Chief Medical Officer As we near Open Enrollment season for both our Medicare and Individual plans, we will provide important information for you and your practices. In this month s brief, we will share a RAF tip, which highlights important changes for ICD-10. Our hope is to make the transition from ICD-9 to ICD-10 as seamless as possible for you and your staff. We will also discuss the implementation of Nuance, a leader in Interactive Voice Response (IVR), to engage in a patient outreach campaign. The use of Nuance will assist Premier Health Plan and PHG to encourage patients to schedule office visits for their screenings and other health care needs. Additionally, It is our pleasure to announce that Premier Health Plan has been awarded NCQA certification as an HMO Health Plan on the Exchange. This certification recognizes that our Health Plan has the structure and processes in place to meet expectations for consumer protection and continuous quality improvement. We congratulate all the hard work that both the Premier Health Plan and Evolent Health teams have put into this achievement. IN THIS ISSUE Network Operations Note from our Medical Director Practice Transformation RAF Tips Medical Record Documentation Nuance Pharmacy Services Fraud, Waste and Abuse As always, if you have any questions or would like to speak to our Chief Medical Officer or our local Medical Director, please call (937) We look forward to our continued work together. Yours in health, Jerry Clark, MD, FACP President and Chief Medical Officer Premier Health Group

2 Network Operations Save the Date PHG will be hosting our next Network Development Meeting November 10, The meeting will be held at Sinclair Community College in the Charity Earley Auditorium from 8 a.m. 2 p.m. We will send out additional details on the event in the upcoming weeks. RAF Completed Forms PHG would like to thank all the physician offices that have submitted their Risk Adjustment Forms. View the offices with an exceptionally high rate of RAF form returns! In-Network Referrals Premier Health Group works to ensure your patients have access to primary care physicians and specialists they need. When referring a patient for additional services, please help them choose a Premier Health Group provider. For more information about accessing our provider directory, please use our Find a Doctor tool. Policy and Guideline Changes New medical and pay policies have been posted online at PremierHealthPlan.org, under Policy and Guidelines. These guidelines have been physician developed. Adhering to these guidelines will help improve quality scores and enhance the coordination of care. Additional updates will be posted on that site as they become available. New Providers New providers may only see Premier Health Plan patients once they are credentialed. If the provider is not yet credentialed, the claim may be denied. If you are adding new providers, please complete a new provider form and send it to the Provider Enrollment Specialists at PHG@PremierHealth.com. Additionally, the Ohio Revised Code requires the credentialing process to be completed within 90 days of submission of a complete and accurate CAQH application. We will assist you in starting the credentialing process early in the course of bringing-on a new provider in order to expedite their ability to see our members. Contact Numbers Please reference the table below for contact information. Department Purpose Contact Number Provider Services Eligibility, claims inquiries (855) and appeals information Medical Management Prior authorization (855) Provider OnLine Technical concerns (855) Pharmacy Services Pharmacy information (855) Medicare Member Member inquiries (855) Services Commercial Member Services Member inquiries (855)

3 Provider Relations Provider questions (937) As always, you can reach out to our Chief Medical Officer or our local Medical Director at (937) A Note from our Medical Director Clinical Practice and Preventive Health Guidelines Premier Health Plan uses nationally recognized clinical practice and preventive health guidelines as the basis for our Condition Management and Quality Improvement programs. These guidelines may include: Adult cholesterol management Attention deficit/hyperactivity disorder Depression Diabetes mellitus health management guidelines Evaluation and management of heart failure outpatient Management of asthma in infants, young children, and adults Management of hypertension Prenatal care guidelines We are pleased to announce the availability of these guidelines online, or call Provider Services at (855) for a hard copy. Sincerely, H. Todd Kepler, DO Medical Director Premier Health Group Why Do We Need Practice Transformation? By Louis Ralofsky, MD, president & CEO, Premier HealthNet, Premier Health Specialist, and Upper Valley Professional Corporation The fee for service payment model is essentially an a la carte, pay-for-each-unitof-service system. We all know that this can promote higher service demand expectations and overuse of services. As patients and physicians, we expect services to be performed when requested. The lay public also often assumes that more service translates to better quality health care. In addition, for many years, the out- ofpocket cost to patients was very low, and, because of insurance design, patients were not personally responsible for a significant portion of the cost, nor the number of services rendered on their behalf. This more is better attitude may suit our society s culture, but in the world of medicine can be dangerous, as well as cost prohibitive. So, the way we have historically paid for health care services drove our demand behavior and helped create the reality of the health care system that we have today. Basically, you get what you pay for. The dilemma is that this type of payment system is not 3

4 financially sustainable, nor is it the best bang for the consumer s/patient s buck that provides the highest quality outcomes at the lowest cost. Hence, as we have all heard, the system is broken. Around the time of Hillary Care in 1993, the system attempted to address some of these issues, but focused on cost alone. As many of you remember, a capitation payment system was attempted, which paid a monthly amount for each patient whom a provider would agree to care for (per member per month). It did not focus on quality, and, in certain cases, it resulted in significant barriers to health care services, such as the gatekeeper model, preauthorization, and more generally an incentive to withhold service, simply so that costs would not rise. The difference today is that the currently changing payment system is focusing on quality and cost at the same time. This helps keep the patient s and consumers best interest in both outcomes, as well as cost met. These value-based payments are only made to providers who meet both quality and cost goals. Practice transformation is an initiative that designs care delivery to optimally care for patients in the new changing environment that is focused on both quality and cost. A transformed model of practice strives to be patient-centric; provide the correct amount of proven and evidence-based care within a team based care model; assure the fastest response and scheduling time; utilize the most convenient method of care delivery; guarantee the lowest cost; and achieve the best evidence-based outcomes. One of the initial stages in practice transformation is evolving to a team-based model of care. This model applies the use of different provider types, such as medical assistants, social workers, dieticians, and counselors, as well as nurse practitioners, physician assistants, and doctors in the same system/office/department working together, while using their highest level of skill and ability to treat patients together. This results in easier access; clear communication; shorter wait times; and more services at the same site of care, as well as enhanced patient experience; higher quality; and provider and staff satisfaction. As the team-based model is built, the transforming practice uses metrics to guide process and quality improvement, track patient experience, and optimize workflow. These improvements allow for streamlined provider, staff, and patient interactions that produce better outcomes. EMR workflow optimization, specialty-specific template design, and embedded, reportable evidence-based measures within the EMR workflow assist in utilizing the EMR as the central tool that enhances the experience and workflow, rather than burden it. Other process improvement and workflow engineering techniques are utilized to work smarter, not harder. Other characteristics of practice transformation are physical design changes. Office space can be redesigned to accommodate the needs of the particular office. A multidisciplinary approach is incorporated into the layout and design. Centralized check-in, community rooms for group visits and educational talks, counseling, care navigator and dietician spaces, or specialty-specific disease management areas, designed for high-risk patient populations, can be instituted to suit the needs of the patient population that the office serves. 4

5 These are a few examples of cultural, operational, and physical transformations that are being implemented around the nation to ensure success in the value-based world that requires a focus on both quality and cost. RAF Tips We are pleased to provide PHG physicians with tips on Risk Adjustment Factor coding. Please be sure to read and distribute these to your practice colleagues upon receipt. I. Diabetes Coding & Documentation in ICD-10 While most Diabetes codes in ICD-9 begin with 250.xx and have 5 characters, Diabetes codes in ICD-10 begin with the letter E and have 4-6 characters If your patient has DM with an associated complication like CKD, neuropathy, or retinopathy, applying the correct ICD-10 code(s) will be necessary for accurate Risk Adjustment reimbursement. Should the patient have DM with a complication, you'll need to link the two conditions in the medical record (i.e. Diabetes with Retinopathy) in order to bill the appropriate code(s) The following ICD-10 DM codes Description qualify for Risk Adjustment (list is not all-inclusive): Code E10.9 Type 1 diabetes mellitus without complications E11.9 Type 2 diabetes mellitus without complications E11.21 Type 2 diabetes mellitus with diabetic nephropathy E11.22 Type 2 diabetes mellitus with diabetic CKD E Type 2 diabetes mellitus with unspecified diabetic retinopathy w/o macular edema E11.39 Type 2 diabetes mellitus with other diabetic ophthalmic complication E11.40 Type 2 diabetes mellitus with diabetic neuropathy, unspecified E11.49 Type 2 diabetes mellitus with other diabetic neurological complication II. Sample Record Verbiage & ICD-10 Code Assignments: CKD stage III due to DM Patient's DM and CKD are both stable. Will continue on insulin for DM and will follow up with his/her nephrologist next week to continue treatment for CKD. ICD-10-CM Codes: E11.22 (Type 2 DM with diabetic CKD) & N18.3 (CKD Stage III) III. RAF Reminders: As always, please be sure your documentation supports the diagnosis, assessment and treatment plan. For additional information on the ICD-10 transition, please go to the following link on the CMS website: GEMs.html 5

6 If you are unhappy with your current EMR vendor, or are having difficulty changing over to ICD-10, you might find Premier EPIC more helpful! Call Provider Relations at (937) if you are interested in becoming a Premier EPIC Affiliate. For questions on the ICD-10 transition, please contact Provider Relations: (937) Medical Record Documentation Will your medical record documentation stand up to an auditor's evaluation? The types of standards typically assessed include the following: Documentation of basic patient demographic and clinical information at intake, including prior medical history, family/social history, and allergies; Ongoing maintenance of the record, including establishing and updating problem and medication lists, and organizing progress notes, lab and consulting reports, and other hard copy documentation within the record; Documentation at each visit of chief complaint, a clinically appropriate treatment plan, follow-up plan, provider signature, and visit date; Documentation of preventive care, including immunizations and patient education (e.g. alcohol, tobacco and drug assessment and counseling), and documentation of advance directives; and Documentation of efforts to coordinate care with other providers, such as follow-up on referrals and initialing of lab findings and reports from consultants. Quality and safety are our top priorities. If you suspect the quality of care has been compromised or have a question, please contact Fraud, Waste, and Abuse at (855) Nuance Automated Patient Outreach As part of our continued focus to provide excellent care, Premier Health Plan has partnered with Nuance Enterprises (Nuance), a leader in Interactive Voice Response (IVR), to engage in a patient outreach campaign for HbA1c Testing, Nephropathy Screening, Colorectal Cancer Screening, Mammogram, and Annual Diabetic Eye Exam. One of the most effective and cost conscious outreach tools is IVR software, where automated calls can be made to a predetermined group of patients. With Nuance s help, Premier Health Plan and PHG will share proven preventative guidelines with many patients in our community encouraging them to schedule an appointment for their screenings and other health care needs. The calls will begin this month, allowing time for your patients to schedule an appointment and be seen prior to December 31, If you have any questions, please reach out to Nora Matthews, Quality Improvement Manager at (937)

7 Pharmacy Services New Class of Medications for treating high cholesterol The PCSK9 inhibitors are a new class of biologic medications that have been shown to dramatically lower LDL cholesterol levels. These medications are monoclonal antibodies that are given via subcutaneous injection. These medications work by inactivating a protein in the liver called proprotein convertase subtilisin kexin 9 (PCSK9). When used in combination with statins, they lower cholesterol more than statins alone. There is no evidence of using the PCSK9 s as monotherapy thus far and is currently being studied. Summary of Praluent (alirocumab) and evolocumab Drug Name Alirocumab (Praluent) Evolocumab Manufacturer Sanofi and Regeneron Amgen Indications Clinical Studies Study Outcomes Dosing Results Adverse Effects FDA Ruling Date Hypercholesterolemia(nonfamilial, HeFH) Mixed dyslipidemia to reduce LDL, TC, TG and to increase HDL Ten, Phase 3, double-blind, randomized controlled trials involving 5,296 patients % change in LDL-C from baseline to week 24 as the primary endpoint, patients remained in their blinded treatment groups for months total Starting dose of 75 mg SC every 2 weeks, (uptitrated to 150 mg Q2W at week 12) Dramatic LDL drop; no CV outcome data LDL drop range 60%; 8.5% placebo did not reach LDL goal (<100mg/dL) Well-tolerated, injection site reaction, and pruritis Hyperlipidemia Mixed dyslipidemia HoFH to reduce LDL, TC, TG and increase HDL Four, Phase 3, 12-week, double-blind, randomized, placebo- or ezetimibecontrolled trials involving 3,152 patients % change in LDL-C from baseline to week 12 % change in LDL-C from baseline to the average of weeks 10 and mg SC once every 2 weeks and 420 mg once monthly Dramatic LDL drop; no CV outcome data LDL change -23% vs. placebo +8% Joint pain, injection site reaction, headache, limb pain, fatigue July 24, 2015 Aug. 27,

8 Fraud, Waste, and Abuse Quality and safety are our number one priorities. If you suspect the quality of care has been compromised or have a question, please contact Fraud, Waste, and Abuse at (855)