In a continuous effort to improve the MSI program, a brief telephone

Transcription

1 Provider News Volume 2, Issue 1 In this Issue: Page 1 MSI Provider Survey Results Page 3 MSI Now Pays for Immunizations The MSI Formulary Available on epocrates Revised Prior Authorization (PA) Criteria For MSI Prescriptions Page 6 Patient Survey Results October 2007 December 2007 MSI Provider Survey Results In a continuous effort to improve the MSI program, a brief telephone survey of five to ten minutes with MSI medical home providers was conducted in October Sixty medical home providers within the MSI physician network (30 Internal Medicine physicians and 30 Family Practice physicians) agreed to participate in the survey. Physicians and/or office managers were asked to rate their level of satisfaction with various areas of the MSI program including the electronic systems in place such as ER Connect, Clinic Connect and the Provider On-line Verification (POV) eligibility system. We also asked about the Utilization Management Department (UMD), the Care Management Unit (CMU), and the MSI program. The overall survey results were very positive! As shown in the graph on page 2, physicians reported relatively high levels of satisfaction with several program areas. An estimated 75% indicated they were very satisfied or somewhat satisfied with the Coverage Initiative program. Providers also expressed high levels of satisfaction with the MSI electronic application and on-line eligibility verification systems. A combined 83% of providers reported being very satisfied or somewhat satisfied with the electronic application, while 85% of providers indicated they were very Page 7 Coal Coalition Education Gram: Obesity and Overweight Provider News is published by the MSI Program, County of Orange Health Care Agency. Dan Castillo, MHA, FACMPE, CHE, Administrator Editor: Robert Schuster, Associate Administrator Continued on page 2 Happy New Year to All Our MSI Partners in the Medical Community!

2 Continued from page 1 satisfied or somewhat satisfied with the on-line eligibility verification system (POV). Due to the presence of ER Connect strictly within our contracted emergency departments, only 17% of PCP-level physicians interviewed indicated that they were aware of the ER Connect interface, which was reflective in our survey results. A more accurate assessment of the ER Connect system will be concluded following a survey with emergency department physicians. Satisfaction ratings for both the MSI Utilization Management Department (UMD) and the Care Management Unit (CMU) were also quite favorable. Over two-thirds of physicians surveyed reported being very or somewhat satisfied with UMD, while over 70% of providers indicated that they were very or somewhat satisfied with CMU. MSI providers will be interviewed in future surveys to keep abreast of physicians perceptions of the Coverage Initiative program across time. The next survey will be conducted in April We will keep you informed of these results! Provider Satisfaction Degree of Provider Satisfaction 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% Very Satisfied Somewhat Satisfied Neutral Somewhat Dissatisfied Very Dissatisfied 0% Coverage Initiative Program Overall On-Line Eligibility MSI Electronic Application ER Connect Utilization Management Case Management Very Satisfied 24% 53% 52% 29% 35% 31% Somewhat Satisfied 49% 33% 33% 18% 33% 41% Neutral 17% 14% 15% 12% 22% 20% Somewhat Dissatisfied 10% 0% 0% 0% 6% 6% Very Dissatisfied 0% 0% 0% 6% 4% 2% Program Area Page 2

3 MSI Now Pays for Immunizations The MSI program encourages medical providers to administer appropriate immunizations to MSI patients according to evidence based research. In addition to reimbursement for the actual immunization, the program will also pay an administration fee (CPT code 90471). The MSI Formulary Available on epocrates For MSI providers convenience, the MSI formulary is currently available at As you may be aware, MSI has switched to a more generic based formulary after consultation with several of our providers. The generic versions of brand name drugs are approved by the FDA and meet the standards for strength, quality and purity. Generic drugs have the same active ingredients and dosage forms as brand name drugs. Generics should be considered the first line of prescribing. MSI routinely makes changes to the formulary, including additional medications that need prior authorization, quantity limits, and step therapy restrictions on certain medications. Revised Prior Authorization (PA) Criteria For MSI Prescriptions Antidiabetic Medications Not PA, but for reference purposes Formulary preferred is metformin, sulfonylurea, and insulin (See ADA guidelines below) Glitazones (Avandia, Actos) are on step therapy requires all preferred medications used first, including intensive insulin therapy For reference the ADA guidelines are: ADA Guidelines: Diabetes Care, Volume 30, Supplement 1, January 2007 Diabetes Care 29: , No. 8, August 2006 Insulin Management Recommendations: Diabetes Care 29: , 2006 Ann Intern Med 145: , 2006 Nutrition Recommendations: Diabetes Care 29: , 2006 New ADA consensus statement expected in 2007 Continued on page 4 Page 3

4 Continued from page 3 Antiemetics Recommend Ondansetron (Zofran generic) x 3 days / course of therapy FDA Approved diagnoses: Nausea and vomiting secondary to chemotherapy Post-operative nausea and vomiting Radiation therapy (MSI specific clinical addition) Non-FDA Approved indications (Not approvable by MSI) Alcoholism Hyperemesis gravidarum Pruritus Clopidogrel = Plavix Indications (FDA approved) arterial thromboembolism prophylaxis myocardial infarction prophylaxis stroke prophylaxis thrombosis prophylaxis stable coronary artery disease congestive heart failure atherosclerosis transient ischemic attack peripheral arterial disease Non-FDA approved (none mentioned) PA Criteria ACC & AHA guidelines: Established Cardiovascular disorders acute coronary syndrome myocardial infarction Stroke PTCA with stenting and PVD Closure of patent foramen ovale, by percutaneous route Post coronary artery bypass surgery If pt has allergy to ASA usage, or GI upset Secondary prevention of stroke, i.e. patients with TIA Most of these patients will be on Plavix for 1 year Concomitant treatment with Aspirin 81mg QD Oxycodone ER = OxyContin Indications (FDA approved) Moderate pain Severe pain Non-FDA approved Arthralgia Bone pain Dental pain Diabetic neuropathy Headache Migraine Myalgia Neuropathic pain Postherpetic neuralgia PA Criteria A Schedule II controlled medication, therefore needs prior authorization Not for use on PRN basis To be used in stepwise fashion starting with nonopioid analgesic, short-acting opiod, and then extended release opioid Not for use in the first 12 to 24 hours of surgery Not for mild pain Use only for moderate to severe pain if persists for an extended time Caution and CI in patients hypersensitive to opioids Respiratory depression CO 2 retention Acute bronchial asthma Paralytic ileus Head injury Hypotension Sleep deprivation Risedronate = Actonel Indications (FDA approved) Osteoporosis Osteoporosis prophylaxis Paget s disease Non-FDA approved Osteolytic metastases Continued on page 5 Page 4

5 Continued from page 4 PA Criteria Bone studies may be performed on different anatomic sites CPT Codes for relevant studies are DXA scans of the hip are the standard measurement for osteoporosis Bone mineral density: T score =<-2.5 Postmenopausal women who have had an osteoporotic vertebral fracture; who have bone mineral density values consistent with osteoporosis (i.e., T-score worse than or equal to -2.5); who have a T-score from -2.0 to -2.5 plus at least one of the following risk factors for fracture: thinness, history of fragility fracture (other than skull, facial bone, ankle, finger, and toe) since menopause, and history of hip fracture in a parent. Patients with BMD T score =<-1.5 if additional risks present Previous fracture as an adult History of fragility fracture in a first degree relative Body weight <57kg Current smoking Use of oral steroid therapy for >3months Previous vertebral, Hip or wrist fracture At high risk patients, menopausal women with family history of fractures, Caucasian, Asian race and early menopause. In Paget s disease with alkaline 2x the normal range or symptomatic patients who are at risk for future complications. Regular exercises, adequate diet, discontinue smoking and preventative measures in home so that falls are avoided. Vitamin D & Calcium recommended. Unfractionated Heparins Recommend Dalteparin (Fragmin) x 3-6 months for DVT and PE when patient is bedridden (MSI specific clinical addition) Non-FDA Approved diagnoses: (Not approvable by MSI) Antiphospholipid antibody syndrome Arterial thromboembolism prophylaxis Cerebral thromboembolism Proton Pump Inhibitors (PPIs) We understand that there may be circumstances in which you feel your patient requires one of the nonpreferred brand PPIs. In these instances, Blue Cross of California has updated its criteria for approval of non-preferred PPI products. These criteria require: Documentation of failure of full therapeutic trials (dose & duration) of preferred products Documented lifestyle and diet modification (antireflux program) Documented compliance with dosing (60 minutes pre-meal) Documented failure with all preferred products such that symptoms occur more than two times per week while on optimal/twice daily dosing Duration of approval will be for three months/90 days Criteria for continued use of products beyond 90 days: Severe disease exceptions Documented lifestyle and diet modification (antireflux program) Documented clinical response with requested product Documented 4-week trial of step-down therapy with an H2RA (Zantac, Pepcid, etc.) AND symptoms recurred more than two times per week FDA Approved diagnoses: Coronary artery thrombosis prophylaxis Deep venous thrombosis (DVT) Deep venous thrombosis (DVT) prophylaxis Pulmonary embolism Pulmonary embolism prophylaxis Thrombosis prophylaxis Unstable angina Acute myocardial infarction Prophylaxis after hip, knee, or abdominal surgery Page 5

6 Patient Survey Results October 2007 December 2007 During the final quarter of 2007, our Patient Education Department performed a survey of 1,152 MSI patients. Patients were asked to rate various aspects of the MSI program, using a rating scale of 1-10, with 10 being the highest. Results of the survey are encouraging as shown in the graph below! MSI patients gave very high ratings to 9 of 10 program areas, including patient education, care management, patient services, the 24/7 MSI Nurse Line and the program overall. These results suggest that the many recent changes to the program have positively impacted MSI members. We will continue to track MSI patient perceptions of the program in future surveys. Patient Ratings of MSI Program Average Rating Program Primary MD/Clinic Specialist Emergency Room Hospital Overall Understanding Eligibility Nurseline Authorizations Care Management Patient Education Patient Services Program Area Page 6

7 COAL COALITION EDUCATION GRAM OBESITY and OVERWEIGHT Monitor for BMI < 25 at Every Visit Obesity is an independent risk factor for cardiovascular morbidity and mortality that is not mitigated by medications. Patients should be assessed for a BMI (body mass index) of less than 25 as part of every physical evaluation. ( The prevalence of obesity and overweight has reached pandemic proportions and is rapidly increasing in both industrialized and developing nations. As a health care provider, you have the ability to make a difference by educating your patients about the importance of weight-loss and the numerous health benefits it can provide. FACTS: Globally, there are more than 1 billion overweight adults, at least 300 million of them obese. Among U.S. adults 20 to 74 years the prevalence of obesity increased from 15% to 32.9% during the 1976 to 2004 time period. Among children 6 to 19 years the prevalence of overweight has increased from 5% to 18%. Obesity and overweight pose a major risk for many chronic diseases, including type II diabetes, cardiovascular disease, hypertension and stroke, and certain forms of cancer. Only 43% of obese persons are advised to lose weight during routine checkups. Health consequences and proportion of disease prevalence attributable to obesity: Disease Prevalence Disease Prevalence Type II Diabetes 61% Hypertension 17% Uterine Cancer 34% Coronary Heart Disease 17% Gallbladder Disease 30% Breast Cancer 11% Osteoarthritis 24% Colon Cancer 11% While most healthcare providers appreciate the clinical consequences of obesity and overweight, there is a lack of awareness that obesity, particularly central obesity, is an independent risk factor for cardiovascular associated morbidity and mortality. This means that while you may prescribe medications to treat the more well-recognized risk factors (hypertension, high cholesterol, diabetes); your overweight or obese patient remains at increased risk for cardiovascular complications without adequate weight loss. In fact, according to a recent study, obese patients compared with those of normal weight in the same cardiovascular risk category are 1.5 to 2 times as likely to die from coronary heart disease. (Odds ratios: 1.43 for low risk and 2.07 for moderate risk.) Some Economic Benefits of Weight Loss: Medication costs are cut in half for people taking anti-hypertensives or diabetes medications once they have lost and kept 20 pounds off for one year. (Collins et al, Preventive Medicine, 1995) Participation in a weight-management program reduces overall health care costs $1,648 a year. (Berkson et al., of Group Health Cooperative of Puget Sound) Assessment of the Obese Patient: One of the goals of assessment in an obese patient is to decide whom to treat. Three main issues must be considered: 1) Whether treatment is indicated. 2) Whether treatment is safe for the patient. 3) Whether the patient is ready and motivated to lose weight. The Practical Guide to the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults by the National Heart, Lung, and Blood Institute of the National Institutes of Health is an evidence-based, decision-oriented guide that is tailored for clinical use. Please refer to the Practical Guide for further information regarding the assessment and treatment of your obese or overweight patients. Pro Pharma Pharmaceutical Consultants, Inc. is not affiliated with any Health Plan, Pharmacy Benefit Management (PBM) Company, or Pharmaceutical Manufacturer. This general information is provided purely for your use and is not slanted toward any product or company. For comments or questions: Call Craig Stern, PharmD, Pharmacy Benefit Consultant, toll free at (888) or craig.stern@propharmaconsultants.com. P.O. BOX NORTHRIDGE, CA (888) FAX (818) Page 7

8 MSI Program P.O. Box 355 Santa Ana, CA Phone: (714) Fax: (714) Provider Relations (714) , Option 5 Case Management (800) , Option 2 Fraud & Recovery Department (714) , Option 5 Eligibility Information (714) /7 Nurse Assistance Hotline (877) Fiscal Intermediary (AMM) (800) (562) Patient Education Department (800) , Option 1 Patient Relations (714) , Option 8 (866) Utilization Management Dept. (UMD) (714) Fax: (714) On-Line Patient Eligibility Verification Visit us on the Web at: DTP499 MEDICAL SERVICES INITIATIVE P.O. Box 355 Santa Ana, CA