Provider Newsletter Fall 2012 Volume 12 Newslette… · Staying Healthy: Screenings, Tests, and...

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Provider NewsletterFall 2012 Volume 12

Five Star Quality Rating System

The Centers for Medicare and Medicaid Services (CMS) have implemented a Five Star Quality Rating System for Medicare Advantage (MA) plans. The rating system was put in place as part of an effort to educate consumers on quality and to make quality data more transparent. The rating system consists of 50+ measures that rate plans in the following areas:

• Staying healthy via preventive services• Managing chronic conditions• Plan responsiveness and care• Complaints, appeals and voluntary disenrollment• Telephone customer service

Data measurement sources include HEDIS (Healthcare Effectiveness Data and Information Set), CAHPS (Consumer Assessment of Healthcare Providers and Systems), HOS (Health Outcome Surveys) and IRE (Independent Review Entity). Once the measures are calculated, stars are awarded to the MA plan. The CMS stars ratings are published annually and are available for viewing by all Medicare beneficiaries prior to Open Enrollment. The Patient Protection and Affordable Care Act of 2010 ties federal reimbursement rates to MA plan performance as measured by the rating system.

Listed are the 2012 star measures. Please familiarize yourself with these measures and assess opportunities to ensure each of the measures is addressed in your daily practice patterns.

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Provider Newsletter Fall 2012 Volume 12

Five Star Rating System(Continued)

Staying Healthy: Screenings, Tests, and Vaccines

Breast Cancer Screening

Colorectal Cancer Screening

Cardiovascular Care - Cholesterol Screening

Diabetes Care - Cholesterol Screening

Glaucoma Testing

Annual Flu Vaccine

Pneumonia Vaccine

Improving or Maintaining Physical Health

Improving or Maintaining Mental Health

Monitoring Physical Activity

Access to Primary Care Doctor Visits

Adult BMI Assessment

Managing Chronic (Long Term) Conditions

Osteoporosis Management in Women who had a Fracture

Diabetes Care - Eye Exam

Diabetes Care - Kidney Disease Monitoring

Diabetes Care - Blood Sugar Controlled

Diabetes Care - Cholesterol Controlled

Controlling Blood Pressure

Rheumatoid Arthritis Management

Improving Bladder Control

Reducing the Risk of Falling

Plan All-Cause Readmissions

Ratings of Health Plan Responsiveness and Care

Getting Needed Care

Getting Appointments and Care Quickly

Customer Service

Overall Rating of Health Care Quality

Overall Rating of Plan

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Five Star Rating System(Continued)

Drug Pricing and Patient Safety

Complaints about the Health Plan

Beneficiary Access and Performance Problems

Members Choosing to Leave the Plan

Plan Makes Timely Decisions about Appeals

Reviewing Appeals Decisions

Call Center - Foreign Language Interpreter and TTY/TDD availability

Introducing the Comprehensive Primary Care (CPC) Initiative

On April 11, 2012, the CMS Innovation Center announced that the Greater Tulsa region (25 counties in Northeastern Oklahoma) had been selected as one of the seven markets across the United States to participate in the Comprehensive Primary Care (CPC) initiative. The selected markets are multi-payer and may include private health plans, state Medicaid agencies, and employers. The CPC initiative is evaluating the impact of two new primary care delivery concepts simultaneously… a change in service delivery and a change in payment methodology. The participating payers in each market will be entering into a Memorandum of Understanding (MOU) with CMS. Once the participating payers in each market have agreed to the terms and conditions of this MOU, the Innovation Center will then release a solicitation to primary care practices in these geographic areas wishing to participate in providing comprehensive primary care as part of this initiative. Approximately 75 primary care practices in each designated market will be selected to participate. The Comprehensive Primary Care (CPC) initiative is a multi-payer initiative fostering collaboration between public and private health care payers to strengthen primary care. Medicare will work with commercial and state health insurance plans and offer bonus payments to primary care doctors who better coordinate care for their patients. Primary care practices that choose to participate in this initiative will be given resources to better coordinate primary care for their Medicare patients. The primary care practice is a key point of contact for patients’ health care needs. In recent years, new ways have emerged to strengthen primary care by improving care coordination, making it easier for clinicians to work together, and helping clinicians spend more time with their patients. All around the country, health care providers and health plans have taken the lead in investing in primary care.

Primary care is critical to promoting health, improving care, and reducing overall system costs, but it has been historically under-funded and under-valued in the United States. Without a significant enough investment across multiple payers, independent health plans - covering only their own members and offering support only for their segment of the total practice population - cannot provide enough resources to transform entire primary care practices and make expanded services available to all patients served by those practices.

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Introducing the Comprehensive Primary Care (CPC) Initiative (Continued)

The CPC initiative offers a way to break through this historical impasse by inviting payers to join with Medicare in investing in primary care in 5-7 selected localities across the country. The resources will help doctors work with patients to ensure they:

• Manage Care for Patients with High Health Care Needs: Patient with serious or multiple medical conditions need more support to ensure they are getting the medical care and/or medications they need. Participating primary care practices will deliver intensive care management for these patients with high needs. By engaging patients, primary care providers can create a plan of care that uniquely fits each patient’s individual circumstances and values.

• Ensure Access to Care: Because health care needs and emergencies are not restricted to office operating hours, primary care practices must be accessible to patients 24/7 and be able to utilize patient data tools to give real-time, personal health care information to patients in need.

• Deliver Preventive Care: Primary care practices will be able to proactively assess their patients to determine their needs and provide appropriate and timely preventive care.

• Engage Patients and Caregivers: Primary care practices will have the ability to engage patients and their families in active participation in their care.

• Coordinate Care Across the Medical Neighborhood: Primary care is the first point of contact for many patients, and takes the lead in coordinating care as the center of patients’ experiences with medical care. Under this initiative, primary care doctors and nurses will work together and with a patient’s other health care providers and the patient to make decisions as a team. Access to and meaningful use of electronic health records should be used to support these efforts.

In June 2012, the CMS Innovation Center will release the application for primary care practices to participate in the CPC initiative. This model will support practices providing comprehensive services to patients on whose behalf they will receive enhanced payment from Medicare and other participating payers, which may include state Medicaid agencies and commercial health plans.

The CPC initiative will be accepting applications from individual primary care practice sites that are geographically located in the above selected markets. If your primary care practice has multiple sites, each physical site that is located in the selected market is eligible to apply and must apply separately. Check your eligibility for participation at https://cmsgov.secure.force.com/cpci/cpciscreening.Upon completing the check, all eligible applicants will receive an email with further details about the upcoming application and how to apply to the program.

The recent CommunityCare newsletter shared results from the 2010 Consumer Assessment of Healthcare Provider and Systems (CAHPS) Star Rating. CommunityCare members gave their doctors a score of 3 out of 5 in the area of Physician / Patient communication. The survey question focused on how well doctors communicate.

Two articles have been selected to assist CommunityCare physicians to gain and strengthen an effective and personal communication style in an effort to improve patient-physician communication and rapport. In addition, selected questions have been provided as examples from the CAHPS 2012 Medicare Satisfaction Survey.

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The CAHPS Improvement Guide Practical Strategies for Improving the Patient Care Experience

Training to Advance Physicians’ Communication Skills

The Problem

People rarely complain about the technical aspects of the health care they receive because – in the absence of an obvious error – patients are generally unable to judge technical competence. However, they and only they are well-equipped to judge the ability of clinicians to communicate with them effectively. Even though a clinician explains a diagnosis, test result, or treatment option to a patient, if the person walks away and does not understand the explanation, it has not been an effective communication.

Poor communication can have a serious impact on health outcomes. Patients may not provide the clinician with adequate information on their health or related concerns; they may not comply with the physician’s orders – and in some cases, they may not even understand what they have been told. According to a study at the University of Kansas School of Medicine in Kansas City, patients’ reports of their understanding of the post-discharge information and instructions they had received was significantly less than what their doctors perceived. For example, while the physicians thought that 89 percent of the patients understood the potential side effects of their medications, only 57 percent of patients said that they understood.[1]

In addition to affecting the patient’s experience with health care, poor patient-physician communication has important consequences for medical practices. One study found that, in a three-year period, 20 percent of Massachusetts state employees voluntarily left their primary care physician because of the poor quality of their relationship, which was a function of trust, the patients’ sense that the physician knew them, the level of communication, and personal interaction.[2] Poor communication is also a contributing factor in a majority of malpractice suits.[3]

“With patient characteristics and structural features of care taken into account, those with the poorest-quality physician-patient relationships in 1996 were 3 times more likely to leave the physician’s practice over the ensuing 3 years than those with the highest-quality relationships.”[4]

While the curriculums of most medical schools now include some form of training in communications skills,[5] this is a fairly recent phenomenon. Traditionally, medical education has paid little attention to the skills that promote effective interactions with patients. Most practicing physicians have not been taught to appreciate the patient’s experience of illness; nor do they learn how to partner with patients and serve as a coach or guide. As a result, they typically do not know how to communicate with patients in a way that maximizes understanding and involvement in decision making, lets the patient know that his or her concerns have been heard, and ensures that the care plan meets the needs of the patient.

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Training to Advance Physicians’ Communication Skills(Continued)

The Intervention

To compensate for this deficiency in medical education, numerous health plans and medical groups are training practitioners in the communication skills they need – either through in-house programs or through communications programs offered by outside organizations. Most of these programs are optional, but a few organizations require the participation of all doctors. In some organizations, the program is mandatory only for those doctors who consistently receive low scores in this area.

The purpose of these programs is to improve providers’ effectiveness as both managers of care and educators of patients. It is also believed that trained physicians may allocate a greater percent of clinic-visit time to patient education, leading to increased patient knowledge, better compliance with treatment, and improved health outcomes. The most effective and efficient way of offering training in physician-patient communication is in the form of seminars or workshops where you can cover many strategies for improved communication in a relatively short period of time. Workshops may also use case studies to illustrate the importance of communication and suggest approaches to improving the physician-patient relationship.

For clinicians, workshops may serve multiple purposes, including increasing their understanding of the physician’s roles, offering insight into the importance of connecting with patients, and increasing confidence in their interviewing skills. In addition to basic communication skills, the training can cover:

history-taking skills, issues related to communicating across cultures, communicating with “problem” patients, interviewing techniques (including skills to help promote behavioral change), and empathic responses.

Some programs also address weaknesses in written communications, which can be a serious problem for clinicians who use e-mail to communicate with some patients. Group Health Cooperative in Seattle, for example, offers a training curriculum on how to write e-mails to patients.

An Example

One of the best known examples of an in-house program to inculcate strong communication skills in clinicians is the Thriving in a Busy Practice program developed by Terry Stein, MD, at Kaiser Permanente. This comprehensive communications curriculum strives to develop the ability of physicians to relate to patients effectively in both routine and difficult settings. In particular, it is intended to help physicians learn and practice techniques for dealing with difficult patient encounters. Over the past decade, the workshops have been expanded beyond the issues that typically confront primary care physicians to include guidance pertinent for different specialists (such as emergency physicians).

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Training to Advance Physicians’ Communication Skills(Continued)

An Example(Continued)

Evaluations of this program have found a positive impact on the clinicians. One study found that clinicians reported improved confidence in their ability to conduct effective medical interviews and handle difficult situations. It also found that, after taking the course, fewer clinicians reported frustration with patient visits (specifically, the percent reporting frustration with 11 percent or more of patient visits fell from about half before the course to about one-third afterwards).[6] However, the impact on patient satisfaction is not yet clear: One study found that the program had no impact, but noted that other factors may have influenced that finding.[7] Learn more at Stein TS and Kwan J. Thriving in a busy practice: physician-patient communication training. Eff Clin Pract 1999;2(2): 63-70. Available at: https://www.cahps.ahrq.gov/Disclaimer.asp?goto=http%3a%2f%2fwww.acponline.org%2fjournals%2fecp%2fmarapr99%2fthriving.htm. Accessed September 22, 2008.

Key Resources

[1] Rogers C. Communications 101. Bulletin of the American Academy of Orthopaedic Surgeons 1999;47(5).

[2] Safran DG, Montgomery JE, Chang H, et al. Switching doctors: predictors of voluntary disenrollment from a primary physician’s practice. J Fam Pract 2001;50(2): 130-6.

[3] Flaherty M. Good Communication Cuts Risk. Physician’s Financial News 2002;20(2): s10-s11.

[4] Safran DG, Montgomery JE, Chang H, et al. Switching doctors: predictors of voluntary disenrollment from a primary physician’s practice. J Fam Pract 2001;50(2): 130-6.

[5] Rogers C. Communications 101. Bulletin of the American Academy of Orthopaedic Surgeons 1999;47(5).

[6] Stein TS and Kwan J. Thriving in a busy practice: physician-patient communication training. Eff Clin Pract 1999;2(2): 63-70.

[7] Brown JB, Boles M, Mullooly J, et al. Effect of clinician communication skills training on patient satisfaction. A randomized, controlled trial. Ann Intern Med 1999;131(11): 822-9.

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Patient – Physician Communication: Why and HowJAOA, Vol 105, No 1, January 2005, 13-18

1. Assess What the Patient Already Knows

Before providing information, find out what a patient already knows about his or her condition. Many times, other physicians or health care providers have already communicated information to the patient, which can have the effect of coloring patient perceptions and perhaps even causing confusion when new information is introduced. For instance, a nephrologist may talk about the patient “getting better” based on improving renal function tests, while a cardiologist is focused on the patient’s severe, irreversible cardiomyopathy. In other scenarios, patients will come to the physician with preconceived notions about a particular condition, perhaps based on less than-authoritative sources. It is important, therefore, to determine what a patient already understands—or misunderstands—at the outset.

2. Assess What the Patient Wants to Know

Not all patients with the same diagnosis want the same level of detail in the information offered about their condition or treatment. Studies have categorized patients on a continuum of information-seeking behavior, from those who want very little information to those who want every detail the physician can offer. Thus, physicians should assess whether the patient desires, or will be able to comprehend, additional information. For the physician without advance knowledge of the patient, this level of need will emerge by degrees as the discussion unfolds and as the physician attempts to synthesize and present information in a clear and understandable manner.

As when obtaining informed consent, a standard first step in presenting information to a patient would be to describe the risks and benefits of the procedure and then to simply allow the patient to decide how much additional information he or she wants. However, as suggested elsewhere in this section, this step may require direct questions, strategic silences, and frequent verification that the information is actually being comprehended. One telling sign of whether the patient understands the information is the nature of the questions patients ask; if questions reflect comprehension of the information just presented, a further level of detail may be warranted. If questions reflect confusion, it is advisable that the physician return to basic information. If the patient has no questions or is obviously uncomfortable, this is a good opportunity for the physician to stop the discussion, ask explicitly how much information the patient desires, and adjust accordingly. Continuing to provide further information is not always the best approach.

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Patient – Physician Communication: Why and HowJAOA, Vol 105, No 1, January 2005, 13-18 (Continued)

3. Be Empathic

Empathy is a basic skill physicians should develop to help them recognize the indirectly expressed emotions of their patients. Once recognized, these emotions need to be acknowledged and further explored during the patient-physician encounter. Further, physicians should not ignore or minimize patient feelings with a redirected line of inquiry relentlessly focused on “real” symptoms. Patient satisfaction is likely to be enhanced by physicians who acknowledge patients’ expressed emotions. Physicians who do this are less likely to be viewed as uncaring by their patients.

4. Slow Down

Physicians who provide information in a slow and deliberate fashion allow the time needed for patients to comprehend the new information. Other techniques physicians can use to allow time include pausing frequently and reinforcing silence with appropriate body language. A slow delivery with appropriate pauses also gives the listener time to formulate questions, which the physician can then use to provide further bits of targeted information. Thus, a dialogue punctuated with pauses leads to deeper comprehension on both sides.

One study found that physicians typically wait only 23 seconds after a patient begins describing his chief complaint before interrupting and redirecting the discussion. Such premature redirection can lead to late-arising concerns and missed opportunities to gather important data.

As a side note, patient satisfaction is also greater when the length of the office visit matches his or her pre-visit expectation. In situations involving the delivery of bad news, the technique of simply stating the news and pausing can be particularly helpful in ensuring that the patient and patient’s family fully receive and understand the information. Allowing this time for silence, tears, and questions can be essential.

5. Keep it Simple

Physicians should avoid engaging in long monologues in front of the patient. It is far better for the physician to keep to short statements and clear, simple explanations. Those who tailor information to the patient’s desired level of information will improve comprehension and limit emotional distress. Again, physicians should be sure to ask whether patients have any questions so that understanding can be checked and dialogue promoted. It is wise for the physician to avoid the use of jargon whenever possible, particularly with elderly patients. An important fact for physicians to keep in mind is that, in the United States, between 20% and 40% of individuals between 60 and 80 years of age have not attained a high school diploma. In patients of all ages, a physician cannot assume the understanding of treatment risks that are described with percentages or numbers. Such “low numeracy skills” of patients require that physicians take special care in outlining the relative risks of diagnostic procedures and treatments.

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6. Tell the Truth

It is important to be truthful. In addition, it is important that physicians not minimize the impact of what they are saying. For example, euphemisms may soften the delivery of sad information but can be extremely misleading and create confusion.

Saying that a patient has “gone” or has “left us,” for example, could be interpreted by an anxious family member as meaning that the patient has left his room to have a radiologic film taken or to undergo a test. Alternatively, physicians who use “D” words (e.g., dying, died, dead), when appropriate, effectively communicate the circumstance and minimize confusion.

7. Be Hopeful

Although the need for truth-telling remains primary, the therapeutic value of conveying hope in situations that may appear hopeless should not be underestimated. Particularly in the context of terminal illness and end-of-life care, hope should not be discouraged. For example, in situations such as the imminent death of a patient, hope can be conveyed to the family by assuring them that therapy can be effective in allaying pain and discomfort. Thus, even when physicians must convey a grim prognosis to a patient or must discuss the same with family members, being able to promise comfort and minimal suffering has real value.

8. Watch the Patient’s Body and Face

Much of what is conveyed between a physician and patient in a clinical encounter occurs through nonverbal communication. For both physician and patient, images of body language and facial expressions will likely be remembered longer after the encounter than any memory of spoken words.

It is also important to recognize that the patient-physician encounter involves a two-way exchange of nonverbal information. Patients’ facial expressions are often good indicators of sadness, worry, or anxiety. The physician who responds with appropriate concern to these nonverbal cues will likely impact the patient’s illness to a greater degree than the physician wanting to strictly convey factual information. At the very least, the attentive physician will have a more satisfied patient.

Conversely, the physician’s body language and facial expression also speak volumes to the patient. The physician who hurriedly enters the examination room several minutes late, takes furious notes, and turns away while the patient is talking, almost certainly conveys impatience and minimal interest in the patient. Over several such encounters, the patient may interpret such nonverbal behavior as a message that his or her visit is unimportant, despite any spoken assurances to the contrary. Thus, it is imperative that the physician be aware of his or her own implicit messages, as well as recognizing the nonverbal cues of the patient.

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9. Be Prepared for a Reaction

Patients vary, not only in their willingness and ability to absorb information, but in their reactions to physician communications. Most physicians quickly develop a sense for the various coping styles of patients, a range of human reactions that has been categorized in several specific clinical settings.

For instance, a certain percentage of individuals will meet almost any bad medical news in a non-emotional, stoic manner. The physician, however, should not interpret this non-reaction as a lack of patient concern or worry. In some cases, these same individuals go on to exhibit distress by other means (e.g., an increased reporting of physical symptoms, additional nonverbal communication of pain, or other behaviors aimed at gaining the attention of the treatment team).

At the other end of the emotional spectrum, the sizable proportion of patients with mild or diagnosable depression and/or anxiety will likely react to bad news with frank displays of crying, denial, or anger. A small percentage of patients who have difficulty forming a trusting relationship with a physician may react to bad news with distrust, anger, and blame. For such patients, establishing a lasting bond of trust with their physicians can be extremely difficult, and although all attempts to communicate should be made, unsettled feelings on both sides are to be expected.

In responding to any of these patient reactions, it is important to be prepared. The first step is for the physician to recognize the response, allowing sufficient time for a full display of emotions. Most importantly, the physician simply needs to listen quietly and attentively to what the patient or family is saying. Sometimes, the physician can encourage patients to express emotion, perhaps even asking them to describe their feelings. The physician’s body language can be crucial in conveying empathic concern in these encounters.

The patient-physician dialogue is not finished after discussing the diagnosis, tests, and treatments. For the patient, this is just a beginning; the news is sinking in. The physician should anticipate a shift in the patient’s sense of self, which should be handled as an important part of the encounter—not as an unpleasant plot twist to a physician’s preferred story line.

Conclusion

Simple choices in words, information depth, speech patterns, body position, and facial expression can greatly affect the quality of one-to-one communication between the patient and physician. To a large degree, these are conscious choices that can be learned and customized by the physician to fit particular patients in clinical situations. Avoiding communication pitfalls and sharpening the basic communication skills previously suggested can help strengthen the patient-physician bond that many patients and physicians believe is lacking.

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CAHPS 2012 Medicare Satisfaction Survey – Selected Questions

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Is your office preparing for ICD-10?

The US Department of Health and Human Services (HHS) has mandated the replacement of the ICD-9-CM code sets used by medical coders and billers to report health care diagnoses and procedures with ICD-10 code sets, effective Oct. 1, 2014. ICD-10 implementation will radically change the way coding is currently done and will require a significant effort to implement. The time for ICD-10 implementation training is now.

Basic Steps to Prepare for Version 5010/ICD-10*

Begin preparing now for the ICD-10 transition to make sure you are ready by the October 13, 2014, compliance deadline. The following quick checklist will assist you with preliminary planning steps.

• Identify your current systems and work processes that use ICD-9 codes. • Talk with your practice management system vendor about accommodations for both Version 5010 and ICD-

10 codes. • Discuss implementation plans with all your clearinghouses, billing services, and payers to ensure a smooth

transition. • Talk with your payers about how ICD-10 implementation might affect your contracts.

• Identify potential changes to work flow and business processes. • Assess staff training needs. Identify the staff in your office that code, or have a need to know the new codes.

• Budget for time and costs related to ICD-10 implementation, including expenses for system changes, resource materials, and training.

• Conduct test transactions using Version 5010/ICD-10 codes with your payers and clearinghouses. Testing is

critical. *www.cms.gov/ICD10

Resources for ICD-10:www.cms.gov/ICD10

www.AAPC.com/ICD-10

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Provider Customer Service

Do you have a question about member eligibility or the status of a claim?

CareWeb is a secure, HIPAA compliant program that allows providers to verify member eligibility, verify and request authorizations, check on the status of a claim and much more.

Secure access is required.Information regarding how to access CareWeb is located at:

http://www.ccok.com/Providers/about-provider-connection.asp

If you need to speak with a Provider Customer Service Representative, please call

(918) 594-5207 or (877) 321-0018

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Senior Health Plan – Zero Cost-Sharing Preventive Services

CMS released the following national coverage determinations (NCDs) during 2011. The Affordable Care Act provided original Medicare beneficiaries the right to coverage for certain preventive services with zero cost-sharing. CMS used its authority to extend that right to beneficiaries enrolled in Medicare Advantage and cost plans. Thus, Senior Health Plan is responsible for covering these preventive services with zero cost-sharing within the network, per 76 Fed. Reg 21432. For more information please visits www.cms.gov.

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New Providers

Please notify CCHMO as soon as it is known that a new provider will be joining your office. New providers cannot see CCHMO members until they have fully completed our credentialing process. This process can take 90 to 120 days, or longer, to complete.

Who needs to be credentialed with CommunityCare HMO?

All independently licensed, doctorate level practitioners - MD, DO, DC, DDS, DMD, DPM, EdD, PhD, PsyD, and OD.

Allied Health Professionals include, but is not limited to the following practitioners:

Advanced Registered Nurse PractitionersAudiologistsClinical Nurse SpecialistsCertified Nurse MidwivesCertified Registered Nurse AnesthetistsLicensed Behavioral PractitionersLicensed Clinical Social WorkersLicensed DieticiansLicensed Marital & Family TherapistsLicensed Professional CounselorsMental Health Case Managers

Occupational TherapistsOccupational Therapy AssistantsOrthotistsProsthetists & FittersPerfusionistsPhysical Therapy AssistantsPhysical TherapistsPhysician AssistantsRehabilitation TherapistsSpeech & Language Pathologists

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Formulary Goes Mobile

Save time, improve quality of care, and reduce administrative burden with CommunityCare’s continually updated formulary feature now offered on Smartphones, iPads and tablets.

CommunityCare now gives you FREE mobile and online access to Commercial and Senior Health Plan formularies. Select the formulary, and then instantly access coverage status for thousands of brand and generic drugs. With this free resource it’s easy to check copay tiers, formulary alternatives and generic substitutions, and prior authorization criteria.

To access via device:

Go to www.ccok.com

Select Prescription Drug Search

Select the Commercial or Senior Health Plan List

Select “Continue”

Then, add to Home Screen – This will allow an icon to be added to your home screen so you can quickly access this web site.

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From the Desk of Jason Cuaderes, D.Ph., Clinical Pharmacist

CommunityCare is dedicated to providing high quality, cost-effective therapy through the support of health management strategies that best align excellence in care with cost effectiveness.

CommunityCare recently reviewed a number of drug classes and made the following changes to its formulary:

For Senior Health Plan Participating Providers:NBI MEDIC Prescriber Prescription Verification RequestsAs part of the ongoing effort to combat fraud, waste, and abuse in the Medicare Part D program, the NBI MEDIC (Health Integrity, LLC) requests prescriber prescription verification during the course of an investigation.

A key element in the early phase of an investigation into potential prescription drug fraud and abuse includes prescriber prescription verification. The NBI MEDIC routinely mails the prescriber a prescription verification form containing the beneficiary’s name, the name of the medication, the date prescribed, and the quantity given. The form also asks the prescriber to check yes or no to indicate whether the prescriber wrote the prescription. The prescriber is asked to respond within two weeks. If no response is received, then the investigator follows up with a second request.

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Medical Director’s Minute

As physicians, we are entering into a new era of accountability. In the past, our quality was measured by how well we felt about the care we gave… our good training… our loyal patients. Today’s world is slightly different. We are measured by patient satisfaction surveys on very specific measures that are not clearly explained to us (or the patients who are being asked). In the not-too-distant future, at least part of our pay will also be based upon these surveys.

It has been quite interesting to go through the evaluation process for our Senior Health Plan and discover what Medicare wants to see in the way of “health care quality”. When we are evaluated based on what health plans typically do (pay claims, member service, etc.) we consistently score 4 or 5 stars out of 5. When it comes to clinical care quality measures, however, there are many indicators that are in the 1 or 2 star range. Some of these lower scores are based on the fact that the data must be obtained from a medical record, not a claim form. As a health plan, we have tried to stay out of the medical record as much as we can… but now, things have changed to the point where it is required. For example, one of the quality measures is whether there is a measure of BMI on the chart. This functions as a screen for obesity and lets the patient and physician know if the patient is overweight, obese or just right. But BMI is not something that is captured on a claim form, as a rule. So, we are looking at ways to be able to capture additional clinical data to improve our scoring.

Other questions on the patient surveys are concerned with what the patient’s experience is during clinic visits. Questions include: if the physician asked them whether they had bladder control issues, whether they had fallen in the last year, questions on physical functioning in the home, and whether they received a flu shot in the last year. All of these are presumed to have happened during a typical health screening exam. In addition, Medicare has added a wellness visit which is designed to answer many of these questions and allow the primary care physician to create a specific care plan for the patient with the patient/family involvement. These are questions that CMS is asking patients to relate… not looking at medical records.

Then the burden of proof is on the documentation. Did you document what you did…as the attorneys would say, if you didn’t document it, you didn’t do it. An additional part of the documentation may be to give the patient a hard copy of the care plan. This helps eliminate questions from family members who weren’t at the visit about “what the doctor said”.Let’s work together to deliver quality care… quality that patients recognize.

Tips, Tools, & Teachings: Learn about Medicare Reimbursement Methodology from Dr. Jack M. Sommers by viewing http://youtu.be/2n68UZIzdow. In this educational tool, Dr. Sommers discusses Hierarchical Condition Categories and how correct coding and documentation is necessary to ensure CMS understands the full scope of the health of each Medicare beneficiary.

Provider Newsletter Fall 2012 Volume 12 Newslette… · Staying Healthy: Screenings, Tests, and...

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