Messages from the Clinicians....

July 2000

Immunization Records

Remember to ask members for immunization records for your files, even if the vaccines were given elsewhere.

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Case Management:
A Case Scenario

A 55-year-old member had a history of poorly controlled seizures and migraines. Case management was initiated in December 1999, due to excessive ER utilization, drug-seeking behavior for narcotics and noncompliance with the PCP’s plan of care. A phone conference was arranged between all practitioners involved to develop a plan of care.

Based on the conference, the following actions were taken.

• Narcotics were discontinued (including those at ER visits)
• The member was directed to a neurologist for a comprehensive evaluation
• Home health was involved to assist with medication management
• A mental health referral was initiated to deal with psychological issues.

Four months after the initial conference, the member’s Er utilization was down 42%, reflecting significant savings in the first quarter. The patient has been off narcotics and is complying with the PCP’s plan of care.

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Clinical Advisory Committee

The Clinical Advisory Committee, composed of 16 physicians from throughout the Upper Peninsula met on June 13 and approved their 2000 goals and objectives. Among them was “To Improve Drug Utilization” with the objectives of:

• Analyze utilization and compare to state and national benchmarks
• Decrease per member per month (pmpm) utilization
• Maintain current generic utilization
• Establish drug utilization protocol for high cost/high volume drugs
• Communicate committee activities in provider newsletter
• Develop and distribute individual provider utilization reports

For a full list of the approved goals and objectives from the Committee, please contact either the Medical Director or Marcie Jones at the Plan at (906) 225-7500

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Remember to check member’s Medicaid and UPHP cards each time a member visits, as over 500 people in the U.P. leave a plan each month.

Watch out for the New Membership Cards!

As of March 31, 2000, UPHP members now have new membership cards. The new cards are UPHP medical cards and Pro Vantage pharmacy cards all in one. Members coming on to the plan in April or making changes to their cards will be receiving them. We hope this makes everyone’s job a little easier. Please begin watching for these cards and let us know if you have any questions.

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Plan Expenses Breakdown

All Medical Expenses                       88.0%

• Pharmacy                               34.0%
• Hospital-Inpatient                 19.2%
• Physician                                16.6%
• Hospital-Outpatient                7.0%
• X-ray                                        3.0%
• Lab                                            1.5%

All Administration Expenses        12.0%

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NOTE: For members 6 through 17 years old, the following products will not longer require prior authorization: Adderall, Dexedrine, and Dextrostat      (10 mg.)

Top 10 Drugs By Cost to The Plan (per month)

1. Prevacid                           $21,500
2. Prozac                               19,000
3. Zoloft                                 18,000
4. Neurontin                          14,800
5. Depakote                           12,100
6. Buspar                               12,100
7. Paxil                                    10,000
8. Claritin                                 9,300
9. Lipitor                                  8,000
10. Cefzil                                     7,000

By September 2000, most family physicians will receive your personalized financial impact reports comparing you with your peers.

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