UPPER PENINSULA HEALTH PLAN

In This Issue....

Clinical Services Report                                                           Antibiotic Project Update
Asthma Medications                                                                           Growth Monitoring
Vaccine Shortage Reference                                                       Smoking-Cessation Kits
Medical-Record Confidentiality                                           Weight-Management Criteria
Claim Notes

Provider Notes

Clinical Services Report

Notes from the Medical Director

The Clinical Services Department at the Upper Peninsula Health Plan (UPHP) is currently involved in a variety of quality projects related to antibiotic use in upper respiratory tract infections; asthma, diabetes, and depression management; preventive health screenings; immunizations; well-child care; and prenatal-postpartum care. You may be receiving query forms related to these topics, which are printed on bright yellow paper. These query forms ask you to acknowledge care and/or results as documented in the medical record; we offer these forms as a means for you to supply us with the required information in the most time-efficient manner. They serve as an alternative to lengthy record copying by your staff.
In return for this information, UPHP will provide your clinic with the most complete reports possible regarding your practice, and the state-published HEDIS results will more accurately reflect UPHP provider quality of care. We have highlighted some areas of study in this edition of the newsletter. We always welcome your questions, concerns, and insights. We have made many improvements to our processes because of your input. 

Studies

Appropriate Antibiotic Use Project Update

UPHP’s Appropriate Antibiotic Use Initiative is moving forward!  Through this initiative, we are providing physicians and members with education and tools about antibiotic prescription use in respiratory tract infections.  Currently in the Upper Peninsula, antibiotics are being prescribed for 35% of visits in which the physician has diagnosed a cold or upper respiratory infection.  This increases to 81% for those diagnosed with acute bronchitis.  These numbers exclude those with comorbidities such as COPD, asthma, and diabetes.

Project Goals

1. Provide feedback to physicians as to their antibiotic prescribing patterns relative to their peers and established guidelines.
2. Decrease microbial resistance.
3. Maintain or improve patient satisfaction and outcomes in care for respiratory tract infections.

Following is a summary of project interventions to date:  

• Guidelines for the Appropriate Treatment of Acute Respiratory Tract Infections (for adults and children) were distributed in September and may be found on our Web site, (Please note that antibiotics are not indicated in upper respiratory tract infections and are not routinely indicated for acute bronchitis.)
• Regional physician seminars provided by local physician leaders are being held throughout the Upper Peninsula. Dates and locations are available on our Web site.
• Cold kits and member education materials are available through UPHP.

Contact Customer Service for member and provider materials.
Your effort and support for this project are appreciated.

For more information about appropriate antibiotic use and antibiotic resistance as a public health issue, visit the following Web sites: Centers for Disease Control and Prevention www.cdc.gov/antibioticresistance and the Michigan Antibiotic Resistance Reduction Coalition (MARR) www.mi-marr.org.  For more information on this UPHP project, check our Web site or contact our Clinical Services department.

Use of Appropriate Medications for Asthma

As a result of Michigan’s 2001 Health Plan Employer Data and Information Set (HEDIS) Use of Appropriate Medications for People with Asthma measure, we are asking you to review current long-term treatment options with your patients. This measure reported that 50% of UPHP members age 5-56 with persistent asthma were prescribed long-term control medications.  Acceptable medications include inhaled corticosteroids, cromolyn sodium, or leukotriene modifiers.  The complete listing of appropriate medications comes from the National Heart, Lung, and Blood Institute (NHLBI).  The Michigan Medicaid reported average for this measure was 58.1%.
UPHP will soon be implementing interventions to improve these rates, which will include contacting provider offices of members who are not utilizing a long-term medication for their persistent asthma. UPHP’s Clinical Practice Asthma Guideline is accessible on our Web site on the Provider Link under Clinical Practice Guidelines. We welcome your comments or concerns in this ongoing effort to improve asthma outcomes.

Growth Monitoring

Please review your medical records for inclusion and utilization of the appropriate growth chart for children through the age of 18 years. Whenever possible, a plotted weight and height should be part of any visit. According to the American Academy of Family Physicians, healthcare providers should routinely monitor growth patterns for all infants at 2 weeks, and at 2, 4, 6, 12, 15, and 18 months. Thereafter, children and adolescents should be monitored at least yearly. Growth monitoring practices of UPHP providers were measured for 1999 and 2000. Results are displayed in this Growth Assessment chart. Improvement in 2000 was noted, but there is still more room for more.  Growth Charts are available at the CDC Web site:  www.cdc.gov/growthcharts.

Vaccine Shortage Reference

We have recently updated, and will continue to update, our UPHP Web site regarding vaccine shortages, as any information becomes available to us through the Michigan Department of Community Health. Check under our Provider Link.

Smoking-Cessation Kits Available

As the new year is upon us, it is a great time to offer services to help your patients quit smoking.  UPHP has a limited supply of tobacco-cessation member education packets from the Michigan Association of Health Plans Foundation. The packet contains patient handouts, suggested guidelines for talking to your patients about quitting, and an insurer’s tobacco-cessation benefits grid that lists what insurers in Michigan cover.  (Please note that this grid indicates UPHP does not cover nicotine gum. UPHP does, in fact, cover a 30-day supply of the gum per year.) If your office would like one or more of these packets, please call UPHP and ask to speak with Patty in the Clinical Services department.

Medical-Record Confidentiality

The Michigan Family Independence Agency (FIA) assistance application, which is signed by individuals seeking Medicaid assistance for themselves or their wards, includes language wherein the applicant acknowledges agreement that the “FIA and Michigan Department of Community Health (MDCH) Medical Service Administration may get and use necessary medical information about me or any of my wards or my minor children, including any information relative to HIV, ARC, or AIDS if applicable.” As a Qualified Health Plan, under contract with the State of Michigan, our medical-record requests are made as agents for MDCH. As such, we are permitted the same access as the MDCH with respect to the use of Medicaid beneficiaries’ medical information.  We are also subject to the same state and federal laws regarding the protection of confidentiality.

Weight-Management Criteria

The UPHP Clinical Advisory Committee unanimously approved evidence-based weight-reduction criteria at the December 11, 2001, meeting. The criteria are in two parts: Part one refers to pharmaceutical intervention; part two refers to surgical intervention. Both parts require prior authorization. Providers may obtain a copy of the criteria from our web site under the Provider Link and Clinical Practice Guidelines or by calling Customer Service.

Claim Notes

Modifiers UC and GJ. Modifiers UC and GJ are no longer required on HCFA-1500 billing.

Bilateral Procedures. Our system pays per line billed.  If you submit a claim for a unilateral procedure when a bilateral procedure was actually performed, and you use modifiers to indicate the bilateral procedure, bill the first line as a unilateral procedure (with no modifier), and we will pay 100% of the allowed amount.  The second line will be billed just like the first line, but use a modifier to indicate that it is a bilateral procedure, and we will pay that claim at 50% of the allowed amount.  If you bill only one line and use the bilateral modifier, we will pay the claim at only 50%.

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Upper Peninsula Health Plan - 228 W. Washington Street - Marquette, MI 49855

1-800-835-2556 or  906-225-7500