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UPPER PENINSULA HEALTH PLAN
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In This Issue....
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Provider Notes
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Notes From the Medical Director
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Provider Performance Reports
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Providing cost-effective, high-quality health care is a goal that we as practitioners all share. In an effort to facilitate this goal, the Upper Peninsula Health Plan (UPHP) has undertaken a major effort in
distributing reports to select larger-volume primary care practices. These reports will detail performance measures in both quality of care and utilization management.
Quality measures will include Care of Women,
Care of Children, and Care for Chronic Diseases. We have adopted various Health Employer Data and Information Set (HEDIS®) measures as our quality standards, as this is the most widely accepted standard in
managed care for measuring quality. These HEDIS® measures will be grouped and reported in the above categories.
Utilization management reports will detail the cost efficiency of care you provide for common
conditions. This cost efficiency measure will be adjusted for disease severity and comorbidities for each of the measures we report. This report will give individual providers feedback as to the cost at which they
provide care for the same conditions relative to their peers.
In recognition of the fact that our patients often see several different primary care providers within a group practice, select measures will be
reported on a group basis. Groups will then be measured against each other and against state and national benchmarks. These results will be blinded and only you will know which group is yours.
These reports will
also contain one more important piece of information. We will list and identify specific members who have not received a recommended service as defined under HEDIS® quality measures. Such services include
breast and cervical cancer screening, well-child visits, and adequately controlled hypertension, among others. This list of members needing additional care will allow your offices a real and tangible basis for
improving the quality of care for our members. We will ask that you contact these individuals and arrange appointments to provide these important services.
This report is the first of its kind for the plan. It
will not be perfect and will have room for improvement. I am, however, confident that this is an important beginning and am looking for your feedback and cooperation in this effort.
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Continuity of Care
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The issue of communication between providers is an important one. We are making efforts to promote two-way communication between providers on a consistent basis.
We also urge our providers to take an active part in this process by:
- Consistently sending adequate referral information to any specialist or other practitioner or
provider involved in a patient’s care. As defined by the National Committee for Quality Assurance, providers include hospitals, long-term care facilities, freestanding surgery centers, and home health
care. It is important to keep those lines of communication open as well.
- Requesting follow-up correspondence as a routine part of your referral process. If you do not receive it, call and inquire.
- Asking your patients to reinforce this message by having them ask other providers to “please send this information to my other doctor.”
- Providing follow-up correspondence or a copy of your own note to the patient’s primary care provider (PCP) whether the PCP has made the original referral to you or not.
- Requesting that a courtesy copy go to the appropriate doctor when ordering tests and procedures.
- Asking for copies of immunizations no matter where they have been given.
When all practitioners and providers are included in the “loop” we strengthen the likelihood of consistent and safe care of patients, and we
decrease duplication of efforts and resources.
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Major Depression Study Results
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The Upper Peninsula Health Plan (UPHP) Clinical Advisory Committee (CAC) reviewed the findings of a recently conducted study on the treatment
of major depression at its June 11, 2002, meeting and recommended that we communicate these findings to providers in an effort to increase the compliance with the clinical practice guidelines. Of particular concern
was the lack of follow-up after prescribing antidepressants. Also, as you will note, screening tools were not utilized according to guidelines. These tools may be cumbersome to use but can be useful. Some tools are
more user friendly than others. If you would like to access the tools referred to in our guidelines, use the link under Clinical Practice Guidelines at www.uphp.com or call Customer Service, and we will assist you. The UPHP guideline also appears at www.uphp.com.
We believe that there is room for improvement in this area of care. The CAC also recommended that when follow-up is given, assessment of medication efficacy is critical to document. If you have any questions or
concerns about this study, please contact Customer Service.
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HEDIS® Medical Record Review Questions and Answers
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Q: For HEDIS® audits, how do you decide which records you ask for?
A: The National Committee for Quality Assurance (NCQA) defines the study methodology. All health plans in the nation work within the same
standard guidelines.
Q: If the care being audited is documented in the medical record, does it always get counted as being given?
A: No, unfortunately. We are bound to follow very specific guidelines for medical record documentation. The following rules apply before documentation can be counted:
- Each page must contain the patient's name or identification number (both are preferred).
- All entries in the medical record must contain the author’s identification, signatures, or initials.
- All entries must be dated. (This means flow sheets as well as progress notes.)
- The record must be legible to someone other than the writer.
Q: Does the health plan report each provider’s individual care to the state or to NCQA?
A: No. We report the care given to the entire population that falls within a measure. However, we must make demonstrable efforts to follow up on quality concerns that may be detected by this audit process. We make
every attempt to prioritize the areas of greatest concern, but sometimes these priorities are mandated by regulations as well.
Q: Does HEDIS® benefit providers?
A: Yes. We have been attempting to “clean” the claims data in an effort to provide a true reflection of the care given so that providers can rely on our findings as an indicator for their own quality-improvement
endeavors. Although we realize that there is extra effort required from providers to assist us in these quality matters, we trust that our providers, too, will see the value in the results being as accurate as
possible. This is how we can show the true reflection of the quality of health care in the Upper Peninsula.
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The CAHPS® (Consumer Assessment of Health Plans Study) Survey is a portion of our annual HEDIS® (Health Employer Data and Information Set) reporting requirement to the state. Providing a list of our members
to a surveying agency accredited by the National Committee for Quality Assurance is the extent to which we actively participate in this process. The surveyors contact and review a total of 107 questions with members
who indicate a willingness to respond. Upper Peninsula Health Plan members have one of the highest response rates in the state.
Traditionally, our members have consistently given both the providers and the health
plan high marks in most areas. Although we do not want to underemphasize this good news, there are a few areas in which we still have room for improvement.
The following questions are taken verbatim from the
CAHPS® survey. These questions cover areas where we did not meet our desired rates in the 2001 survey.
Immunization Advice (lower than the state average)
__ “After your child was born, did you get any
reminders to bring him or her in for a check-up to see how he or she was doing for shots or drops? (Reminders can come by mail, telephone, or in person during a visit.)”
Emergency Department Utilization (higher than the state average)
__ “In the last 6 months, how many times did your child go to an emergency room?”
__ “In the last 6 months, how many times did you go to
an emergency room to get care for yourself?”
Tobacco-Use Assessment and Cessation Advice (lower than the state average)
__ “Have you ever smoked at least 100 cigarettes in your entire life?”
__ “Do you now smoke __every day, __some days, or __not at all?”
__ “How long has it been since you quit smoking cigarettes (__6 months or less, __more than 6 months, __don’t know)?”
__ “In the last 6 months
on how many visits were you advised to quit smoking by a doctor or other health provider in your plan __none, __1 visit, __2 to 4 visits, __5 to 9 visits, __10 or more visits, __no visits in the last 6 months?”
We ask you to consider your own practices in terms of how they impact these areas. If you have patients who fall into these categories and you
feel interventions from our Clinical Services department would be beneficial, please make a referral to us.
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Tobacco Use
A recent survey of providers throughout the
Upper Peninsula indicated that tobacco-usage status was only documented about 50% of the time and interventions for smoking cessation were documented in only 46% of an identified smoker’s medical
records. Although some providers routinely and consistently document tobacco status, many do not have a consistent procedure in place. The Upper Peninsula Health Plan (UPHP) would like to join in the
effort to increase providers’ documentation and treatment efforts. We have a Medical Records Vital Sign sheet available to any provider. The sheet includes a tobacco-status check box for each time
vital-sign entries are made in the chart. Just as vital signs are consistently obtained with most office visits, so too could tobacco-use status. Every visit can be a great opportunity to advise
quitting! If you believe your practice would find this sheet beneficial, call Customer Service, and we will send you a copy. The form is also available at www.uphp.com
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Web Site Updates
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The following information has been added to the Upper Peninsula Health Plan’s Web site: www.uphp.com
- There is a new Coding Guide to help you properly code for Health Employer Data and Information Set (HEDIS®) measures. We recently mailed this guide to 118 primary care offices in the Upper Peninsula.
- The Preventive Healthcare Guideline for Pregnant Women has been revised and is available to download from the Web site.
- Depression screening tools are available via a link under Clinical Practice Guidelines.
- Utilization Management Medical Necessity Criteria:
- Weight-Reduction Criteria
- Cosmetic Versus Functional Surgical Requests
- Medical Records Vital Sign Sheet, which can be used for recording vital signs, including the status of tobacco use.
Check our printable-forms site periodically for changes, since we update them regularly. If you cannot access this Web site, please call Customer Service, and we will send you copies of the forms you desire.
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Call it Quits Smoking Cessation Program
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Call It Quits is a free telephone counseling service for all UPHP Medicaid patients who are looking for additional support to help
them quit smoking. This program provides them with a tool kit to help them quit, six telephone calls with a personal counselor, and support and encouragement for six months.
UPHP covers nicotine gum
(30 days of therapy per year), nicotine patches, and Zyban (90 days of therapy per year). Please give our members a stop-smoking prescription and the Call It Quits toll-free telephone number:
1-800-834-4781.
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CLAIM NOTES
Sterilization Consent Forms
If you wish, you may fax consent forms for male or female sterilizations to Sandy in claims at 906-225-7690.
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Formulary Change
The prior-authorization requirement for Ultram has been removed, and the generic equivalent, Tramadol, is
available.
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Please contact our Webmaster with questions or comments about this site.
© Copyright 1999 Upper Peninsula Health Plan, Inc. All rights reserved.
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Upper Peninsula Health Plan - 228 W. Washington Street - Marquette, MI 49855
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