UPPER PENINSULA HEALTH PLAN

In This Issue....

Pharmacy Crisis                                                                         2003 Focus on Improvement
MDCH Key Quality Indicators                                                   Pediatrics and Adolescents
Obstetrics                                                                                                         CAC Updates
Claim Notes                                                                       Cold Kits for Cold and Flu Season

Provider Notes

Notes From the Associate Medical Director

Pharmacy Crisis

The Upper Peninsula Health Plan (UPHP) is currently experiencing a crisis in pharmacy cost.  Only with joint cooperation of the UPHP staff members; providers (especially the physicians and nurses involved in the care of the patient); and patients all working together can we avoid a financial catastrophe. Medicaid expenditures for drugs have been growing at an average of 18% each year during the past five years compared to all Medicaid expenditures of 7.7%.  Physician charges have increased during this comparative time by 2% and hospital charges by 4%, as compared to the Consumer Price Index increase of 2.7%. The number of prescriptions per capita rose 6% annually from 1992 to 2000. Currently the average UPHP prescription written is 20% higher in cost and 30% higher in utilization than a comparable Michigan Medicaid population.  Currently 35% of all total UPHP expenditures are related to pharmacy. These pharmacy expenditures are currently rising at a rate of 10% to 12% per year. The health plan faces some difficult decisions, as this trend cannot continue secondary to limited funding.
The pharmaceutical industry has brought to market many advances in treating, curing, and preventing diseases, many of which previously had no treatment or only poor treatment options available. These therapeutic advances come with a substantial cost to an individual or to society as a whole. It is our goal to improve the quality of health care delivered to our patients through the plan, in the most cost-efficient fashion available.
To address these issues, the health plan is faced with a dilemma.  Either we control the cost of pharmaceuticals (while not sacrificing the quality of health care to our population), or quality of care is in jeopardy. Strategies to curb the pharmacy spending include the following:

• Prior authorizations
• Preferred drug lists
• Mandatory generic substitution
• Quantity limits
• Patient and provider profiling
• Educational programs
• Copayments
• Disease management
• Patient-focus drug-utilization review
• Program-focus drug-utilization review

We are requesting the following consideration from prescribing practitioners:

• Review all opportunities for generic utilization and dose optimization.
• Consider cost-benefit ratio in prescribing.
• Avoid poly pharmacy
• Participate in the Upper Peninsula Health Plan Blue Cross/Blue Shield of Michigan efforts to maximize the efficiency in effective drug utilization.

We believe that only through a cooperative effort will we be able to contain these costs.  Without practitioner involvement, we cannot address these complex issues, which will ultimately result in the decisions being taken out of our hands.
Secondary to limited funding, the health plan has to address its major source of cost increases. We will take measures as described above to control our cost while at all times maintaining the best possible quality health care given to our members.
The UPHP Clinical Advisory Pharmacy and Therapeutics Committee recommended formulary changes at its meeting on September 10, 2002.  These changes will be provided to you in a detailed letter expected to be mailed in November 2002 with an effective date of January 1, 2003.

Top

2003 Focus on Quality Improvement

Some quality issues that will be reassessed based on year 2002 services are:

• Patient safety - Appropriate antibiotic use in RTIs
• Continuity-of-care communication between providers
• Tobacco use assessment and cessation advice
• Chronic asthma patients receiving primary therapy for long-term control
• Diabetic patients’ (annual) HbA1c screening and control, LDL screening; urine microalbuminuria (unless documented kidney disease); dilated diabetic eye exam by an eye exam professional; routine foot exams by providers.
• Hypertensive patients - control of blood pressure: goal of <= 140/<= 90
• Anti depression medication management - three provider contacts in the first 12 weeks of therapy.
• Prenatal care - Standard in the first trimester and postpartum exam 21 to 56 days after delivery.
• Mammography screening - every two years for women age 52 - 64
• Pap smear screening - every three years fro females age 21 - 64
• Chlamydia screening - annual testing for all sexually active women age 16 - 24
• Immunizations - evidence of an up-to-date vaccination status at age 2 years and 13 years including varicella immunization / chicken pox disease history.
• Well child care: 0 to 15 months - evidence of six well-baby exams; adolescents age 2 to 20 years - one annual well-care exam (except for 7th and 9th year). Evidence of all the following components must be documented for well care:
• A health and development history (physical and mental)
• A physical exam
• Health education / anticipatory guidance

Note:  If a child comes in for reasons other than well care, but well care was also provided, this can be counted as long as all of the components of well care are present. Included here are charts of our Health Employer Data and Information Set (HEDIS®) results for the past two years. For a complete copy of the report, please call Customer Service.

Top

Upper Peninsula Health Plan MDCH Key Quality Indicators:
HEDIS Comparison 2001-2002

Pediatrics and Adolescents

You Can Identify Needed Well-Child Visits
One way of identifying your practice’s UPHP members who need well-child or preventive services is by reviewing the Upper Peninsula Health Plan Active Members by PCP Roster.  This roster is sent to all providers on a monthly basis.  Please take the time to review this list, then compare it with your members medical records or information systems.  If a member has not been seen within this past year, please take the time to contact him or her and arrange a visit before the new year.  In the future, we hope to provide more population-based lists of members with specific conditions or in-need-of preventive services.  UPHP believes this joint effort will benefit you, your patients, and our members. If you have any questions or would like additional information on the specific populations that UPHP is focusing on this year, please contact Customer Service.

MSA Updates EPSDT Policy
The newly updated Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Medical Services Administration (MSA) policy effective September 1, 2002, was recently distributed to all providers by the State of Michigan.  There are some slight changes in the policy, and you may want to review the components for each age group. The EPSDT Periodicity Table from this policy is posted on our Web site at www.uphp.com.  For more information, please contact Customer Service.

Missed Opportunities
In 2001, UPHP's population of adolescents 12 to 21 years of age was 2960 members.  The number of these members receiving well-child visits was only 699 (23.6%).  Yet, our data revealed that of those members, 1540 (51%) received and filled some type of prescription medication.  Data also revealed 95 members who were seen on a routine basis (376 visits total) anywhere from 1 to 9 times for attention deficit hyperactivity disorder (ADHD); yet, they did not receive a well-child visit. These are instances of missed opportunities to assess for and/or render needed preventive services.  Please take the time to review your current practice patterns and any systems you may have in place for tracking routine preventive care.  If you need assistance obtaining preventive flow sheets for your medical records, please call Customer Service.

Screen for Lead Poisoning
The State of Michigan mandates lead testing to be performed on children at 12 and 24 months of age and on children 36 to 72 months who have not been previously screened. Childhood lead poisoning is considered the most preventable environmental disease of young children, but almost 1 million children have elevated blood lead levels. Additional information about prevention of childhood lead poisoning is available through the National Lead Information Center at http://www.epa.gov/opptintr/lead/nlic.htm or by calling 800-424-LEAD (800-424-5323).

Top

Obstetrics

The Upper Peninsula Health Plan has revised the clinical practice guideline (CPG) for pregnancy and postpartum care to include an evaluation of postpartum depression at the six-week postpartum visit. The American College of Obstetrics and Gynecologists (ACOG) states that the postpartum visit is a good time to assess for postpartum depression.  It is also important for providers to distinguish between the “baby blues,” “postpartum depression,” and “postpartum psychosis,” according to an ACOG news release of January 2002. Screening tools for depression can be of value for providers. The Edinburgh Postnatal Depression Scale and the Postpartum Depression Screening Scale are two examples.  You can access the CPG and the links to the depression tools at www.uphp.com.

Top

CAC Updates

On September 10, 2002, the UPHP Clinical Advisory Committee (CAC) met, reviewed, and approved several guidelines and proposed management programs, which include:
Preventive Health Care Guidelines
€ Ages Birth-24 Months € Ages 2-6 Years  € Ages 7-12 Years € Ages13-18 Years  € Ages 19-39 Years  € Ages 40-64 Years  € Ages 65 and Over
Clinical Practice Guideline for Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder (ADHD)
Diabetic Management Program
Pain Management Program (beginning with management of migraine headaches)
Attention Deficit Hyperactivity Disorder Program
Utilization Management Criteria for Second MRI/MRA Requests
 These guidelines and criteria are available to download and use in your practice from our Web site: www.uphp.com.  You may also obtain copies from Customer Service. For comments or further information about these guidelines or programs, or about our annual quality-improvement evaluation and program goals, please call Debbie in Clinical Services.

Top

Cold Kits for Cold and Flu Season

As the cold and flu season settles in, please remember that cold kits and other member education materials are available from the Upper Peninsula Health Plan (UPHP). These materials are a product of UPHP's Appropriate Antibiotic Use Initiative, one goal of which was to reduce antibiotic prescriptions for upper respiratory tract infections.
For cold kits and other member education materials, contact UPHP Customer Service. For more information about appropriate antibiotic use and antibiotic resistance as a public health issue, visit the following Web sites: www.cdc.gov/drugresistance/community (Centers for Disease Control and Prevention) and www.mi-marr.org (Michigan Antibiotic Resistance Reduction Coalition).

Top

Claim Notes

Location Code UC and Modifier GJ. Please continue to use the location code UC (for Urgent Care) and the modifier GJ (which indicates either a Walk-in Clinic or Urgent Care visit).
Fetal Non-Stress Tests. Claims for fetal non-stress tests (CPT 59025) may be submitted without prior authorization. Lunelle Injections. The HCPCS code for Lunelle injections is Z8515. The current fee  is $16.61.
Polycarbonate Lenses (Single Vision). The HCPCS code for single-vision polycarbonate lenses is HCPCS Z1202. Two units will be paid when billed this way.
Immunizations/Vaccines for Children Program . The system configuration is complete for billing immunizations for the Vaccines for Children (VFC) program. Per CPT guidelines, to report the administration of a vaccine or toxoid, the vaccine/toxoid product codes must be used in addition to the immunization-administration codes (90471-90472). The following is an example of a correct billing: