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Quality Corner ................................................................................................. 2

Extended Visit ................................................................................................. 3

Technology Assessment Committee ................................................................ 4

PHYSICIAN PARTNERUpdate A PUBLICATION OF UPMC HEALTH PLANFEBRUARY 2011

Medicare and SNP Prior AuthorizationThere have been calls from providers inquiring about prior authorizations for physical therapy services and select MRI services. There has been a delay in implementing prior authorization for these services, and they do not currently require a prior authorization. A written 30-day notification will be provided prior to the implementation of prior authorization for these services.

Help for Members with Complex Medical NeedsIf you have patients with a complex medical or behavioral health condition and feel like they could use some extra help, UPMC Health Plan can provide assistance through our complex case management program.

The program puts your patients in touch with a health coach who will work with them and their medical team. A health coach helps patients get health care services and understand their treatment plan and teaches them and their caregivers about their condition. In addition, the health coach assists patients in obtaining community services and encourages collaboration among all providers who care for the patient.

Using claims data, UPMC Health Plan contacts patients who could benefit from having a health coach. Providers can also refer their patients to the program. Patient enrollment in this program is voluntary and members may decide to disenroll at any time.Additional information about our Complex Case Management Program can be found in the UPMC Health Plan Provider Manual at http://www.upmchealthplan.com/providers/manual.html. If you have questions about the program, call us at 1-866-778-6073. Representatives are available Monday through Friday from 8 a.m. to 5:30 p.m.

adultBasic Program EndingFebruary 28, 2011UPMC Health Plan has been notified by the Pennsylvania Insurance Department that the adultBasic health insurance program will cease to provide coverage to enrollees beyond February 28, 2011, due to lack of funding. Amendments that remove UPMC for a Healthy You (adultBasic) from provider participation agreements have been sent via mail.

Individuals with adultBasic coverage who have health care services scheduled beyond February 28, are being encouraged to discuss with their health care providers whether any of those services could be appropriately provided prior to February 28.

If a UPMC for a Healthy You (adultBasic) member received care for a covered medical procedure on or before February 28, and the claim is submitted after that date, it will be reimbursed. Any claims for services rendered after February 28, 2011, will not be reimbursed, with the exception of claims associated with covered services for members who are inpatients on February 28, 2011.

If you have questions, contact Provider Services at 1-866-918-1595. Updates about the adultBasic program will be posted on the PA Insurance Department’s website at www.insurance.pa.gov (click on adultBasic).

www.upmchealthplan.com 2 February 2011

PHYSICIAN PARTNERUpdate

Health Care Costs Continue to Rise — U.S national health care spending accounted for 16% of the Gross Domestic Product (GDP) in 20041 and grew 4% to 17.6% of GDP by 2009 ($2.5 trillion or $8,086 per person). It is projected to climb to 19.3% by 2019.2 Medicare spending increased 7.9% ($502.3 billion) in 2009, accounting for 20% of the total health expenditure, and is expected to rise at a rate of 6.9% per year through 2019.2 This Medicare projection may be understated, given the increase in the aging U.S. population.

The U.S. Population Continues to Age — The number of people over age 65 in the U.S. increased from 31 to 34 million between 1990 and 2000. By 2030, it is projected that 1 in 5 Americans will be > 65 years old. The fastest growing segment of this population is the “very old,” defined as > 85 years.3

Opportunity to Improve Preventive Care Counseling in the Elderly – Greater disparities in the access and use of health care services exist among minorities, the poor, the disabled, and the elderly, especially the very old.4 Both groups — U.S. adults age 18 and over5 and the vulnerable elderly age 65 and over — receive only half of the recommended preventive care and screenings, measured by the percentage of time providers adhered to care indicators.6 In addition, quality of care varied significantly among different conditions and types of care. Adherence to quality of care indicators was highest for treatment of medical conditions (81%), especially for acute medical care (83%) compared to chronic condition management (51%), and was lowest for preventive care (43%). There was disparity among older adults for both acute and chronic care management (41% and 29% respectively). Preventive care counseling was least provided among the elderly, including for conditions such as dementia, urinary incontinence, gait disturbance, and fall prevention.6 A 2004 Government Accountability Report also stated that Medicare patients were less likely to receive recommended preventive care.7 These reports demonstrate a real need for improving processes of care to provide more consistent and effective preventive care counseling to elderly patients.

Opportunity to Decrease Burden of Illness and Health Care Costs in the Elderly — Older adults are more susceptible to conditions that affect their ability to function and remain independent. As a result, preventive counseling has significant potential to improve health and function and to reduce the burdens of morbidity, mortality, hospital and nursing home admissions, and health care costs in the elderly.7,8

CMS Health Outcomes Survey (HOS) and Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey — In order to monitor and help improve functional health care quality and outcomes in the elderly, CMS contracts with NCQA to administer the Health Outcomes Survey and with the U.S. Agency for Healthcare Research and Quality (AHRQ) to administer multiple Consumer Assessment of Healthcare Providers and Systems (CAHPS) Surveys. These annual surveys are administered directly to Medicare members to collect patients’ perspectives and satisfaction with the care they have received across the health care system from individual physicians, medical practices, health plans, and health care facilities, including hospitals and nursing homes. The CMS goals include using information from these surveys to standardize measurement across the health care system and promoting transparency of provider information to help

patients make more informed health care choices.9

Methods for Improving Preventive Care: Strategies to improve preventive care, as well as HOS and CAHPS scores, require 2 main principles:

1. Direct physician recommendation/counseling on key areas of preventive care. Patients cite “physician recommendation” as the major motivator for getting preventive care. Screening rates were higher among doctors who say, “I recommend ….”10

2. Coordinating the physician’s recommendation with a patient-centered team approach to improve preventive care. The physician’s advice is a catalyst, but it alone is not sufficient. The doctor’s recommendation works best as part of a planned, integrated, and coordinated team effort, which includes:11,12 • Identifying patients who need preventive care;• Engaging and educating those patients with effective initial and

follow-up communication;• Providing relevant information that is personalized to the patient;• Providing clear, written materials, decision-support prompts, and

patient follow-up reminders.

(continued)

QUALITY CORNERImproving Preventive Care in Medicare Patients:Focus on Key Measures Monitored by CMS in the Medicare Hospital Outcomes Survey (HOS) and the Consumer Assessment of Healthcare Providers and Systems (CAHPS)

Nicholas DeGregorio, MD, FACP, MMM

www.upmchealthplan.com 3 February 2011

PHYSICIAN PARTNERUpdate(continued from page 2)

There is strong evidence that the manner of communication with patients can influence whether or not they follow through with your preventive care advice. Communication by both doctor and the care team will be more effective, considered more thoughtfully, and retained for a longer period of time when:

• It is delivered in a concerned, caring, and compassionate manner;

• It is made personally relevant to the patient so he or she understands why and how it is important to him or her. This is the basis of Becker’s Health Belief Model, which suggests that individuals who perceive individual susceptibility are more likely to follow through with physicians’ advice.13

In our next issue of Physician Partner Update, we will share a helpful preventive care tool to assist you in preventive care discussions with your patients.

References:1. Cylus J. and Anderson G.F. Multinational Comparisons of Health Systems Data, 2006.

New York: The Commonwealth Fund, Apr. 2007.2. Centers for Medicare & Medicaid Services (CMS). “National Health Expenditure

Data – NHE Fact Sheet.” Last Modified January 13, 2011. https://www.cms.gov/NationalHealthExpendData/25_NHE_Fact_Sheet.asp.

3. Litwin M.S. Older Americans 2000: Key Indicators of Well-Being. Federal Interagency Forum on Aging-Related Statistics, Washington D.C. U.S. Government Printing Office, 2000.

4. De Lew N. and Weinick R. An Overview: Eliminating Racial, Ethnic, and SES Disparities in Health Care. Health Care Financing Review 21(4):1–7, Summer 2000.

5. McGlynn E. et al. “The Quality of Health Care Delivered to Adults in the United States.” NEJM 348(26):2635–2645, June 26, 2003.

6. RAND Health. “The Quality of Health Care Received by Older Adults,” Copyright 2004: http://www.rand.org/content/dam/rand/pubs/research_briefs/2005/RB9051.pdf. This highlight summarizes RAND health research reported in the following publications:a. Developing Quality of Care Indicators for the Vulnerable Elderly: The ACOVE

Project. Santa Monica, Calif.: RAND Corporation, RB–4545, 2002. b. Higashi T. et al. “The Quality of Pharmacological Care for Vulnerable Older

Patients.” Annals of Internal Medicine Vol. 140, pp. 714–720, 2004.c. Rubenstein L.Z., Solomon D.H., Roth C.P., et al. “Detection and Management of

Falls and Instability Among Vulnerable Elders by Community Physicians.” Journal of the American Geriatric Society, in press.

d. Wenger N.S., Solomon D.H., and Roth C.P., et al., “The Quality of Medical Care Provided to Vulnerable Community-Dwelling Older Patients.” Annals of Internal Medicine Vol. 139, pp. 730–747, 2003.

7. Government Accountability Office 2004. Medicare Preventive Services: Most Beneficiaries Receive Some But Not All Recommended Services. A Testimony Before the Subcommittee on Health, Committee on Energy and Commerce, House of Representatives, September 21, 2004.

8. Williams, R.D. “Urologic Diseases in America Project.” The Journal of Urology 173:679, March 2005.

9. Garfinkel S.A. “The Consumer Perspective on Health Care: CAHPS II, UNC Program on Health Outcomes Seminar,” November 8, 2002.

10. Levy B. et al. “Why Hasn’t This Patient Been Screened for Colon Cancer? An Iowa Research Network Study.” Journal of the American Board of Family Medicine 20:458–468, 2007.

11. Kreuter M.W. et al. “How Does Physician Advice Influence Patient Behavior? Evidence for a Priming Effect.” Archives of Family Medicine 9:426–433, May 2009.

12. Steward M.A. “Effective Physician-Patient Communication and Health Outcomes: A Review.” Canadian Medical Association Journal 152(9):1423–1433, May 1, 1995.

13. Becker M.H. “The Health Belief Model and Personal Health Behavior.” Health Education Monographs 2:324–473, 1974.

Extended VisitUPMC Health Plan recently sent a letter to PCPs who are caring for UPMC for Life and UPMC for Life Specialty Plan members. In that letter, UPMC Health Plan encouraged these members (Medicare and SNP) to schedule an extensive annual physical examination with their PCPs. • UPMC Health Plan will reimburse PCPs at the rate of $140 for

each annual comprehensive visit for these members — both new and established.

• In order to receive proper reimbursement, the following codes should be used:− G0438 — Annual wellness visit — includes a personalized preventive plan of service (PPPS); first visit − G0439 — Annual wellness visit — includes a personalized preventive plan of service (PPPS); subsequent visit

• These members will NOT have a copayment for this service.

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www.upmchealthplan.com 4 February 2011Copyright 2011 UPMC Health Plan, Inc. All rights reserved. FEB PPU C20110203-01 (BAM) 2/25/11 MPD

The Technology Assessment Committee meets regularly to review medical technology. The following chart details recent committee decisions. Please refer to the designated policy for complete indications and limitations.

Technology Assessment Committee

Subject Reason for Review UPMC Health Plan Summary

AlloDerm® Skin Substitute Policy Review Covered for breast reconstruction (all products).

GRAFTJACKET® Regenerative Tissue Matrix (non-injectable)

Policy Review Covered when used for open wounds of wrist, hand, or fingers involving tendons (all products).

GRAFTJACKET® XPRESS Flowable Soft Tissue Scaffold (injectable)

Policy Review Considered Experimental and Investigational for all products.

Endoform Dermal Template™ Policy Review Considered Experimental and Investigational for all products.

Breast reconstruction with external breast prosthesis

Policy Review UPMC Health Plan follows Medicare (CMS) guidelines.

PLAC testing Policy Review Considered Experimental and Investigational for all products except Medicaid.

Microprocessor Ankle Policy Review Considered Experimental and Investigational for all products except Medicare. For the Medicare products, requires prior authorization.

Gamma Graft Policy Review Considered Experimental and Investigational for all products.

Circulating Tumor Cell Tests Policy Review Considered Experimental and Investigational for all products.

Circulator Boot (End Diastolic Pneumatic Compression Therapy)

Policy Review Considered Experimental and Investigational for all products.

Bronchial Thermoplasty Policy Review Considered Experimental and Investigational for all products.

Metal on metal hip resurfacing Policy Review Considered Experimental and Investigational for all products.

SHOX DNA Assay Policy Review Considered Experimental and Investigational for all products.