Provider Perspective

Inside this issue…

Message from Dr. Jeremy Cauwels

Patient Safety & Quality

HEDIS® Performance Measuress Results and The Future of HEDIS®

Nicotine Cessation Benefits

NCQA Special Edition – September 2020

Jeremy M. Cauwels, MDSenior Vice President, Clinic Quality and Medical Officer, Sanford Health Plan

Call me Jeremy: A message from Senior Vice President, Clinic Quality and Medical Officer, Sanford Health PlanBy: Dr. Jeremy Cauwels

Please forgive me, in that this is the first column that I am writing for the health plan, I thought that I might go off script just a little. Usually, one of our physician leaders spends time talking about some aspect of insurance that would be useful to all involved. For this column, I would rather introduce “something totally different.”

My name is Jeremy and anyone who runs into me in the hall is welcome to call me that. When I was born, my mother did not call me Dr. Cauwels and my family still laughs at me when somebody calls my house and asks for me by title. Professionally, everyone at the Health Plan or Sanford in general should know that you are an expert in something that I probably know very little about. I believe that if my title ever gets in the way of you sharing your expertise, I have done damage to our mission.

I grew up 45 miles south of Sioux Falls, in a small town called Hawarden, Iowa. My upbringing was marked, but certainly not scarred, by meeting a lot of doctors due to a congenital heart defect. I think it stunted my growth (that joke is only funny when you meet me, I’m 6’4”). I was informed very early that

medicine was a possibility for me, not because of my brilliance, but because my handwriting was so bad that being a doctor was one of the few jobs open to me.

I was asked to join Sanford Health Plan a couple of months ago and I believe it was for one major reason, integration. Sanford has entered a place where the best way we can take care of patients is to understand all the facets of their care and be nimble enough to make decisions that result in their best outcomes, for as many patients as possible. That means that we can use the power of our system differently…more open communication, knowing when it would be smart to involve the rest of the system, learning about data sharing so our doctors know what our health plan knows about peoples’ habits and patterns and so much more. Communication and care management from the health plan will be a focus of our regularly scheduled business in how we work together as a team.

Overall, I join a very new leadership team with some impressive experiences in other places. We are quickly beginning to understand how we can help the Sanford Health

Plan begin to look at integration and start working with the patients and providers we serve. I look forward to meeting and working with you on this journey.

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Breakdowns in patient safety in primary care are real. The Agency for Healthcare Research and Quality (AHRQ) has identified key risks in primary care that are amenable to improvement through patient and family engagement. These risks include:

• Errors in diagnosis: the failure to establish an accurate and timely explanation of the patient’s health problem(s) and communicate that explanation to the patient.

• Communication breakdown: occurring within the practice, including incomplete and ineffective communication with patients and families, failure to communicate test and laboratory results, and within clinic team communication.

• Medication errors: including failures in communicating, prescribing, filling, and dispensing, as well as patient misuse of medications.

• Fragmentation of care: resulting from patient transitions across care settings (acute and primary care) and between outpatient care team members.

In primary care, the relationship between the clinician and the patient is key to high quality, safe, and effective healthcare. Patient and family engagement in primary care helps to forge trusting relationships that promote safety.

Finding the time to engage patients is one of the biggest obstacles in primary care. Clinicians lack time for the patient encounter, time to dedicate to quality improvement and time to manage all competing pressures within the practice.

The AHRQ has created a useful guide composed of four evidence-based strategies that promote meaningful engagement with patients and families in ways that improve safety. Each strategy contains practical materials to support adoption of the intervention within primary care practices. These items include specific implementation and evaluation guidance, training materials, job aids and patient facing materials.

Click HERE to review the AHRQ guide.

PATIENT SAFETY & QUALITY

Electronic prior authorizationTo better serve our members and providers, we will require electronic prior authorization submission effective Oct. 1, 2020. Providers currently not using the electronic submission option will need to submit referrals electronically.

Sanford Employees and internal users: Please see the training resource HERE, or sign up for additional classes in the Sanford Success Center.

EXTERNAL PROVIDERS: Please submit authorization requests via Provider Portal HERE. For questions, please contact Provider Relations at (800) 601-5086.

Do you know a Primary Care Provider, specialist, therapist, counselor, psychiatrist, or psychologist that would be a benefit to your patients to be contracted with Sanford Health Plan? Did you know you can nominate them online or by calling customer service?

Follow the instructions online to complete the nomination request. Sanford Health Plan will contact the provider that has been nominated to see if they are interested to start the credentialing process.

Nominate other providers

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HEDIS® (Health Plan Effectiveness Data and Information Set) is a set of standardized performance measures designed to ensure that purchasers and consumers have the information they need to reliably compare health care quality. HEDIS® was developed by the National Committee for Quality Assurance (NCQA) and is the measurement tool used by the nation’s health plans to evaluate their performance in terms of clinical quality and customer service.

HEDIS® rates are part of Sanford Health Plan’s NCQA health plan accreditation rating and are required by various State and Federal regulatory agencies. HEDIS® rates are also increasingly being utilized in value-based contracting arrangements.

We would like to highlight some of the most notable areas in this year’s results and share a few observations. While Sanford Health Plan has seen many increased rates this year, there are still a number of areas where improvement can be made.

Click HERE for HEDIS® 2020 Commercial HMO rates and recommendations.

HEDIS® PERFORMANCE MEASURES RESULTS

Specialty referrals If you have a Sanford Health Plan member requiring a specialist, and the practitioner they are requesting is unavailable, please assist them by offering alternative options. In some instances, the members may need to be seen by a specialist, but that specialist is unavailable for a variety of reasons.

Often times, a similar specialist may offer services right in your own clinic. In those instances, we ask for your assistance in offering these patients the option to see other like specialists in your clinic. If your specialist is unavailable and you do not have other options available in your clinic, please refer that patient to Sanford Health Plan Customer Service Department at (605) 328-6800 or (800) 752-5863 and our team can assist the patient in finding an alternate practitioner.

COVID-19: UPDATED COVERAGE ANNOUNCEMENTTo best service our members in this time of uncertainty, Sanford Health Plan will waive all cost-sharing for treatment of COVID-19 through September 30, 2020. This means members will receive care and treatment and Sanford Health Plan will cover all of their out-of-pocket costs related to COVID-19. This provides for coverage of testing and treatment, including outpatient treatment and inpatient hospital stays. Stay up-to-date on all COVID-19 information and find resources specifically for providers by visiting this webpage.

Have additional COVID-19 questions? Submit your questions HERE.

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As NCQA HEDIS® measures continue to evolve and grow at Sanford Health Plan, we want our providers to be in the driver’s seat and have the tools they need for success. What’s new? ECDS is new. What is ECDS? Great question! Electronic Clinical Data Systems (ECDS) measures are a reporting standard for HEDIS® using a network of data containing information from a health plan member’s personal health information and includes a record of their experiences of the health care they receive. Providers are encouraged to get a head start on applying, recording and coding for these measures as measures will continue to evolve.

Check out the new HEDIS® ECDS measures and how you, as a provider, can get a jump start on these measures and improve quality of care.

DSF — Depression screening and follow-up for adolescents and adultsMembers 12 years of age and older who were screened for clinical depression using a standardized instrument, and if screened positive, received follow-up care within 30 days of a positive screening.

*Exclude members with bipolar disorder or depression

Instruments for Adolescents (12–17 years) Positive Finding

Patient Health Questionnaire (PHQ-9)® Total Score ≥5

Patient Health Questionnaire Modified for Teens (PHQ-9M)® Total Score ≥5

PRIME MD-PHQ2® Total Score ≥3

Beck Depression Inventory-Fast Screen (BDI-FS)®* Total Score ≥4

Center for Epidemiologic Studies Depression Scale-Revised (CESD-R) Total Score ≥17

Edinburgh Postnatal Depression Scale (EPDS) Total Score ≥9

PROMIS Depression Total Score (T Score) ≥52.5

Instruments for Adults (18+ years) Positive Finding

Patient Health Questionnaire (PHQ-9)® Total Score ≥5

PRIME MD-PHQ2® Total Score ≥3

Beck Depression Inventory-Fast Screen (BDI-FS)®* Total Score ≥4

Beck Depression Inventory (BDI-II) Total Score ≥14

Center for Epidemiologic Studies Depression Scale-Revised (CESD-R) Total Score ≥17

Duke Anxiety-Depression Scale (DADS)®* Total Score ≥30

Geriatric Depression Scale Short Form (GDS) Total Score ≥5

Geriatric Depression Scale Long Form (GDS) Total Score ≥10

Edinburgh Postnatal Depression Scale (EPDS) Total Score ≥9

My Mood Monitor (M-3)® Total Score ≥5

PROMIS Depression Total Score (T Score) ≥52.5

Clinically Useful Depression Outcome Scale (CUDOS) Total Score ≥11

THE FUTURE OF HEDIS® AND WHAT PROVIDERS CAN DO TODAY

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DMS — Utilization of the PHQ-9 to monitor depression symptoms for adolescents and adults Members twelve years of age and older with a diagnosis of major depression or dysthymia, who have an outpatient encounter with a PHQ-9 score present in their record in the same assessment period as the encounter.

* Exclude members with bipolar disorder, personality disorder, psychotic disorder, or pervasive developmental disorder

DRR — Depression, remission or response for adolescents and adults Members 12 years of age and older with a diagnosis of depression and an elevated PHQ-9 score (>9), who had evidence of response or remission within 4-8 months of the elevated score.

* Exclude members with bipolar disorder, personality disorder, psychotic disorder, or pervasive developmental disorder

PND — Prenatal depression screening and follow-up Percentage of deliveries in which members who were screened for clinical depression while pregnant and, if screened positive, received follow-up care within 30 days of a positive screening.

*Exclude members with deliveries at less than 37 weeks gestation

Instruments for Adolescents (12–17 years) Positive Finding

Patient Health Questionnaire (PHQ-9)® Total Score ≥10

Patient Health Questionnaire Modified for Teens (PHQ-9M)® Total Score ≥10

PRIME MD-PHQ2® Total Score ≥3

Beck Depression Inventory-Fast Screen (BDI-FS)®* Total Score ≥4

Center for Epidemiologic Studies Depression Scale-Revised (CESD-R) Total Score ≥17

Edinburgh Postnatal Depression Scale (EPDS) Total Score ≥9

PROMIS Depression Total Score (T Score) ≥52.5

Instruments for Adults (18+ years) Positive Finding

Patient Health Questionnaire (PHQ-9)® Total Score ≥10

PRIME MD-PHQ2® Total Score ≥3

Beck Depression Inventory-Fast Screen (BDI-FS)®* Total Score ≥4

Beck Depression Inventory (BDI-II) Total Score ≥14

Center for Epidemiologic Studies Depression Scale-Revised (CESD-R) Total Score ≥17

Duke Anxiety-Depression Scale (DADS)®* Total Score ≥30

Geriatric Depression Scale Short Form (GDS) Total Score ≥9

Geriatric Depression Scale Long Form (GDS) Total Score ≥5

Edinburgh Postnatal Depression Scale (EPDS) Total Score (T Score) ≥52.5

My Mood Monitor (M-3)® Total Score ≥11

PROMIS Depression Total Score (T Score) ≥52.5

Clinically Useful Depression Outcome Scale (CUDOS) Total Score ≥11

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PDS — Postpartum Depression Screening and follow-upPercentage of deliveries in which members were screened for clinical depression during the postpartum period, and if screened positive, received follow-up care

ASF — Unhealthy Alcohol Use Screening and follow-UpMembers 18 years of age and older who were screened for unhealthy alcohol use using a standardized instrument and, if screened positive, received appropriate follow-up care within 2 months.

* Exclude members with alcohol use disorder in the measurement year or history of dementia

Screening Instrument Positive Finding

Alcohol Use Disorders Identification Test (AUDIT) Screening Instrument Total score ≥8

Alcohol Use Disorders Identification Test Consumption (AUDIT-C) Screening Instrument

Total score ≥4 for menTotal score ≥3 for women

Single-Question Screen: “How many times in the past year have you had 5 (for men) or 4 (for women and all adults older than 65 years) or more drinks in a day?”

Response ≥1

Strategies for improvementDiagnosis, treatment and follow-up for depression will lead to significant improvement in the patient’s condition. Here are some ways to improve member care to ensure you are delivering high quality care.

• Members of the care team understand the importance of depression screeningo All clinic staff receives training on depression screenings and follow-up care within the required time

frame according to each ECDS measure if the screening is positiveo Staff will be versed in strategies to engage patients on completing and understanding the screening

tool administered

• Patients are screened at new visits, on an annual basis at well care visits, or when clinically indicated o Collaborative depression care is performed in a primary care setting to improve outcomeso Primary care setting includes BH serviceso A care manager or team member coordinates care and follow-up

• Options for community counselors and psychiatry are available for patients interested in that option if screened positive

o Providers and clinic staff can refer to Sanford Health Plan Behavioral Health Cards to find a BH provider in a patient’s community

• Primary Care Providers are encouraged to collaborate with a behavioral health provider than can offer psychotherapy treatments

o Always offer general checkups, including medication checks, and follow-ups even if the patient in being followed by a behavioral health provider

• Encourage exercise and other behavioral changeso Eat better, avoid alcohol and drugso Daily physical exerciseo Meditationo Mindfulness or breathing exercises

At Sanford Health Plan, we do our best to keep our providers informed on the future of HEDIS®. Be on the lookout for the HEDIS® Provider Toolkit with more in-depth information regarding HEDIS® measures, coding information and strategies for improvement.

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Sanford Health Plan members can get their out-of-pocket costs for quitting nicotine covered. For most health plans, current members receive the following tobacco cessation benefits at no cost or copay to the member:

• Prescription medications

• Counseling sessions for nicotine cessation

• Wellness coaching/consultation

Members can learn how to utilize their nicotine cessation benefits for their specific health insurance plan by contacting Customer Service at (800) 752-5863 for more information.

HOW TO BREAK A HABIT

We all know that habits are hard to break, it seems that they are just so easy to do. How did this habit start? The brain is wired to seek rewards. Once we try a behavior that rewards the brain, it wants to do that same action over and over again.

One of the ways to break a habit is to use mindfulness. Paying attention, in a very particular way, on purpose and being in the present can help nicotine users— or anyone that has a habit to break— can help you analyze the reward you are receiving from your bad habit.

The next time you are starting to do your bad habit, whether it is using nicotine, eating candy or (fill in the blank), use mindfulness to help you analyze what is going on and push the action away so that you don’t have to complete it.

• Engage all five senses

• Notice what’s happening

• Name what’s happening

• Let go of what’s happening, all feelings and push the thought, craving or urge away

• Seek a new, healthier action instead

Sometimes this may not always work and it takes some practice to be able to clear your mind of a habit, but eventually you will find that your mindfulness can help you to make more conscious decisions for your health and rewire the brain to want a new reward.

NICOTINE CESSATION BENEFITS

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Each year, we review medical charts for our HEDIS® reporting, checking to make sure that general standards are being met. For 2020, the three standards that had the lowest compliance rates out of the seventeen total elements were:

• An immunization record for children is up to date, or an appropriate history has been made in the medical record for adults

• Personal biographical data include the address, home and work telephone numbers

• There is evidence that preventive screening and services are offered in accordance with the organization’s practice guidelines

In an effort to continue high-quality care for our members, we want to remind you of the importance of accurate and complete clinical documentation. The absence of complete documentation within a patient’s record can negatively influence clinical preparedness, continuity of care, and financial planning for a patient’s treatment.

Why is complete medical record documentation important?

Each year, Sanford Health Plan completes a medical record documentation compliance audit. Records from both Sanford clinics and non-Sanford clinics are included in this review. The medical record documents the history of a patient’s health and is an important factor for high quality of care. A complete medical record supports:

• Physicians and other health care professionals in the evaluation and planning of a patient’s immediate treatment and the monitoring of a patient over time

• The communication and continuation of care among physicians and other health care professionals involved with the patient’s care

• Accurate and timely claims review and payment

• Appropriate utilization review and quality-of-care evaluations

• The collection of data that could be useful for education and research

Are these items easily identified and up-to-date in your patient records? This is the question to ask yourself and your organization when reviewing your own patient records.

MEDICAL RECORD DOCUMENTATION AND RESULTS OF AUDIT

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SVHP-3514 Rev. 8/20

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Translation Assistance for Non-English Speaking Members (800) 892-0675

Contact Us:CONTACT FOR: Eligibility & benefits, claim status, provider directory, complaints, appeals, report member discrepancy information

memberservices@sanfordhealth.orgCustomer ServiceMonday-Friday, 7:30 a.m. to 5:00 p.m. CST | 800) 752-5863

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CONTACT FOR: Preauthorization/precertification of prescriptions or formulary questions

pharmacyservices@sanfordhealth.orgPharmacy (855) 305-5062

NDPERS Pharmacy (877) 658-9194

ND Medicaid Expansion (855) 263-3547

CONTACT FOR: Preauthorization/precertification for medical servicesum@sanfordhealth.orgUtilization Management (800) 805-7938

NDPERS Utilization Management (888) 315-0885

ND Medicaid Expansion Utilization Management (855) 276-7214

CONTACT FOR: Assistance with fee schedule inquiries, check adjustments & reconciling a negative balance, request explanation of payment (EOP), claim reconsideration requests, W-9 form, change/updating information, provider education

providerrelations@sanfordhealth.orgProvider Relations (800) 601-5086

CONTACT FOR: Requests to join the network and contract-related questions and fee schedule negotiation

sanfordhealthplanprovidercontracting@sanfordhealth.orgProvider Contracting (855) 263-3544