Current Newsletter September

NEPHO NEWS

September 2018 Edition – click here  NEPHO News September – FINAL
OPTUM Insider Newsletter: September Focus – Vascular Disease

 

PHYSICIAN and PRACTICE CHANGES/UPDATES

New Physicians

  • Justin Fernandes, MD has joined Beverly Shafer, M.D. 900 Cummings Center Suite 112W
    Beverly, MA 01915 978-927-8844 (F) 978-927-8845
  • Humera Kausar, MD has joined Lahey Infectious Disease, Beverly 85 Herrick Street
    Beverly, MA 01915 978-816-3131 (F) 978-816-2091

Physician/Practice Changes

  • Effective 9/17/2018, Patton Park Medical has changed their EMR to Athena.

The following providers have terminated their affiliation with the Northeast PHO:

  • Dennis Stoler, MD of Microsurgical Eye Associates
  • Ajay Sharma, MD of Northeast Medical Practice
  • David Goldberg, MD of Lahey Cardiology, Beverly 
  • Noel Wheeler, MD of Lahey Pulmonary, Beverly
  • Tarun Patel, MD of Northeast Medical Practice

The following providers have closed their patient panel to accepting existing patients only:

  • Mauri Cohen, MD of Lahey Primary Care, Danvers
  • Hugh Taylor, MD of Family Medicine Associates 
  • Gail Ellis, MD of Lahey Primary Care, Beverly 
  • Tina Waugh, MD of Lahey Primary Care, Beverly

 

SAVE THE DATE

Open Meeting Presentation II 

  • Date: Wednesday, October 10, 2018 @5:30 p.m.
    Place: Beverly Hospital Lecture Hall & AGH & LOCD
  • Date: Thursday, October 18, 2018 @12:30 p.m.
    Place: Beverly Hospital Lecture Hall & AGH & LOCD
  • Date: Tuesday, October 23, 2018 @7:00 a.m.
    Place: Beverly Hospital Lecture Hall & LOCD only

 

RSVP: Lisa Driscollat Lisa.M.Driscoll@Lahey.org  or
 978-236-1744

Please note:
For your convenience we are conducting three sessions.
The same presentation will be given at all sessions.

MD Orientation

Date:  October 22, 2018 @5:30 P.M.
Place: 500 Cummings Center, Suite 6500
Good Harbor Conference Room
Beverly, MA  01915
RSVP: Alycia Messelaar at Alycia.Messelaar@Lahey.org 
or 978-236-1784

 

IPA / POD MEETING SUMMARIES 

Pharmacy
Carol Freedman RPh, NEPHO Manager of Pharmacy, presented cost savings related to pharmacy
classes used to treat erectile dysfunction and asthma and COPD.   Advair to Airduo switch
represents a savings to both patients and system.   September pod attendees had a chance to
see names of their patients who would benefit from the switch.

Care Manager Update

Alison Gustafson, NP distributed a care manager by plan contact list for practices.   This will
be electronically sent to offices, providers, and placed on the PHO website.

Medicare Shared Savings Program (MSSP)

Dr. Di Lillo presented an update on the 2017 Medicare ACO Performance.   Based on savings
achieved compared to benchmark, there was a surplus generated in the program which is
shared 50% with Medicare.   The Proposed changes for 2019 MSSP were also reviewed.

Reporting
Dr. Di Lillo, Medical Director, distributed the updated meeting attendance report.  Dr. Di Lillo
also distributed OOPHO detail by provider for June through July timeframe.

  • There has been a decrease in OOPHO since January, and this trend continues.
  • The majority of OOPHO cases are going to Lahey (32%).
  • The top 3 Specialties leaving the network numerically are: All pediatric sub-specialties except
    Ortho, Cancer, and Orthopedics (although the % remains low).
  • Local leakage to North Shore was 25 referrals (4%).

Quality Update
Liz Isaac, Director of Quality and Performance Improvement provided an update on
2018 AQC Quality performance year to date with measure by measure comparison to prior year
performance and areas of focus.   One area of focus is DM Hypertension and Hypertension
measures as these are triple weighted measures.

Alison Gustafson, Population Health NP and Ms. Freedman presented the next phase of the
Hypertension Intervention Program (HIP) in which patients with upcoming visits and history of
high BPs will be reviewed in collaboration with respective PCPs for opportunities for therapy for
medication adjustment.

The updated JNC 8 Guidelines were also discussed with focus on different strategies to initiate
and adjust medications to achieve target BPs.

 

MEDICAL SERVICES CONFERENCE – CME Available

Management of Acute and Chronic Pain in the Midst of the Opioid Crisis

Presented by Dr. Kenneth Branton and will be held on
October 24, 2018 in the BH Lecture Hall from 5:30 p.m. — 6:30 p.m.,
with video conferencing to AGH.

Objectives:

  • Recognize physiologic changes related to pain and mechanisms of action of analgesia and co-analgesia
  • Describe critical elements in the approach to treating pain
  • Discuss state regulations for opioid prescribing

Thank you to The EVELYN LILY LUTZ FOUNDATION for their
generous support.

    Click to enlarge or to print poster

 

 

 

 

 

 

 

 

PHARMACY UPDATES

Medication Prior Authorization Data Collection Pilot Results:

In response to concerns providers have voiced regarding medication prior authorizations (PAs), NEPHO implemented a data collection pilot to assess the processes and best practices within the organization.

In May practices were asked to collect data on medication PAs during a
2 – 4 week snapshot.   Data was collected from 11 different practices,
(6 Primary Care and 5 Specialty) with 104 individual PA events.

The average PA took about 27 minutes of medical assistant, nurse and/or provider time with about 52% approved, 24% denied and the rest still pending or did not require a PA.

The following is what we learned from this data:  (see the attached presentation link)

  • Majority of practices utilize “Cover My Meds” platform, an electronic automated on-line program to assist with management and follow-up of the PA for each patient https://www.covermymeds.com/main/
  • Prior Authorization processes with provider involvement BEFORE the PA is initiated had fewer PAs on a weekly basis
  • Prior Authorization process with direct PA requests from pharmacies (Faxed or via Cover My Meds) had more PAs on a weekly basis (without provider involvement)
  • Generally, the specialty practice PA process (g. specialty meds) takes more time than PCP practices
  • Finding a formulary alternative is “painful” for some health plans
  • Currently Epic does not provide formulary / alternatives for medications requiring a prior authorization.
  • The health plan websites and/or MMIT Formulary http://mmitnetwork.com/formulary-search can provide covered alternatives.

If your practice has any best practices or pearls to improve the PA process, please share them with Carol Freedman, RPh, BCGP at Carol.Freedman@Lahey.org

 

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Click icon to view presentation

 

QUALITY

Meet the Medication Related Quality Measure: Statin Adherence in Patients with Diabetes

What is the measure?

  • Measures the percentage of patients 40-75 years of age with diabetes, who do not have
    atherosclerotic cardiovascular disease (ASCVD)
    who remained on a statin medication (any strength), for at least 80% of the treatment period.
  • The treatment period begins on the first day that a statin prescription is filled.
  • If a patient is not prescribed a statin during the measurement period, they are not included
    in the measure.

What are the keys to success with this measure?

  • DO counsel the patient to take the medication as prescribed (not as needed).
  • DO explain to patients the cardiovascular benefits and potential side effects of statin therapy
    (consider alternative statin or adjust dose).
  • DO set the expectation with patients that you/your clinical delegate will be following up soon
    to see if the medication is being tolerated and if adjustments are necessary.
  • DO consider prescribing 90 day prescription once patient is tolerating statin.
  • DO code for muscle pain or weakness if this is cause for statin discontinuation.  Coding for
    these conditions removes the patient from the measure. Otherwise, the patient will remain
    in the measure and will be counted as non-compliant/non-adherent due to the disruption in
    therapy.  See codes below.

    • G72.0 Drug Induced Myopathy
    • G72.2 Myopathy, due to other toxic agents
    • G72.9 Myopathy, unspecific
    • M62.82 Rhabdomyolysis
    • M79.1 Myalgia

Please contact Carol Freedman, Manager Pharmacy Services, for more information
at Carol.Freedman@Lahey.org or 978-236-1774

 

PAYOR UPDATES

Harvard Pilgrim Health Care
Advance Care Planning Coverage
Most patients don’t realize that if they are married and too sick to make healthcare decisions, their spouse is not automatically authorized to make decisions on their behalf.  Despite that fact, more than 70% of Americans don’t have an advanced care plan. That’s why provider support in documenting patients’ wishes is critical to ensure their care plan is known and executed.

Advance care planning is a crucial step to ensuring that patients get the medical care they want when they are unable to speak for themselves due to illness or injury. Without clear end-of-life conversations, family members may be burdened with worry that they will make a choice their loved one would not have wanted, and patients may receive more aggressive treatment than they would have chosen. Conversely, early and frequent conversations among providers, patients, and families about their preferences for end-of-life care can provide the patient with peace of mind that his or her medical wishes will be followed, ease the burden on family members, and prevent unwanted treatment.

While clinical research has found that advance care planning can improve the quality of life for patients with serious, progressive, and potentially fatal conditions, patients rarely initiate these conversations with their doctors and family members. As a result, it’s important for physicians to educate patients about advance care options — such as hospice or palliative care — discuss their preferences with them, and encourage them to prepare an advance directive.

Coverage for advance care planning
Recognizing the importance of advance care planning, Harvard Pilgrim encourages you to use the following codes to support these important conversations:

99497 — Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate

99498 — Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure)

CCA One Care Update
Effective 10/1/2018, the Northeast PHO entered into a non-risk contract with Commonwealth Care Alliance (CCA)
for their One Care product.  CCA One Care is for adults ages 21-64 who are eligible for both Medicaid and Medicare.

If you have questions regarding your participation in this “messenger model arrangement”, please contact
Alycia.Messelaar@Lahey.org  or 978-236-1784

 

PROVIDER RELATIONS

Office Manager Meeting Highlights
There were 2 main topics at the quarterly NEPHO office manager meeting held on September 12th:

  • Outpatient Therapy at Addison Gilbert Hospital (AGH), Beverly Hospital (BH), and
    Lahey Outpatient Center, Danvers (LOCD)
  • Tufts Health Plan Update

Outpatient Therapy
Melinda Adam, PT OCS the Director of Rehabilitation and Mandy Lok-Mano, the Manager of Access Services spoke about the outpatient therapy referral process.  Melinda outlined their rehabilitation services, which include Physical Therapy, Occupation Therapy, Speech Therapy and Audiology. There are three locations for outpatient therapy services: AGH, The Medical Building at BH and LOCD.

Referrals can be initiated for outpatient therapy in the following ways:

  • Provider creates an order through Epic which goes to the Rehabilitation work queue
  • The patient is given a written prescription and they contract the Rehabilitation department to
    schedule an appointment
  • The office calls each site directly (best option for urgent requests)

As for Epic Order Entry, below you will find a screenshot of the field where providers with Epic access would have the options to select the Rehab locations.

Click to enlarge

The Access department faxes the PCP office a request for authorization the same day
the evaluation is booked. Melinda provided examples of situations that require urgent access to PT/OT services, such as acute neck or back pain, acute joint sprain/strain or acute onset of dizziness. In such situations, it is best to have the office staff call the clinic directly and speak to the manager and they will do their best to provide an appointment within 24 – 48 hours. Click here for Outpatient Rehabilitation Locations

Tufts Health Plan Update
Heather Lawson,Tufts Health Plans Education Program Manager, Provider Relations and Communications also presented at the NEPHO office manager meeting. Heather outlined
the four divisions of Tufts products:

  • Commercial
  • Medicare
  • Tufts Health Senior Care Options (SCO)
  • Tufts Health Public Plans

An overview of each product and member cards can be referenced at the following link. As a reminder, it is important to use the Tufts Health Plan’s secure Provider Portal to verify member eligibility before the scheduled appointment to determine the member’s plan type, referral requirements and other benefit information.

If your office does not already have access to the secure Provider Portal, you may register by
clicking here. Please note there are two separate registrations:

  • Tufts Health Provider Connect (Tufts Health Public Plans only)
  • Tufts Health Plan Provider Portal (Commercial and Senior Products)

The Provider Portal for Commercial and Senior Products offers convenient options for claims
status inquiries, eligibility and benefits, referral inquiries and submissions, and inpatient notification request submissions.  There is a new option to conduct “free form” searches while looking for claims status inquiries. You can enter any information related to the claim, placing commas and/or a space in between the search items.

Claim adjustments/disputes for Commercial and Senior Products can be submitted online.
Claim adjustments/disputes for Tufts Health Public Plans are handled by mail only, which
requires a  Request for Claim Review Form to be sent for each claim adjustment request with
any supporting documentation to Tufts Health Public Plans.
The address is:
Provider Payment Disputes
P.O. Box 9194
Watertown, MA 02471-9194

Claim reviews must be filed no later than 60 days after you receive the explanation of payment (EOP)

To avoid the disputes being returned, it is important to list a valid claim number, Tufts Health Plan message code and indicate the appropriate review type on the form.  Please see the screenshot below:

 

Other claim tips include:

  • Submitted claims no later than 90 days after the date of service
  • Submit claims on paper when you need to include an attachment

Heather shared this chart to demonstrates the specialist referral policy applicable to
Tufts Health Together (MCO) plan and Accountable Care Partnership Plans (ACPPs).

*Check mark indicates NO REFERRAL is required. Click to enlarge

To take this grid a step further: 

NEPHO specialists (#2) will NOT need referrals to see patients assigned to NEPHO PCPs (#1)
NEPHO specialists (#2) will need referrals to see patients assigned to Atrius PCPs (#1)

THPP services that currently require Prior Authorization include:

  • Services from out-of-network providers
  • Certain covered services (e.g. elective inpatient admission, surgery)
  • Non-preferred in-network facilities, specialists and providers
  • Daily home health care (HHC) services or for HHC extending beyond six months in duration
  • Certain behavioral health services
  • Certain drug authorizations
  • Advanced radiology imaging services, interventional pain management spinal surgeries and management of joint surgeries

Heather introduced two methods of submitting Prior Authorization requests:

  1. Online: either through the MedHOK portal via Tufts Health Provider Connect for Tufts Health Together and Tufts Health Direct or directly through Tufts Health Provider Connect portal for Tufts Health Unify.
  2. Fax: the Standardized Prior Authorization form can be completed and faxed to 888-415-9055.

For more information regarding the Prior Authorization process specific to THPP, Senior or Commercial Products, please refer to the individual plans authorization policy by clicking the links provided below.

Heather also shared that PCP offices can print the Member PCP Change Request Form by clicking this link and distributing directly to the patient at the time of his/her visit to be completed and submitted to Tufts. There are  additional printable resources for Tufts Members by clicking here.

Please keep the following numbers on hand to potentially save you from longer wait times and internal transfers when you need to speak with Tufts Health Plan:

Click to enlarge

 

 

 

 

Please contact Alycia Messelaar if you would like to receive a copy of the Office Manager meeting slides, Alycia.Messelaar@lahey.org or 978-236-1784.

 

PRACTICE  RECOGNITION

The Northeast PHO recognizes colleagues who provide a positive experience for our patients, help us keep care local and meet our quality targets.

Click photos to enlarge
This month’s gift card winners are:

Ann Wonson, Lahey Health Primary Care, Beverly was recognized for her efforts to keep specialty care in the Northeast PHO network.

Denise Ryan, Cape Ann Medical Center was recognized for her excellent patient outreach efforts scheduling needed appointments.

Alicia Fairbank, Garden City Pediatrics was recognized for her positive patient comment on a recent patient experience survey:  “You are all wonderful from the check-in/reception – Alicia is the BEST! to all the nurses and of course the physicians”.

We appreciate their efforts in supporting the PHO goal to provide high quality, community health care. We will deliver gift cards to the winners each month, and they will be announced in the newsletter and posted on our website.  Be sure to look for the new winners in next month’s issue!

 

PATIENT EXPERIENCE COMMENTS

Brian Orr Pediatrics
Brian Orr’s practice is exemplary in all ways.

Danvers Family Doctors
Dr. Bhattacharya and his staff consistently provide
excellent care – I have excellent confidence in his care. It’s
always nice to be greeted by name as soon as you step into the
office. Office staff and medical staff are very good.

Lahey Primary Care,  Beverly– 100 Cummings Center, Ste. 126Q
Dr. Elsie Diaz-Schroeder  I am VERY pleased with my care
with this doctor. Dr. Diaz REALLY listens and takes as
much time as necessary to address my concerns. She also stays
on top of my medical issues and is well-informed about them.

Lahey Primary Care, Beverly–30 Tozer Rd., Ste. 202
I needed a same day appointment and was scheduled with
Dr. Neeraj Mahajan. He was excellent….very thorough
and I liked him a lot.

Lahey Primary Care, Danvers–140 Commonwealth Ave. Ste. 201
Mauri Cohen has always provided excellent care at
this office and I have always felt very comfortable.

Lahey Primary Care, Danvers
Dr. Kristina Jackson is the best doctor I ever had!
Very friendly, courteous and respectful!

Lahey Health Primary Care, Danvers – 5 Federal St.
Dr. Steven Keenholtz − Excellent CARE and SERVICE.

Lahey Primary Care, Gloucester – 298 Washington St. 1st Floor
I always feel like an individual, where my health truly matters
to Dr. Amy Esdale and her care team.

Lahey Primary Care, Gloucester – 298 Washington St. 4th Floor
Kim Graham, NP is very helpful. She always treats me with
courtesy and respect.

Leonard Horowitz, MD
I don’t remember any bad experience in over 20 years with
Dr. Leonard Horowitz.

North Shore Pediatrics
Dr. Lance Goodman is the best! We love him, but we also
feel confident with all providers at North Shore Pediatrics.

North Shore Preventive Health Care, P.C.
Dr. Roy Ruff is always “present” for my appointment.
He is knowledgeable, patient, and listens attentively to my
concerns and provides feedback and references. He is the
best and I have complete confidence in his judgement.

Thomas Pearce, MD
Dr.Thomas Pearce is one of the best!
Great visit – very good care given.

Thompson Medical Associates
Dr. Candace Thompson takes time to talk and listen to
me and is the best ever, have already recommended her to my
friends, can’t praise her enough for her concern and care.