News from NEPHO – December 2018 Edition

NEPHO NEWS
December 2018 Edition
December Newsletter – click here to print 
OPTUM Insider Newsletter: December Focus – Pulmonary Fibrosis and other Lung Disease

PHYSICIAN and PRACTICE CHANGES/UPDATES

New Providers

• Matthew Plosker, MD has joined Family Medicine Associates, A Member of Lahey Health
  195 School Street Manchester, MA 01944 978-526-4311  (F) 978-525-2342

Practice Changes/ Updates

• Barry Paul, MD and Kendra Martin, MD of Barry Paul, M.D. have relocated to
  500 Lynnfield Street, East 2 Lynn, MA 01904
• Effective 11/12/2018 Essex County OB GYN  has changed their EMR systems to Epic CC 

SAVE THE DATE

MD Orientation
Date:  January 21, 2019 @7:30 A.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

PAYOR UPDATES

Harvard Pilgrim Health Care
About the change

• Health Care makes select medical drugs (administered by the provider in a doctor’s office/clinical setting) available through both the buy and bill process and the specialty pharmacy to allow members and providers greater choice and convenience.
• Members are being charged an appropriate cost share if their medical drug is obtained through buy and bill, but not through the specialty pharmacy.
• As of July 1, 2019, any member receiving a medical drug will be responsible for appropriate cost-sharing.
• The change affects providers minimally. There are no changes if they obtain these drugs through buy and bill or if the medical drug doesn’t require prior authorization. However, if they would like to utilize the specialty pharmacy for medications on the attached list that do require prior authorization, beginning on July 1, 2019, they must contact CVS Health-NovoLogix for prior authorization, rather than MedImpact.
• Since providers currently request authorization for medical drugs that are buy and bill only from CVS Health-NovoLogix, we anticipate that providers will find this change easy to manage.

Attached List

• Medical Drugs Obtained through Specialty Pharmacy —Effective July 1, 2019 for commercial plans, if a provider opts to obtain a medical drug that requires prior authorization through specialty pharmacy, the authorization request must be made through CVS Health‐NovoLogix, rather than MedImpact.

Members receiving medical drugs obtained through specialty pharmacy will be charged the appropriate cost share as of July 1, 2019; previously, cost sharing was applied inconsistently due to systems configuration differences for buy and bill versus specialty pharmacy. Please click on the links above to be directed to the full Network Matters articles and resources. If you have questions please contact:  Carol Freedman at carol.freedman@lahey.org  or 978 236 1774

• Network Matters Updates on Medical Drugs Obtained Through Specialty Pharmacy

CARE MANAGEMENT SERVICES  

Care Management Update 2019

• The holiday season is a reminder to start filling our 2019 calendars.
• Continuing with our commitment to provide quality Care Management Services to our high risk patients the ACO and PHO Care Managers will be contacting our practices to schedule Care Management rounds on a monthly basis in 2019
• These rounds are essential and help allow the Care Managers and Providers to identify the High Risk Population.
• Care Management interventions help support the High Risk Population management of care.
• We ask that each practice make an effort to schedule a monthly Care Management visit and invite the providers, RN’s, RNP’s and PA’s to participate along with any other team member that is involved with patient care and care planning.
• Please contact Kenneth King, Director of Care Management, Lahey ACO/NEPHO at  Kenneth.King@Lahey.org

POPULATION HEALTH

Population Health Focus: Cervical Health Awareness
According to the National Cancer Institute, more than 13,000 women in the U.S. will be diagnosed cervical cancer this year and more than 4,000 of these women will die. Most women with HPV will not develop cervical cancer, but it’s very important to have regular screening tests.

A few important steps women can take to stay healthy:

• Encourage women to get their well-woman visit this year.
• Let women know that most insurance plans must cover well-woman visits and cervical cancer screening. This means that, depending on their insurance, women can get these services at no cost to them.
• Talk to parents about how important it is for their pre-teens to get the HPV vaccine. Both boys and girls need the vaccine.
• If your patient prefers a GYN provider for screenings please refer her to one of our in-network providers – https://www.nepho.org/provider-directory/

IPA / POD MEETING SUMMARIES 

Efficiency: OOPHO

• Dr. Di Lillo shared an analysis of the YTD 2018 NEPHO Out-of-PHO Referral Database trends.
• Top locations by volume and top specialties by referral volume were reviewed.
• A detailed analysis was offered for the top 5 specialties.
• The NEPHO Referral Authorization Policy and LCPN template patient letters for practices to use regarding care retention were also shared.

Efficiency: Pharmacy

• Carol Freedman discussed changes to PPI coverage for BCBS patients effective January 2019.
• Less costly options for patients to obtain these meds were discussed.
• Carol Freedman also reviewed a deprescribing protocol that providers can utilize for patients.

Quality – Year End Push

• Liz Isaac reviewed the current scorecard and end of year PUSH measures.
• A 2018 “what if” performance scorecard and assumptions were shared to highlight the need for continued focus through year end.
• Specific asks for push measures were presented.
• Alison Gustafson shared updated information regarding providers with patients who have near compliant blood pressures where there is opportunity to retake BPs before year end.
• Also shared were patients by provider whose blood pressures are well above BP targets, representing an opportunity for clinical review and action planning by providers.

Patient Experience – 2018 MHQP Preliminary Results

• Liz Isaac shared an update on the gate scores by each domain, Communication, Integration, Knowledge of Patient,
  Access for NEPHO Adult and Pedi aggregate.
• Domain gate scores by each MD were shared to allow comparison to the aggregate performance.
• Specific questions which scored lower in each domain were reviewed.

Medical Director Update

• Dr. Di Lillo reviewed new BORM CME requirements that will change for 2019 and the new Federal Violence Against Women Act.

QUALITY

Year End Quality Highlights
With the final days of 2018 approaching, the PHO Quality Team would like to recognize our providers and our office colleagues for all of the hard work they have put in over the past year.

The ultimate goal of any quality program is to improve patient health and outcomes.
Here are some of the highlights from 2018:

• 1200 patients were screened for colorectal cancer
• 1370 patients received pap smears
• 1690 patients had mammograms
• 440 patients with diabetes had their diabetic eye exams
• 800 patients with diabetes completed their nephropathy screening
• 870 young women were screened for chlamydia
• 4450 adolescents had physical exams

These numbers include patients in our commercial plans (Blue Cross HMO & PPO, HPHC & Tufts Health Plan).  This is only a small sampling of the great work our practices accomplish every day.  Thank you all for working with the PHO over the past 12 months and for allowing the Quality Team to support your efforts.  Happy Holidays to all from the Quality Team!

PHARMACY UPDATES

Pharmacy 2018 Year-End Update
The good news is pharmacy expenses, which comprise about 20% of Total Medical Expenses (TME), are trending downward with a -3% trend for 2018. This is largely due to a decrease in expenses in specialty medication classes for oncology, hepatitis-C and multiple sclerosis.  In other medication
classes, such as respiratory and dermatology, we continue to see cost increases and our goal is to share all opportunities for savings, for both NEPHO and our patients.

Please see some pharmacy cost-savings initiatives initiated this year.   We ask all providers to continue to consider these recommendations moving forward:

• Combination Inhalers: Airduo (fluticasone / salmeterol) Respiclick- consider this combination inhaler instead of more costly, Advair (fluticasone / salmeterol). Airduo may also be less expensive than other combination products such as, Symbicort, Breo Elipta and Dulera.
  • Currently only HPHC, BCBS, Tufts and Mass Health cover Airduo and it is available at a lower copay than Advair (fluticasone / salmeterol). Savings to NEPHO is $250 – $375 per prescription by prescribing Airduo instead of Adviar and about $10 – $50 copay savings per prescription for patients.
  • CASH cost of Airduo is about $52 when a Good Rx coupon is used. https://www.goodrx.com/ Paying CASH with a coupon may be helpful for Medicare Part D patients whose copay for Advair or other combination inhaler expenses are high OR for patients who are in the Medicare Part D donut hole.
  • Dosing for Airduo (fluticasone / salmeterol) is TWICE DAILY, the same as Advair; however the concentration of each inhaler is slightly different; think LOW DOSE, MEDIUM DOSE or HIGH DOSE. (see below)
• PPIs – as of January 1 2019, BCBS will no longer cover PPIs such as omeprazole, esomeprazole, pantoprazole etc. Exceptions include only patients who are < 18 years old and those being treated with combination therapy for H. Pylori.
  • OTC PPIs range $5 – $25 per month. Encourage patients to shop around (e.g. Costco, Walmart etc.) or use Good Rx coupons and pay CASH.   https://www.goodrx.com/
• Medications for Erectile Dysfunction – generic sildenafil (Viagra) is now available and the cost is declining (Good Rx coupon sildenafil 50 mg #30 ~$40). In addition, generic sildenafil 20 mg tablets are available; provide patient a PRINTED prescription (e.g. sildenafil 20 mg tablets – 2 ½ tablets = 50 mg dose); patient must NOT use prescription plan but rather pay CASH for savings and no limit on number of doses (e.g. generic sildenafil 20 mg #60 tablets ~$20).
• Ophthalmic Drops – see the attached chart for cost effective comparison of some common ophthalmic drops by therapeutic class.
• Topical Corticosteroids – see the attached chart for cost effective comparison of commonTopical%20Steroids%20Comparison.pdf topical corticosteroids by potency class.

For questions or more information please, contact Carol Freedman at carol.freedman@lahey.org or 978-236-1774.

DECEMBER CODING TIP OF THE MONTH

ICD-10- CM Diagnosis Codes Reset January 1, 2019

• A major component of the Hierarchical Condition Categories (HCCs) model is that the individual HCCs are only valid for one year. Regardless of the HCCs fundamental chronicity, on January 1, 2019 the patient’s HCC listing will be blank.
• For example, a patient with diabetes with complications would need to have a face-to-face encounter with a provider where diabetes is discussed and documented for the appropriate HCC to be reported in the new base year.
• There are two important aspects to remember when HCC coding:
  • Analyzing health record documentation to identify reportable conditions
  • Accurately assigning ICD-10-CM codes to these conditions
• Providers and risk adjustment professionals need to work together to ensure quality and thorough documentation of patient conditions to support risk adjustment and quality reporting initiatives. With such an emphasis on yearly code capture, provider education becomes a higher priority early in the year to prevent the loss of HCC diagnosis.
• The NEPHO will be working to educate providers beginning early 2019 to help continue efforts to impact the patient’s health status.
• The following coding education will be a focus for 2019:
  • Risk Adjustment Accurate Documentation and Coding Practices
  • Importance of Risk Adjustment
  • Risk Adjustment Auditing and Monitoring
• The NEPHO will be working with providers directly to address education opportunities and to ensure accurate coding and reporting of HCCs is continued through the year. Working together can help ensure compliance and optimal financial results under HCC risk adjustment contract models.
• Please reach out to NEPHO directly if you would like to review risk adjustment education opportunities for your practice. Contact Shawn Bromley at  Shawn.M.Bromley@Lahey.org or call 978-236-1704.

PROVIDER REFERRAL MANAGEMENT

Health Policy Commission Patient Appeals Update
The Health Policy Commission has recently updated their requirements for Risk Bearing Provider Organizations (LCPN/Northeast PHO) in managing the process for internal and external patient appeals with regards to their referral management process.  This process applies if the patient seeks a referral (or other treatment option, etc.) and is informed that their request is denied and that is NEPHO’s final determination, they may seek to appeal (and have it tracked).

This policy applies to patients with coverage under any of the following plans:

• Blue Cross Blue Shield of Massachusetts
• Harvard Pilgrim Health Care
• Tufts Health Plan
• Cigna

We have designed a process to have these appeals captured through the NEPHO Referral Management Telephone Line
at 978-236-1755.

The HPC has required that we post a patient notification within our primary care practices, to make patients aware of this telephone number. We have attached a copy of the Patient Appeals Notification which we request that Primary Care Practices post in their office as soon as possible.  In addition, we have attached a copy of the Patient Appeals FAQ’s.

Please do not hesitate to contact Ann Cabral if you have any questions. Ann.Cabral@Lahey.org or  978 236-1758.

PATIENT EXPERIENCE COMMENTS

Family Medicine Associates, Hamilton

• Dr. Laurence Gordon is an outstanding practitioner. He listens and is unhurried which makes me feel very confident in him.

Family Medicine Associates, Manchester

• Dr. Harlow LaBarge has been my family doctor for over 20 years! The best of caring, always!”

Garden City Pediatric Associates

• Dr. John Dean is always helpful, available and knowledgeably. I’m always so happy with his practice.
• Dr. Dean is warm, informative, caring, thoughtful, and professional

Lahey Primary Care, Bevelry – 30 Tozer Rd., Beverly, MA

• Dr. Susan Deluca has excellent ability and knowledge to respond to all of my questions “Best doctor ever in my 80 years!”

• “I have seen Dr.Deluca in 3 other practices over the years (30). This office is by far the best laid out, organized, staffed.  The support staff allows Dr. Deluca time with the patient which is the key to patient care and confidence in a provider.
• Dr. Nicholas Avgerinos is the best doctor I have ever dealt with.

Lahey Primary Care, Danvers – 480 Maple St., Danvers, MA

• Dr. Kristina Jackson “Everyone in this office is always friendly, helpful and concerned”

Leonard Horowitz, MD

• Dr. Leonard Horowitz has always treated me with great respect and I would highly recommend Dr. Horowitz and his colleagues.

North Shore Pediatric Associates

• Dr. Lance Goodman is very caring and his staff is very attentive.
• Dr. David Danis is passionate about his work and provides outstanding, thoughtful care. He goes to great lengths to explain illnesses and treatments to patients and parents in a way that allows children to understand and values the perspective and insights of parents.  He is an outstanding pediatrician and teacher – definitely the best medical provider anyone in our family has seen. His conversation with my 13-year-old son following his physical was the best I have heard an adult engage in about risky behavior.  He goes above and beyond to connect with patients, treat families with respect, and provide thoughtful care.  He takes time to listen.

PRACTICE  RECOGNITION