LifeSmart program is making a big difference

An estimated 51 million people in the United States have prediabetes or metabolic syndrome. Metabolic syndrome includes multiple risk factors that may make some people more likely to develop type 2 diabetes or other health conditions that can lead to decreased health and a poor quality of life. Prediabetes often leads to full blown diabetes and can be caused by overeating and physical inactivity.

UPMC Health Plan and Heritage Valley Health System (HVHS) partnered to develop LifeSmart, a diabetes prevention program. LifeSmart provides healthy lifestyle programs for adults in the HVHS community who have been identified as having risk factors for prediabetes or metabolic syndrome.

“The UPMC Health Plan/Heritage Valley Health System collaboration is an example of a successful community health initiative between a provider and insurer,” says Michael Culyba, MD, vice president, Medical Affairs, at UPMC Health Plan. “The Health Plan is proud to partner with the physicians and hospitals of Heritage Valley to build a strong, healthy community.”

More than 320 people have participated in the LifeSmart program, which is now in its second year. Participants decreased their weight by almost 8%, and more than 70% of participants increased their physical activity to at least 150 minutes per week. These results are similar to other diabetes prevention programs. LifeSmart helps people make meaningful lifestyle changes. “It was a very positive program and I feel wonderful,” says Maria Rexroad, a LifeSmart participant. “I’ve got so many tools to help me live a healthier life.”

LifeSmart identifies people at risk for diabetes, links them to a primary care physician from HVHS, and provides them with the kind of support they need to reduce their risk factors. Heritage Valley physicians help screen individuals and direct them to specially designed support programs.

The LifeSmart program continues to gain exposure in the communities HVHS serves, including Allegheny, Beaver, Butler, and Lawrence counties, as well as parts of eastern Ohio and the northern panhandle of West Virginia.

“Heritage Valley Health System is committed to providing community health initiatives to residents in the region, helping them live healthier lives,” says Dr. Brooks. “The LifeSmart program allows us to do that.”

LifeSmart offers a variety of programs designed to reduce risk factors for diabetes. Together, the patient and HVHS physician determine the program that best meets the patient’s particular needs.

Group Lifestyle Balance (GLB) Program
This 12-week program is based on the highly successful lifestyle interventions used in a large national study known as the Diabetes Prevention Program. This program has been modified by faculty from the Diabetes Prevention Support Center at the University of Pittsburgh Diabetes Institute. It helps patients make healthy food choices, increase physical activity, and develop problem-solving skills.

Individual Nutrition Education
This program includes five sessions scheduled over a six-month period. A registered, licensed dietitian helps patients set nutrition goals that meet their health needs and fit their lifestyle.

Smoking Cessation Classes
This six-week program includes group sessions led by a smoking cessation counselor. It uses the UPMC Health Plan MyHealth Ready to Quit™ program, which HVHS adapted for its use.

Exercise and Fitness Opportunities
Participants can take advantage of special offers at participating exercise and fitness facilities.

With LifeSmart, UPMC Health Plan and HVHS help translate best practices and the latest medical research into healthier lifestyles for participants so they can enjoy better health and a better quality of life.

We'd like to thank Heritage Valley physicians and office staff for embracing the LifeSmart program and making it a success. Dan Brooks, MD, vice president, Heritage Valley Community Health Services, has been a strong supporter of LifeSmart since its inception. His leadership efforts and commitment to the program have helped many area residents get healthy.

UPMC for You expands into the Lehigh-Capital region

UPMC Health Plan was recently approved by state-regulating authorities to expand its business to the south central and eastern part of Pennsylvania. As part of this expansion, the UPMC for You Medicaid product will operate in a 10-county service area known as the HealthChoices Lehigh-Capital region, which includes Adams, Berks, Cumberland, Dauphin, Lancaster, Lebanon, Lehigh, Northampton, Perry, and York counties. This new area became part of the UPMC for You network on April 1, 2010. The UPMC for Kids CHIP product expanded its service area to Berks, Lancaster, Lehigh, and Northampton counties between April 1 and June 1, 2010. Expansion of the UPMC Health Plan commercial provider network is currently under development — the anticipated time frame for new business is 2011.

UPMC Health Plan originally targeted this area in response to a Request for Proposal (RFP) by the Department of Public Welfare (DPW) for the managed Medical Assistance business. This initiative closely ties to UPMC Health Plan’s goal to become a statewide “footprint” and to become an insurance carrier for all Pennsylvanians. This service area expansion was one of the most aggressive network development goals since the inception of the Health Plan and could result in our provider network almost doubling in size.

We are proud of this accomplishment and are looking forward to further developing our provider relationships.

Provider Satisfaction Survey

The Myers Group, a National Committee for Quality Assurance (NCQA) Certified Survey Vendor, conducted UPMC Health Plan’s 2009 Provider Satisfaction Survey. Information obtained from this survey allows health plans to measure how well they are meeting their providers’ expectations and needs. Based on the data collected, this report summarizes the results and assists in identifying plan strengths and opportunities.

The chart below presents the 2009 Summary Rates for UPMC Health Plan’s overall satisfaction attributes and ratings. In the survey, providers were asked to rate UPMC Health Plan and all other health plans in which they participate. The chart shows the comparison between these scores.

Understanding older patients

What was once called bedside manner and considered etiquette and personal style has now been the subject of a large number of empirical studies. The results of these studies suggest that the initial patient interview is integral to the process and outcomes of medical care.

Effective communication has practical benefits. It can:

• Help prevent medical errors.
• Strengthen the patient-provider relationship.
• Make the most of limited interaction time.
• Lead to improved health outcomes.

Communicating with older patients involves special issues. Stereotypes about aging and old age can lead patients and health professionals alike to dismiss or minimize problems as an inevitable part of aging. Older patients are unique and diverse — you may see frail 60-year-olds and active 80-year-olds. As a health care provider, it is important that you see older people as individuals who have a wide range of health care needs and questions.

Use the proper form of address
Establish respect right away by using formal language. You might ask your patients about preferred forms of address and how they would like you to address them. Avoid using familiar terms likes “dear” and “hon,” which are patronizing. Be sure to talk to your staff about the importance of being respectful to all patients, especially those who are older and perhaps used to more formal terms of address.

Make older patients comfortable
Ask your staff to make sure patients have a comfortable seat in the waiting room and help with filling out forms, if necessary. Be aware that older patients may need to be escorted to and from exam rooms, offices, and the waiting area. Staff should check on them often if they have to wait a long time in the exam room.

Take a few moments to establish rapport
Introduce yourself clearly. Show from the start that you accept the patient and want to hear his or her concerns. In the exam room, greet everyone and apologize for any delays. With new patients, try a few comments to promote rapport: “Are you from this area?” or “Do you have family nearby?” With established patients, friendly questions about their families or activities can relieve stress.

Try not to rush
Avoid hurrying older patients. Time spent discussing concerns will allow you to gather important information and may lead to improved cooperation and treatment adherence. Feeling rushed leads people to believe that they are not being heard or understood. Be aware of the patient’s own tendency to minimize complaints or to worry that he or she is taking too much of your time.

Avoid interrupting
One study found that doctors, on average, interrupt patients within the first 18 seconds of the initial interview. Once interrupted, a patient is less likely to reveal all of his or her concerns. This means finding out what you need to know may require another visit or some follow-up phone calls. Older people may have trouble following rapid-fire questioning or torrents of information. By speaking more slowly, you will give them time to process what is being asked or said. If you speak quickly, especially if your accent is different from what your patients are used to hearing, try to slow down. This gives them time to take in and better understand what you are saying.

Use active listening skills
Face the patient, maintain eye contact, and when he or she is talking, use frequent, brief responses, such as “okay,” “I see,” and “uh-huh.” Active listening keeps the discussion focused and lets patients know you understand their concerns.

Demonstrate empathy
Watch for opportunities to respond to patients’ emotions, using phrases such as “That sounds difficult,” or “I’m sorry you’re facing this problem; I think we can work on it together.” Studies show that empathy can be learned and practiced and that it adds less than a minute to the patient interview. It also has rewards in terms of patient satisfaction, understanding, and adherence to treatment.

Avoid jargon
Try not to assume that patients know medical terminology or a lot about their disease. Introduce necessary information by first asking what they know about their condition and then building on that. Although some terms seem commonplace — MRIs, CT scans, and stress tests — some older patients may be unfamiliar with them. Check to be sure your patient understands what you are saying.

Reduce barriers to communication
Older adults often have sensory impairments that can affect communication. Vision and hearing problems need to be treated and accounted for. Ask older patients when they last had vision and hearing exams.

Be careful about language
Some words may have different meanings to older patients than to you. For example, the word “dementia” may connote insanity and the word “cancer” may be considered a death sentence. Although you can’t anticipate every generational difference in language use, being aware of the possibility may help you to communicate more clearly. Use simple, common language and ask if clarification is needed.

From the National Institute on Aging

Help in the fight against childhood obesity

Obesity is a serious health concern for children and adolescents. Results from the 2007-2008 National Health and Nutrition Examination Survey, which uses measured heights and weights, indicate that an estimated 17% of children and adolescents ages 2–19 years old are obese.

Obese children and adolescents are at risk for health problems during their youth and as adults. For example, during their youth, obese children and adolescents are more likely to have risk factors associated with cardiovascular disease (such as high blood pressure, high cholesterol, and type 2 diabetes) than are other children and adolescents.

Most family physicians, pediatricians, and other health care providers know the importance of sound nutrition and regular physical activity in helping to prevent childhood obesity. And they understand the chronic, life-threatening problems that can result if it is left untreated. Many are taking steps to help their patients understand the importance of making healthy lifestyle choices.

Family physicians, pediatricians, and other health care providers are a trusted source of health information and guidance. In your practice, you are able to identify at-risk children and youth whose parents or other caregivers can most benefit from that guidance.

Within the time constraints of a busy practice, there are a number of things you can do:

• Provide parents with a copy of Healthy Families, Healthy Weight (available on the We Can!^® website) and review the suggestions.
• Suggest that parents get a free copy of the We Can! Parents Handbook by calling 1-866-35-WECAN toll-free. You can also order the handbooks for a nominal fee and go over them with your patients.
• Refer parents to the We Can! website and tell them to search for a local We Can! community site where they and their children can learn about ways to maintain a healthy weight.
• Display We Can! materials, such as posters and tip sheets, in your office and waiting areas

What is WE CAN!?

UPMC Health Plan is a proud supporter of the We Can! Pittsburgh movement. We Can!^® (Ways to Enhance Children’s Activity & Nutrition) is a science-based, national education program developed by the National Institutes of Health — part of the U.S. Department of Health and Human Services — to help children ages 8 –13:

• Improve food choices
• Increase physical activity
• Reduce screen time (TV, computers, and video games)

We Can! is a childhood overweight and obesity prevention program with evidence-based materials that are flexible and easy to use. Currently, over 750 communities around the country are participating in We Can! programs for parents and youth. These community groups range from hospitals, health departments, and clinics, to faith-based organizations, YMCAs, and schools.

The program is also reaching out directly to parents with products such as the We Can! Families Finding the Balance: Parent Handbook, as well as helpful hints and tip sheets.

Visit the We Can! website at http://wecan.nhlbi.nih.gov.

Chlamydia: Help stop a silent infection  

Chlamydia is the most common sexually transmitted disease (STD) and is caused by the bacterium Chlamydia trachomatis. Chlamydia is the most frequently reported bacterial STD in the United States, according to the Centers for Disease Control and Prevention (CDC), and it is also one of the most silent, with three-quarters of infected women and about half of infected men showing no symptoms. Approximately three million cases are reported annually in adolescents and young adults.

Women infected with chlamydia are at increased risk of pelvic inflammatory disease (PID), which can lead to infertility. If you are treating a young woman who is sexually active and who is under 25 years old, she is in the most at-risk group and should be screened for chlamydia.

A prime opportunity to order a chlamydia screening is in combination with a urinalysis or urine pregnancy test. A chlamydia screening can also be ordered on urine, cervical, and genital swabs, as well as in combination with Pap smears.

Please encourage women to have this important screening.

The CDC recommends an annual chlamydia screening for all women who may be at risk, including sexually active women who:

• Are under 25 years old
• Are pregnant
• Don’t consistently use barrier contraceptives
• Have signs of a possible cervical infection
• Have previously had an STD
• Women of any age who have a new sexual partner or multiple partners

The following chlamydia screenings, which can be ordered in combination with other tests, are covered through UPMC Health Plan:

The Clinical Guidelines below are available at www.upmchealthplan. com. Select “Providers” on the homepage, then the “Patient Health” link, and finally the “Patient Health Guidelines.” link from the menu on the left. To view the Preventive Guidelines for children and adults, follow the steps above and click on the “Preventive and Immunization Guidelines” link.

To request a hard copy of the clinical guidelines, call Provider Services at 1-866-918-1595.

*Includes recently updated information.

News from the New England Journal of Medicine

March 11, 2010; Volume 362
Medical Imaging in the 21st Century — Getting the Best Bang for the Rad
Brenner D. J.
In the United States, the average radiation dose to which we are exposed has doubled in the past 30 years. The average dose from natural background sources has not changed. In 1980, medical imaging was responsible for only about 15% of the total radiation exposure to the U.S. population from all sources; now the proportion is about 50%.

March 10, 2010; NEJM online
How to Think About Future Health Care Spending
Fuchs V. R.
An important element in the debate over health care reform concerns the level of future health care expenditures. The Congressional Budget Office is obliged to provide its best estimates of future costs … the media dutifully report these numbers … Lost in the din are two critical problems related to future spending.

Feb. 4, 2010; Volume 362
Medicare and Medical Technology — The Growing Demand for Relevant Outcomes
Neumann P. J. and Tunis S. R.
In deciding whether to pay for new medical technologies, the Centers for Medicare and Medicaid Services is becoming more specific about its requirements for evidence of improved health outcomes in the Medicare population.

Feb. 4, 2010; Volume 362
Comparative Effectiveness and Health Care Spending — Implications for Reform
Weinstein M. C. and Skinner J. A.
Title VIII of the American Recovery and Reinvestment Act of 2009 authorizes the expenditure of $1.1 billion to conduct research comparing “clinical outcomes, effectiveness, and appropriateness of items, services, and procedures that are used to prevent, diagnose, or treat diseases, disorders, and other health conditions."

Jan. 20, 2010; NEJM online
Cottage Industry to Postindustrial Care — The Revolution in Health Care Delivery
Swensen S. J., Meyer G. S., Nelson E. C., Hunt G. C. Jr., Pryor D. B., Weissberg J. I., Kaplan G. S., Daley J., Yates G. R., Chassin M. R., James B. C., and Berwick D. M.
Although other industries have transformed themselves using tools such as standardization of value-generating processes, performance measurement, and transparent reporting of quality, the application of these tools to health care is controversial, evoking fears of “cookbook medicine,” loss of professional autonomy, a misinformed focus on the wrong care, or a loss of individual attention and personal touch in health care delivery.

Jan. 28, 2010; Volume 362
Medicine’s Ethical Responsibility for Health Care Reform — The Top Five List
Brody H.
Early in 2009, members of major health care-related industries such as insurance companies, pharmaceutical manufacturers, medical device makers, and hospitals all agreed to forgo some future profits to show support for the Obama administration’s health care reform efforts.

Jan. 6, 2010; Volume 362
Health Care Reform and the Need for Comparative-Effectiveness Research
Mushlin A. I. and Ghomrawi H.
Health care reform will eventually pit the goal of expanding health insurance coverage against strong pressure to reduce the growth in health care costs. If left to measures in the proposed reform legislation, cost containment will be driven primarily by marketplace
incentives, programmatic initiatives, and organizational changes that would partially offset the costs of expanding coverage.

Jan. 6, 2010; Volume 362
Ranking 37th — Measuring the Performance of the U.S. Health Care System
Murray C. J. L. and Frenk J.
The World Health Report 2000, Health Systems: Improving Performance, ranked the U.S. health care system 37th in the world
— a result that has been discussed frequently during the current debate on U.S. health care reform.

Dec. 31, 2009; Volume 361
Ending End-of-Life Phobia — A Prescription for Enlightened Health Care Reform
Corn B. W.
A debate is now raging over a wide span of topics, including prescription plans, physician reimbursement, and solutions for the medical liability problem. But thought leaders have been remarkably reticent with respect to one aspect of the health care system: end-of-life care.

Dec. 24, 2009; Volume 361
On Mammography — More Agreement than Disagreement
Partridge A. H. and Winer E. P.
More than 190,000 women receive a diagnosis of invasive disease annually and more than 40,000 die of breast cancer each year. During the past two decades, there have been modest but real decreases in breast-cancer mortality that have been attributed to improvements in early detection and treatment. It is in this context that the recent controversy surrounding the optimal approach to breast-cancer screening should be considered.

Dec. 24, 2009; Volume 361
Cervical-Cancer Screening — New Guidelines and the Balance between Benefits and Harms
Sawaya G. F.
One of the greatest challenges in developing cancer-screening guidelines is devising strategies that maximize screening benefits and minimize screening harms. The benefits of cancer screening — decreased cancer-related morbidity and mortality — are well known and widely promoted; the harms of cancer screening receive less attention and can take many forms.

Dec. 10, 2009; Volume 361
Primary Care and Accountable Care — Two Essential Elements of Delivery-System Reform
Rittenhouse D. R., Shortell S. M., and Fisher E. S.
With discussions about U.S. health care reform focused heavily on insurance reforms, relatively little attention has been paid to the delivery-system reforms that will be required to improve the quality and coordination of health care and slow the growth of spending. The “patient-centered medical home” and the “accountable care organization” are two widely discussed models for delivery-system reform.

News from the American Medical Association

March 10, 2010; Volume 303
Charting a Path from Comparative-Effectiveness Funding to Improved Patient-Centered Health Care
Conway P.H. and Clancy C.
While physicians strive to tailor recommendations to the unique characteristics and circumstances of each patient, many decisions today must be made without reliable comparative information. That information gap is frustrating for physicians, as well as for patients who too often undergo trial and error medicine.

March 3, 2010; Volume 303
The Healthcare Innovation Zone: A Platform for True Reform
Kirch D. G.
By any standard, 2009 was a remarkable journey for those who seek transformational change in the U.S. health care system. The passage of health care legislation through the House of Representatives and the Senate represents historic progress toward the goal of an affordable, efficient, and just health care system to meet the 21st-century needs of all Americans.

Feb. 24, 2010; Volume 303
Trends in the Work Hours of Physicians in the United States
Staiger D.O., Auerbach D.I., and Buerhaus P.I.
The potential expansion of health insurance coverage and associated reform of the delivery system, combined with recent forecasts of physician shortages (particularly in primary care), have catapulted issues related to the adequacy of the physician workforce high up on the health policy agenda.

Feb. 17, 2010; Volume 303
Dynamics of Obesity and Chronic Health Conditions Among Children and Youth
Van Cleave J., Gortmaker S.L., and Perrin J.M.
Over the past 30 years, the prevalence of chronic conditions in children and adolescents has increased, particularly for asthma, obesity, and behavior/learning problems. Children with cystic fibrosis and sickle cell anemia now survive longer. These increases raise important questions concerning the course of chronic conditions over time: what are the collective incidence, persistence, and remission rates?

Feb. 10, 2010; Volume 303
Replicating High-Quality Medical Care Organizations
Mechanic D.
There is strong interest in developing accountable care organizations that have the capacities to (1) meaningfully monitor patient needs and outcomes, (2) use performance indicators for assessment of physicians and other professionals, and (3) implement new forms of reimbursement that result in improved quality while constraining increases in cost.

Jan. 27, 2010; Volume 303
Improving Health by Taking It Personally
Snyderman R. and Dinan M.A.
To resolve the nation’s health care dilemma and tackle exploding costs, the current sporadic and reactive focus on treating episodes of disease must be transformed into one that is coordinated to improve health and minimize the consequences of chronic diseases.

Jan. 13, 2010; Volume 303
U.S. Preterm Births: “D” Is for Dismal
Voelker R.
Too many infants in the United States are born too soon, according to recent reports from the March of Dimes and the National Center for Health Statistics. But even though some solutions may seem clear-cut — reducing smoking rates among pregnant women and improving access to prenatal care, for example — experts say the highly complex reasons for prematurity still are not well understood.

Jan. 13, 2010; Volume 303
U.S. Preventive Services Task Force (USPSTF) and Breast Cancer Screening
DeAngelis C.D. and Fontanarosa P.B.
Despite careful assessment of the science behind the updated guidelines, the USPSTF recommendation statement for breast cancer screening, particularly the recommendation regarding routine mammography screening for women aged 40 to 49 years, immediately generated controversy among physicians, disagreement from professional associations, and outrage from some breast cancer survivors and advocacy groups.

Research study available for smokers
 
Investigators at Western Psychiatric Institute & Clinic are conducting a 26-week research study using the FDA-approved medication Chantix (varenicline tartrate) to help subjects quit smoking. To be considered for this study, subjects must be between 18 and 65 years old, be diagnosed with bipolar disorder, currently smoke at least 10 cigarettes per day, and be motivated to quit smoking. To be considered for the study, participants must be willing to use either Chantix or a placebo for 12 weeks. Participants will be reimbursed for each visit and can receive up to $250 for completing the entire study. For more information, please call Jaspreet Brar at 412-246-6604 or Patty Schlicht at 412-246-5258.

Research study available for people struggling with grief

Researchers from the Late Life Evaluation and Treatment Program at the University of Pittsburgh are seeking adults ages 18 to 95 who have experienced the loss of a loved one and feel as if they are stuck in the grieving process. The study purpose is to determine the efficacy of antidepressant treatment for complicated grief, when administered with and without Complicated Grief Therapy. Complicated grief is a debilitating condition that is estimated to affect millions of people in the United States. The grief is prolonged, causing distress and interference with functioning. Participants have a 50% chance of receiving the therapy and will also be randomized to receive either medication or a placebo. The study lasts 20 weeks with a follow-up assessment at six months.

Eligible participants must be experiencing some of these symptoms of grief for six months or longer, following the death of a loved one:

• Inability to accept the death of a loved one
• A sense of disbelief regarding the death
• Anger and bitterness
• Recurrent, painful emotions with intense yearning and longing for the loved one
• Distressing and/or frequent thoughts related to the death
• Avoidance of situations and activities that are reminders of the loved one

For more information on the study, contact the Late Life Depression program at 412-246-6006.

Emergency Department Diversion Grant

The Department of Public Welfare, in collaboration with UPMC for You and UPMC McKeesport, was awarded a grant of $1.6 million to reduce the cost of Emergency Department (ED) care in McKeesport for the Medical Assistance and Medicare Special Needs population. A central tenet of the grant is to reduce overutilization of the ED for non-emergency care — care that is better provided in a primary care physician’s office.

Key elements of the grant include:

• Setting up standards of care in the ED to reduce the costs associated with care variation.
• Staffing EDs with a “Patient Navigator” who provides education, identifies community resources, and connects patients to their PCP through appointments and follow-up.
• Giving patients an alternative to ED care by offering same-day appointments with mid-level practitioners.
• Providing medical care to the behavioral health (BH) population at Mon Yough Community Services to reduce the number of times BH patients seek care at the ED.
• Using Telehealth Technology to reduce ED visits and admissions/readmissions for patients who have chronic health conditions, such as heart failure and COPD.
• Conducting a communications campaign to educate patients, PCP practices, and the population at large to the importance of having an established and trusting relationship with their PCP or medical home.

Early results show a reduction in unnecessary ED visits and increased PCP visits.

Since the Department of Public Welfare (DPW) issued Medical Assistance (MA) Bulletins 99-08-10 (Screening for Developmental Delays and Autism Spectrum Disorders) and 99-08-13 (Updates to the Early and Periodic Screening, Diagnosis and Treatment [EPSDT] Program Periodicity Schedule), MA providers have asked for examples of validated screening tools and for specific resources to help them in screening for developmental delays and ASDs.

In response, on September 8, 2009, DPW issued MA Bulletin 99-09-97 (Structured Screening for Developmental Delays and Autism Spectrum Disorders). This bulletin discusses validated tools that are useful in screening for particular developmental delays and ASDs. Providers are responsible for using validated tools for related screenings. A copy of the tool used to conduct the screening must also be maintained in the child’s medical record. If the structured screening indicates a need for diagnostic evaluation, the provider should then refer the child to early intervention services. Below are a few examples of validated screening tools that providers may use.

1. PEDS (Parents’ Evaluation of Developmental Status) is used to screen for developmental delay. This tool can be ordered at www.pedstest.com.
   
2. M-CHAT (Modified Checklist for Autism in Toddlers) is used to screen for ASD. This tool is available at no cost at www. firstsigns.org/downloads/m-chat.PDF.
3. Ages and Stages Questionnaire is used to screen for developmental delay. This tool can be ordered at www. brookespublishing.com/store/childdevelopment.htm.
4. Denver Developmental Screening Tool is used to screen for developmental delay. This tool can be ordered at www. denverii.com/.

A list of current validated tools (Validated Screening Tools for Developmental Delays and Autism Spectrum Disorders) is included in MA Bulletin 99-09-97. UPMC Health Plan is currently reviewing the memos, processes, and validated tools required for these screenings. Our suggested list of tools and related process information will soon be available on our website at www.upmchealthplan.com.

If you have any questions, contact Provider Services or your Network Management representative.

Topical fluoride varnish

DPW currently pays enrolled dentists for topical fluoride varnish treatments provided to children eligible for Medical Assistance. In order to expand access to pediatric preventive dental services, DPW will now pay physicians and CRNPs who have been properly certified for the application of topical fluoride varnish on children under the age of five. Topical fluoride varnish treatments are paid in addition to an office visit on the same date of service (MA bulletin D2106).

This change applies to all physicians and independently practicing CRNPs enrolled in the MA program who render services to MA recipients in the Fee-for-Service delivery system, including ACCESS Plus.

Tooth decay, or dental caries, is a very common but preventable childhood disease. The application of topical fluoride varnish for children is proven to be safe and effective in preventing tooth decay. Children who do not receive fluoride varnish treatments are more than twice as likely to develop tooth decay.

The American Academy of Pediatrics (AAP) offers, at no cost to the provider, an online training module titled “Oral Health Risk Assessment: Training for Pediatricians and Other Child Health Professionals.”

With service dates effective on or after April 1, 2010, certified physicians or CRNPs may submit claims to the MA program as follows:

You must complete and submit a training certificate for the one-time online training module titled “Oral Health Risk Assessment: Training for Pediatricians and Other Child Health Professionals.” This training is available on the AAP website at aap.org/oralhealth/cme/.

At the top of your training certificate, include your 13-digit MA provider ID number and all of your service locations.
Mail your training certificate to:

Department of Public Welfare
Office of Medical Assistance Programs
Provider Enrollment
Attention: TFV Indicator
P.O. Box 8045
Harrisburg, PA 17105-8045

You may fax your training certificate to 717-772-6765, Attn: TFV Indicator, Provider Enrollment.

It will take approximately 30 days from the time the Enrollment Unit receives your certification to update your file. You will be notified by letter when your file is updated.

Important changes for Medical Assistance members

UPMC for You introduced benefit design changes for some members on April 1, 2010. Some of the changes are similar to the benefit limitations adopted by the Department of Public Welfare (DPW).

Based on the member’s benefit category, he or she may be limited to 18 office visits per year, six prescriptions per month, or have copayments for some services. There are exceptions:

• Limits do not apply to members under the age of 21.
• Copayments do not apply to members under the age of 18.
• Copayments and limits do not apply to pregnant women (including through the post-partum period), nursing facility residents, members who reside in an Intermediate Care Facility, and members eligible under the Breast and Cervical Cancer Prevention and Treatment Programs, Title IV-B Foster Care, and IV-E Foster Care, and Adoption Assistance.
• Pharmacy limits only apply to members in the General Assistance benefit category if they have not met one of the exceptions listed above. Exceptions to the limit on prescriptions may be granted if the member has a serious chronic illness or other serious health conditions.

Providers are required to collect copayments for rendered services; however, providers may not deny services if the member cannot pay the copayment. Providers do not have to waive the copayment requirement and members are liable for the copayment. Providers may attempt to collect the copayment by billing the member for the overdue amount.

Some members have an 18-visit limit per year for certain routine office, clinic, and home visits when performed by physicians, certified registered nurse practitioners (CRNP), podiatrists, optometrists, chiropractors, outpatient hospital clinics, outpatient medical clinics, Rural Health Clinics, or Federally Qualified Health Centers (FQHC).

Visits to a PCP or PCP-referred specialist that exceed the 18-visit limit are automatically approved for a benefit limit exception and do not require an additional request unless the visit is to a chiropractor or podiatrist.

After June 30, 2010, the benefit year will begin on July 1 of every year.

Providers may submit benefit limit exception requests to the Medical Management Department. You may submit your request by telephone at 1-800-425-7800, by fax at 412-454-2057, or by mail at the following address:

UPMC for You
Attention: Medical Management
One Chatham Center
112 Washington Place
Pittsburgh, PA 15219

Bidwell Training Offers Electronic Record Medical Assistant (ERMA) Program
 
Bidwell Training Center, in partnership with UPMC Health Plan, is launching an Electronic Record Medical Assistant (ERMA) training program designed to meet the growing need for employees who can skillfully navigate the Electronic Health Record System.

The U.S. Bureau of Labor Statistics’ Occupational Handbook, 2010-11, predicts that the need for Medical Records and Health Information Technicians will increase by 20% and the need for medical assistants will increase by 34% through 2018. The electronic health record is widely viewed as being among the most valuable tools for reducing health care costs and increasing efficiency. It is quickly becoming the industry’s standard method of recording and monitoring patient data.

This exciting new 10-month diploma program uses simulative technology to provide one of the most sophisticated medical assistant training programs available. The ERMA program provides students with 112 hours of instruction dedicated to mastering the electronic health record. Applicants must possess a high school diploma or GED, obtain acceptable scores on Bidwell’s battery of assessment tests, successfully interview with the admissions panel, and submit an ACT 33 Clearance.

Course Length: 30 weeks, 900 hours (didactic); 4 weeks, 160 hours (externship)

Class Schedule: Monday through Friday, 8:30 a.m. to 2:55 p.m.

For more information on Bidwell Training Center’s Electronic Record Medical Assistant program, visit their website at www.bidwell-training.org or call 412-323-4000 ext. 150.

A helping hand for members with chronic disease

Members who have a chronic disease have a lot on their mind. They may be overwhelmed by how many medications they need to take and when, dietary restrictions, and frequent doctor visits. UPMC Health Plan can help these members. Health coaches from our health management programs will work with members if they have asthma, COPD, diabetes, depression, or cardiovascular health issues like heart failure, coronary artery disease, hypertension, or high cholesterol. Our health coaching staff includes nurses, social workers, diabetes educators, nutrition and exercise specialists, and more.

Here’s what members can expect when they join the program:

• A health coach will call to ask about their health, diet, and medications, and how their condition affects their daily life. The health coach will help them learn more about the signs and symptoms of their condition, their medications, and their recommended diet and exercise guidelines if they are following a specific plan.
• With permission, the health coach will contact a participant’s doctor to keep him or her apprised of the member’s health status.

Please consider referring your patients to our health management programs. To do so, call 1-866-778-6073 toll-free. TTY services are available at 1-800-361-2629. Representatives are available Monday through Friday from 8 a.m. to 4:30 p.m.

We can help patients who have complex medical issues

UPMC Health Plan members who have complex medical or behavioral health conditions may benefit from additional support in managing their health, and we have a program that can help them. Our program encourages collaboration among providers who care for the same member.

Our health coaches coordinate health care services, support physician treatment plans, and identify gaps in care. They educate members and their caregivers on self-management of their condition. Health coaches also connect members with support services available in the community.

A health coach will contact members who could benefit from our complex case management program, based on claims data. Enrollment is voluntary and members may decide to disenroll at any time.

If the member agrees to participate, the health coach will assess the member’s needs and work with the physician, member, and caregiver to develop a work plan. The health coach will contact the member’s physicians, when needed and with permission, to clarify the plan.

Please consider referring your patients to our complex case management program. To do so, contact us at 1-866-918-1588. Representatives are available Monday through Friday from 8 a.m. to 4:30 p.m.

UPMC Health Plan's "Partners in Excellence" program — health care that fits your life

"What a coincidence," Georgine thought, as she saw an article about the Patient-Centered Medical Home (PCMH) in a news magazine. "My doctor was just telling me about some new ways he was going to run his practice to turn it into a medical home, and now here's an article about it." Georgine began reading the article and discovered that in a PCMH, health care is provided with a more holistic approach. Her personal physician would lead a health care team that works together to provide care that fits her specific needs. They would help her become more informed about her health and wellness, provide her with timely health care reminders, and even help arrange care with other providers as needed. "Sounds pretty good to me!" Georgine thought. "I'm really looking forward to this new way of getting healthy."

Just as the name suggests, the patient is at the center in a PCMH. A PCMH is primarily about the ongoing relationship between you and your physician. UPMC Health Plan's PCMH program is called "Partners in Excellence." In it, your physician provides care that is continuous and comprehensive through all the stages of your life. This care includes acute and chronic care, preventive services, and end-of-life care. Your physician will assist you in arranging health care with other professionals, including specialists. In addition, you'll have better access to routine care, which means making regular appointments — and that may help you avoid trips to an urgent care center for problems that aren't emergencies.

In Partners in Excellence, your care is coordinated across the entire health care system. This means that if you need to go to a rehabilitation unit, hospital, or nursing home, or need any other health care service, you'll receive help from your doctor's office to get that care.

UPMC Health Plan is expanding the Partners in Excellence program among its network practices. We are working to ensure they have the tools and information they need to become patient-centered medical homes. Here's what we're doing:

• Placing practice-based care managers in many of our doctors' offices — care managers help you understand your diagnosis, your treatment plan, and next steps. Care managers coordinate your care and will help you navigate the complex health care system.
• Providing doctors with prescription pads so they can prescribe health coaching for their patients. UPMC Health Plan's health coaching services can help you lose weight, quit smoking, establish healthy eating habits, and get started on an exercise program.
• Educating providers and their office staff on UPMC Health Plan's array of online tools, including MyHealth online, where you can track your prescription usage, recent doctor's visits, and claims data. You can also learn about a host of medical procedures by watching interactive videos. Many other tools are available online at www.upmchealthplan.com.
• By using our claims data, we are working hand-in-hand with doctors to make sure our members get the care they need, when they need it. If you have diabetes and forget to have your annual A1c test, for example, we will call to remind you about it in addition to your doctor's office calling to remind you.

In Partners in Excellence, your physician works with a team of dedicated health care professionals to integrate your health information, coordinate your care, and help you get the care you need when and where you need it. It's truly a new way to look at health care — a way that fits your life.

This is the first in a series of articles about Partners in Excellence. Please continue to read Caring for You for more information about this new way to deliver health care.