PHPUpdate �

The Physicians Health Plan of South Michigan Newsletter is produced by:

PHP of South MichiganNetwork Services DepartmentP.O. Box 4055Jackson, MI 49204

We welcome your comments and article ideas.Please contact Laurie Wellman or Rhonda Browning at (517) 782-7154 or fax us at (517) 782-4512.

Third Edition 2005

FDA Updates Labeling for the Ortho Evra Contraceptive PatchThe FDA updated labeling for the patch was the result of the manufacturer’s analysis comparing hormone levels in users of Ortho Evra and typical oral contraceptive users.

It was found that Ortho Evra users were exposed to 60% more estrogen than the users of oral contraceptives containing 35 micrograms of estrogen. Please note that the maximal blood level of estrogen is about 25% lower with Ortho Evra than they are with typical birth control pills.

It is generally thought that increased estrogen exposure may increase the risk of blood clots, but is not known whether women using Ortho Evra are at a greater risk of experiencing these serious adverse events. Although total estrogen exposure is higher the peak blood levels were still lower. It is still unknown how this factor contributes to the health concerns.

Women should talk with their health care provider to weigh the potential risk associated with higher estrogen levels against the risk of pregnancy especially if there is a lower compliance with typical oral contraceptives.

For more information providers and consumers can go online at: www.fda.gov.cder/drug/infopage/orthoevra/default.hml.

Newsletter for Practitioners, Providers and Office Managers

Inside This Issue FDA Updates Labeling for the Ortho Evra Contraceptive Patch ....................................... 1

Drug Names Around the World ........................ 2

New Technology Evaluations ........................... 2

Important Changes to the Prescription Drug List (PDL) ......................... 3-4

AsthmaWatch ................................................ 4

AstraZeneca: Important Alert Regarding Medication Errors ........................................... 4

CMS Guidelines for Billing a POS 11 ................. 5

Enhanced Half Tablet Program Underway .......... 5

Our Website Has a New Look ........................... 6

Practitioner/Providers New to or Leaving the PHPSM Network ....................................... 6

Disparities in Health Care ............................... 7

Non-Par Referrals .......................................... 7

PHP Passport................................................. 8

PHPSM Offering Category A Employee Safety Training .............................................. 8

Social Security Number Privacy Act .................. 8

PHPSM Reimbursement for the Fecal Occult Blood Test (FOBT) ................................ 9

PHPSM’s High Deductible Health Plan (HDHP) ... 9

PHPSM Rolls out a New Initiative – Healthy at Heart ...........................................10

Therapeutic Alternatives Program Key Elements of the Patient Demographic Form ......10

Quality Improvement Program Documents .......11

Practitioner/Provider Appeals of Care Coordination Determinations ..........................12

Key Elements of the Patient Demographic Form .. 12

PHPUpdate �

We occasionally hear from members interested in procuring prescription drug products from Canada or other countries who feel that this practice could save our health plan a great deal of money. We also talk with members who will be traveling abroad for extended periods of time who are concerned about running out of their medications outside of the United States and their ability to fill a prescription overseas with the medication that they normally take. While much of the media attention on prescription drugs from other countries has been focused on the cost and quality of the drug product, another potential problem is that BRAND NAME DRUG PRODUCTS FROM DIFFERENT COUNTRIES MAY CONTAIN DIFFERENT ACTIVE INGREDIENTS.

A recent, well publicized example is the case of an individual taking the brand name drug Dilacor XR (diltiazem extended release) who ran out of his medication while traveling in Serbia. A Serbian pharmacist filled a prescription for Dilacor for this individual. Unfortunately the Serbian Dilacor product is a

brand name for digoxin, an entirely different drug. Upon his return to the United States the man was hospitalized with digoxin toxicity.

To make matters more confusing, the same brand name may be used for a variety of active ingredients, depending on where the drug is marketed. From our Dilacor example, the brand name Dilacor is also used for verapamil in Brazil and barnidipine in Argentina. Some drug names in different countries also look and/or sound alike but are very different drugs. For example, the drug “Amyben” in the United Kingdom contains the active ingredient amiodarone, while the drug “Ambien” in the United States contains the active ingredient zolipdem tartrate. The dangers of obtaining prescription drugs from or in other countries, especially when relying solely on the brand name, seem obvious.

How can this occur, and what can your patients do to avoid potential problems? There isn’t a coordinating body or world authority to ensure that brand names for drug products are consistent. (Generic drug names,

on the other hand, tend to be much more consistent worldwide.) Hence, if a brand is marketed in the United States or any other country, there are no specific safeguards to prevent the name from being used for different drug products in other countries. This potential for confusion is one of many reasons that drug importation from other countries into the United States is strongly discouraged. The potential adverse effects from one case of an incorrect and/or potentially toxic drug being taken by a patient seem to outweigh any potential cost advantage.

Please advise patients traveling abroad, to take an adequate supply of medications, allowing for potential delays in their return home. They should also carry a list of their medications, with brand and generic names as well as drug strength and dosage schedule. The more information that your patient has about their medications, the easier it will be for a medical practitioner in another country to determine the exact medication that they need if they should happen to run out or lose a prescription.

New Technology EvaluationsPhysicians Health Plan of South Michigan (PHPSM) has a formal mechanism to evaluate and address new developments in technology, and new applications of existing technology, for inclusion in the benefits plan. This allows PHPSM to keep pace with changes and to ensure that members have equitable access to safe and effective care. To make utilization management decisions regarding new technology, PHPSM contracts with United HealthCare (UHC). Medical policy updates are published monthly by UHC to assist health care professionals in making utilization management decisions for recognizing and evaluating technological advances in medical and behavioral health procedures, pharmaceuticals, and devices. UHC does the research and posts the findings into the UHC KNOWLEDGE library. This information is subsequently available to

the PHPSM Medical Director and Care Coordination staff during case review to support decisions based upon current scientific findings.

After receiving UHC recommendations, the PHPSM’s Pharmacy & Therapeutics Committee (P&T) may accept or decline recommendations specific to Drugs and Biologicals. The PHPSM Care Coordination and Quality Improvement Committee (CCQI) accepts or declines recommendations specific to Diagnostic & Medical Treatment and Surgical & Invasive Procedures.

If you have any questions, or would like more information about the evaluation of new technology, please contact Deborah Hall-Turner, RN, BSN, Director Care Coordination and Quality, at (517) 782-7154.

Drug Names Around the World

PHPUpdate �

Important Changes to the Prescription Drug List (PDL)

Blood glucose testing products and insulin product changes

The following IMPORTANT CHANGES will occur to our Prescription Drug List (PDL) on January 1, 2006. We are making you aware these changes in advance, as your PHP patients who are affected by them may ask you about alternative treatments. Many practitioners also received a letter in September detailing the upcoming PDL changes for insulins and blood glucose testing products.

Category Product Name Current Copay Tier Copayment Tier After January 1, 2006

Insulins

Novolin and Novolog Vials 2 1

Humulin and HumalogAll Forms 2 3

Novolin and Novolog Pens 2 2

Diabetic Test StripsFreestyle/Precision 2 1

One Touch (Lifescan) 2 1AccuChek 2 3

Ophthalmic Solution Xalatan (latanoprost) 23

(Note: Lumigan and Trav-atan remain tier-2)

Nasal Corticosteroids Beconase AQ (beclometh-asone) 2

3(Note: Nasonex, Flonase, Rhinocort Aqua remain

tier-2)

Other Agents Orapred (Prednisolone 15mg/5ml) 2 1

FemHRT (ethinyl estra-diol/norethindrone) 2

3(Note: Activella moved

down to tier-2 on 9/1/05)

Please also note that Antara (fenofibrate), Lofibra (fenofibrate), Advicor (lovastatin + niacin), and QVAR inhaler (beclomethasone) were moved from co-payment tier-3 to co-payment tier-2 on June 1, 2005. These changes are expected to benefit prescribers, and their patients, by resulting in lower out-of-pocket costs for many patients, and eliminating the need for prior authorization requests for those without a 3-tier pharmacy benefit.

Other Anticipated PDL Changes for January 1, 2006

Exclusions

Benzoyl peroxide products will be excluded from coverage due to the availability of OTC equivalents. The exclusion does NOT apply to products combining benzoyl peroxide with antibiotics or urea.

Up-tiering changes

Brand Name Generic Name Treatment Tier changeTazorac Tazarotene Psoriasis/ Acne 2 to 3

Ditropan XL Oxybutynin OAB 2 to 3Ortho OC’s Various Birth Control 2 to 3Ortho Evra Ethinyl estradiol/ norelgestromin Birth Control 2 to 3

Viagra Sildenafil Ed 2 to 3Novarel Chorionic Gonadotropin Fertility 2 to 3

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PHPUpdate �

AsthmaWatchAsthma is a chronic disease and managing asthma is a lifelong process. Research has shown individuals with the disease can live a normal healthy lifestyle when their asthma is controlled. The AsthmaWatch program is provided free of charge to members with asthma. It offers members with asthma a range of services that are tailored to their age and the severity of their illness. The program offers information, education, and care coordination services to assist members in gaining and maintaining control of their asthma.

PHPSM members are automatically enrolled in the program based upon practitioner, hospital and pharmacy claim information. Although members are automatically enrolled, it is not a mandatory program; members can choose to not participate. Members are also enrolled through referrals. To make a referral or for more information about the AsthmaWatch program, please contact the Care Coordination department at (517) 782-8238.

PHPSM has adopted the National Heart, Lung, and Blood Institute clinical practice guidelines for the management of asthma. The effectiveness of the program is assessed using the following measurements:

Measure DescriptionUse of appropriate medications for people with Asthma (all ages)

At least one prescription for corticosteroids, cromolyn or nedocromil

Percent of members having a Pulmonary Function Test at least annually

Down-tiering Changes

Brand Names Generic Names Treatment Tier change

Enablex Darifenacin OAB 3 to 2

Vesicare Solifenacin OAB 3 to 2

Asmanex Monmetasone Inhaled Asthma Maintenance 3 to 2

Boniva Ibandronate Osteoproesis 3 to 2

Fosrenol Lanthanum Hyperphosphatemia 3 to 2

Our Prescription Drug List (PDL) management’s main consideration is a medication’s total health care value. We evaluate clinical efficacy, cost, and pharmacoeconomic (outcomes and health care cost offset) factors to determine a medication’s “health care value” which determines tier placement.

We believe that these changes are positive, reducing costs for the member and the employer, while maintaining clinical options within each of the categories. Please contact the Care Coordination department at (517) 782-8238 or 1-888-807-7633 for additional information, or to discuss any questions or concerns that you may have.

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AstraZeneca: Important Alert Regarding Medication Errors

AstraZeneca reported medication errors involving the medication Toprol-XL. According to medication error reports both verbal and written prescription were involved. Confusion between the names and available strengths of involved medication contributed to the errors.

The medications involved were Toprol-XL with Topamax, Tegretol and Tegretol XR. The fact that these three products are placed close together on pharmacy shelves contributed to the mix-up.

To help minimize the risk, AstraZeneca is notifying health care professionals as to the potential for name confusion.

If you become aware of any name confusion or dispensing incidents please contact the involved manufacturer. Report medication error to the FDA’s MEDWATCH program at: www.fda.gov/medwatch, call at 1-800-FDA-1088 or fax to 1-800-FDA-0178, or notify USP_ISMP Medication Error Reporting Program at 1-800-233-7767.

For more information visit www.TOPROL-XL.com.

PHPUpdate �

CMS Guidelines for Billing a POS 11(Source: WPS Medicare e-News for Monday, October 17, 2005)

The Centers for Medicare and Medicaid Services (CMS) defines the Place of Service (POS) 11 as a “Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis”.

PHPSM pays a service provided in an office at the non-facility rate to reimburse the provider for the additional expense he/she has when maintaining an office. Some of the items to consider when billing an 11 POS include: whether the physician owns the space; whether the physician has any financial liability; whether the space is a specifically designated space; whether patients would routinely expect to see the physician in that space.

When billing a POS 11, Medicare does not require that a physician own the space he/she calls an office. However, CMS does require there be some type of financial liability (e.g., fair market value rent, mortgage payments). Additional CMS considerations include:

The physician typically employs the staff used in that space as opposed to the staff being employees of a facility.

The ancillary staff cannot be a cost to another organization or entity.

The physician is responsible for his/her own liability insurance and the insurance for the space.

The physician may or may not have responsibility for physical upkeep.

Supplies must be furnished by and represent a cost to the physician.

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Enhanced Half Tablet Program UnderwayOn October 1, 2005 United Healthcare launched a nationwide program designed to allow members to save money by “splitting” tablets of select prescription medications. The new Half Tablet Program is completely voluntary and in most cases, the member will pay half their regular co-payment. Members who choose to participate in the program will need to

obtain appropriate prescriptions from their providers (i.e. double strength, half the quantity of tablets), and the pharmacist will dispense this quantity with instructions to “take a half tablet” rather than a whole tablet. Members, along with their physicians, will have to decide if this program is appropriate for them. The medications currently included are:

Category MedicationsACE inhibitors Aceon, Mavik, UnivascAngiotensin Receptor Blockers (ARBs) Atacand, Avapro, Benicar, Cozaar, DiovanAntidepressants Lexapro, Pexeva, ZoloftLipid-lowering medications Crestor, Lipitor, Zocor, PravacholAntivirals Valtrex

Some of the tablets included are not scored or specifically designed for splitting, but the selection process looked for medications where small variations in daily dosing would have little impact on therapeutic efficacy Members may NOT

initiate participation in the program by simply asking the pharmacist to dispense a

higher dosage strength.

If you have questions or concerns about the program please contact our Care Coordination

Department at (517) 782-8238 or 888-807-7633.

PHPUpdate �

Our Website Has a New LookTo provide our Practitioners and office Management with increased online functionality, PHPSM has redesigned our web site. Phpcares.com is now easier to use and is loaded with useful health information. Providers can now access the following:

Printable Provider ManualContact Network Services onlineClinical Practice GuidelinesUtilization ManagementPrintable FormsTips for Safe CareEnhanced Provider DirectoryPrescription Drug Information including:

Consumer Drug List3-Tier ExplanationFrequently Asked Questions

Health Management Resources including:

It’s Your Life health management programSmoking Cessation ProgramWeight Watchers weight reduction programHealth Evaluator Modules/EducationHealth Focus Programs with online registration

Living Well with Diabetes (with BMI calculator)Asthma WatchDepression

Reminder Programs

Please visit us at www.phpcares.com to look around. If you have questions about our new web site, please call our Network Service Department at (517) 782-7154. One of our representatives will be happy to help you.

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Network ChangesPractitioners New to the PHPSM Network

Atif A. Abdalla, MD Internal Medicine

Abid Agha, MD Physical Medicine & Rehabilitation

Bassel Altantawi, MD Internal Medicine

Herbert Aronow, MD Cardiology

Mark R. Benson, MD Cardiology

Chiquita Berg, MD Obstetric/Gynecology

Allison A. Bissot, MD Optometry

Robert Cropsey, MD Surgery - General

Roberta Hunter, MD Gastroenterology

Noel Lucas, MD Internal Medicine

Miranda Makulski, MD Family Practice

Lorraine Nall, MD Internal Medicine

Per Lamont Okey, MD Family Practice

Tamara Pelish, MD, Obstetric/Gynecology

Elfateh Seedahmed, MD Internal Medicine

Maria Del Carmen Soto, DO Family Practice

Geoffer Stevens, MSW Social Worker

Practitioners No Longer Providing Services

John Dustin, OD Optometry

Erin Mazur, NP Nurse Practitioner

University of Michigan Practitioners

Please consult the Provider Directory at www.phpcares.com or contact PHPSM Cus-tomer Services at (517) 782-7154 or toll free (800) 428-7163.

NEW PRACTITIONERS TO THE PHPSM NETWORK

Atif A. Abdalla, MD Internal Medicine

Abid Agha, MD Physical Medicine & Rehabilitation

Bassel Altantawi, MD Internal Medicine

Herbert Aronow, MD Cardiology

Mark R. Benson, MD Cardiology

Chiquita Berg, MD Obstetric/Gynecology

Allison A. Bissot, MD Optometry

Robert Cropsey, MD Surgery - General

Roberta Hunter, MD Gastroenterology

Noel Lucas, MD Internal Medicine

Miranda Makulski, MD Family Practice

Lorraine Nall, MD Internal Medicine

Per Lamont Okey, MD Family Practice

Tamara Pelish, MD, Obstetric/Gynecology

Elfateh Seedahmed, MD Internal Medicine

Maria Del Carmen Soto, DO Family Practice

Geoffer Stevens, MSW Social Worker

PRACTITIONERS LEAVING PHPSM

John Dustin, OD Optometry

Erin Mazur, NP Nurse Practitioner

UNIVERSITY OF MICHIGAN PRACTITIONERS*

*Please consult the Provider Directory at www.phpcares.com or

contact PHPSM Customer Service at (517) 782-7154 or (800) 428-7163

PHPUpdate �

Disparities in Health CareOne of the hottest topics in medicine today is health care disparities. The Institute of Medicine (IOM-www.iom.edu) defines health care disparities as “differences in the quality of care provided to minorities in comparison to non minorities when there is equal access to care”. In other words, the IOM is saying that even when all else is equal, the quality of care provided to minorities is lower than the quality of care provided to non minorities.

In its report on the topic entitled, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, the IOM builds a solid case for its definition. After surveying the relevant literature, the IOM pointed to such facts as Blacks presenting with cardiac symptoms being much less likely to be referred for additional evaluation and treatment than Whites with similar symptoms. The IOM and other researchers have observed similar findings with diabetes, HIV/AIDS, and Behavioral Health concerns. Researchers have also noted that Black patients are less likely to have adequate pain management than White patients.

Blacks are not the only minorities to experience these differences in care. The same findings have been reported with American Indians and to a lesser extent with Hispanics.

How does one explain these observed differences? Surely physicians are highly trained professionals who would not deliberately ignore significant symptoms in patients because of race or ethnicity. According to the IOM and others, there are probably many reasons a physician might overlook symptoms in a patient. Certainly, the possibility of overt racism must be considered; however, if for no other reason than medical liability, that would probably not be a major reason for most physicians.

The IOM believes that for historical reasons, some physicians may be guilty of subconscious prejudices that affect their judgment. Additionally, when pressed for time, physicians may be guided by negative stereotypes without realizing it. Cultural differences, language barriers and patient distrust can also interfere with a physician administering proper care.

How do we address prejudices, especially if they are subconscious? The first step is to be aware they exist. It is impossible to grow up and live in a society that is as race conscious as America without having some race-based opinions of people. When caring for minority patients practice asking yourself if you’re treating/reacting to them differently than you would if they were a non-minority. Also, if you regularly see patients from certain ethnic or religious backgrounds ask them to help you become sensitive to their needs.

A second technique is to learn, or have ready access to the most current best practice standards. Treating, for example, all diabetics according to the latest standardized recommendations minimizes the chance for bias to sneak in.

Health care disparities are a reality. It’s often easier to think of these disparities as resulting from poverty, lifestyle choices, lack of access, poor patient compliance and language barriers. While these are certainly important causes of disparities and need to be addressed, it is important for all of us providing health care to confront our biases and learn to treat all patients in accordance with the current highest standards of care.

More information on this topic, along with the IOM’s complete report “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care” can be found at http://www.iom.edu/report.asp?id=����

“Non-Par” ReferralsPhysicians Health Plan of South Michigan (PHPSM) members are urged to ensure that the health care professionals they see are participating providers. Benefits may be significantly reduced or not available for non-emergent medical services provided by providers who are out-of-network, or “non-par.” Participation status can be verified by referencing the PHPSM Provider Directory, by calling the Customer Service Department at (800) 394-7569, or by visiting www.phpcares.com.

Per contract, PHPSM participating providers agree to refer patients to in-network providers. If your patient insists that you refer them to a provider that does not participate with PHPSM, you should direct them to call PHPSM’s Customer Service Department to verify whether out-of-network benefits are available. Coverage cannot be guaranteed to non-participating providers.

Services that cannot be rendered by a network provider may be referred to a practitioner that is out-of-network. In such instances physicians must notify PHPSM of the referral and to request a benefit determination. Please encourage your patients to make sure that the notification is in place before going to his or her appointment. Call the Care Coordination Department for this verification at (888) 807-7633.

PHPUpdate �

PHP PassportPHP Passport is a program that allows our members to see physicians and providers who participate in other PHP Plans in Kalamazoo or Lansing and applies to Practitioners/Providers that have a current participation agreement with Physicians Choice Network (PCN). Services provided through the PHP Passport Program are governed by the Practitioner/Provider’s PCN Participation Agreement. The PHP Passport Program does not apply to Medicaid or self-funded payors.

If a PHPSM member has chosen a Primary Physician in Kalamazoo or Lansing, they will automatically be enrolled in the PHP Passport Program and receive a

packet that explains the program and how it works. All PHP Passport members are issued a sleeve for their identification card. This sleeve provides you with the necessary information to correctly submit a claim. Additionally, the Member card identifies the name of the PHP Plan in which the Member is enrolled, or you can identify what plan a Member is enrolled in by the Member ID number located on the card.

For additional information, please reference Section 15 of the Physician and Provider Manual. If you have any questions, please contact Laurie Wellman, Network Services Representative, at (517) 782-7154.

PHPSM Offering Category A Employee Safety TrainingEnsuring that our members receive care in a safe environment is a priority for PHPSM. As partners in providing care to our members, we want you to be aware that there are regulatory requirements to maintain a safe and efficient medical office. Part of those requirements includes making sure your Category A office staff (those who may come into contact with infectious agents) are appropriately trained to create and maintain a safe office. The training must be documented and office inspections to ensure compliance must occur at least every two years.

To assist you in meeting State of Michigan and Federal (Centers for Medicare and Medicaid Services) requirements, PHPSM will be offering Safety Training and Testing for Category A personnel who are employed

by our network practitioners. Two training dates have been set; Wednesday, March 15, 2006 from 8:00 a.m. to 12:00 p.m. and Thursday, September 21, 2006 from 1:00 p.m. to 5:00 p.m. Reservations will be necessary and reminders will be sent prior to the trainings.

Offices will be responsible for having an OSHA Manual available on-site and staff should be familiar with it.

The program will be free of charge to the staffs of all network Primary Care Physicians and Specialists having at least 100 member encounters per year.

Please feel free to contact Mary Guild, RN at (517) 782-7154 with any questions that you have regarding this new program.

Provider Newsletter: Article SSN Privacy ActNew Identification Cards excluding the member’s SS# have been issued, and will continue to be issued to become compliant with the Social Security (SSN) Privacy Act.

We are asking all providers to be conscious of this recent change. The initial impact for obtaining the new ID cards is crucial for claims processing and eligibility not only for your office, but for outside entities such as Radiologist, Pathologist and Emergency Room services.

It is recommended that your office obtain a copy of the member’s ID card upon each visit. This language can

be viewed by going to the Provider Manual; Section 2; Product Overview and Member Eligibility now available on line at www.phpcares.com.

A letter went out to our members in October, 2005 asking that they present their new card to providers and destroy the old card immediately.

Please note that it is still permissible under the SSN Privacy Act for PHPSM to collect the member’s SSN during enrollment and to ask for your member’s SSN to verify their identity.

PHPUpdate �

PHPSM Reimbursement for the Fecal Occult Blood Test (FOBT)Fecal occult blood is one of the accepted screening methods for colorectal cancer, which affects the large intestine and the rectum. Colorectal cancer is the second leading cause of all cancer deaths in the United States. Physicians Health Plan of South Michigan encourages practitioners to screen following the guidelines set forth by the American College of Gastroenterology.

When billing for FOBTs, there are two CPT codes that may be used :

82270 Blood, occult, by peroxidase activity (e.g., guaiac), qualitative; feces, 1-3 simultaneous determinations Please note that the 2006 description for 82270 was updated accordingly - Blood occult, by peroxidase activity (eg, guiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm

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screening (ie, patient was provided three cards or single triple card for consecutive collection)

82274 Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations.

When billing either of these codes, only one unit should be reported on the claim form regardless of the number of specimens collected. Both CPT codes are CLIA waived and approved on PHPSM’s office list. The difference between the two codes is the reagent used to recognize the heme product in the stool. Guaiac reagents detect any heme product including that from red meat consumption. Immunochemistry reagent is sensitive to human heme product.

If you have any questions, please contact Network Services at (517) 782-7154.

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PHPSM’s High Deductible Health Plan (HDHP) A high-deductible health plan (HDHP) is a health plan that has a minimum individual deductible of $1,250 or a minimum family deductible of $2,100. An HDHP also has a maximum out-of-pocket limit of $5,100 for individual coverage and $10,200 for family coverage. These plans offer substantial savings over traditional coverage because of plan design. This makes them more affordable to employers and employees.

At PHPSM, we want our members to have affordable health coverage and we want our members to be healthy. For members enrolled in our High Deductible Health Plan, PHPSM pays first dollar coverage for preventive services. Preventive services include:

Annual physicals or health evaluations

Screening services like mammograms

Routine prenatal care

Well-child care

Child and adult immunizations

It’s Your Life health management program

PHPSM Smoking Cessation Program

PHPSM offered Weight Watchers program

Nutritional counseling

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What is a Health Savings Account?

In addition to affordable health coverage, we have also partnered with BASIC Benefits to offer members Health Savings Accounts (HSAs). An HSA is a tax-exempt vehicle funded by individual and/or employer cash contributions that may used to pay for qualified medical expenses now or retiree expenses later. The HSA offers:

Complete ownership by the individual

No “use it or lose it” rules

Complete portability from one employer to the next

Tax incentives to save for future health care expenses

Account balance growth through investment earnings

Health Savings Accounts empower employees to make the right decisions

about their health care and their health care financial planning.

For more information on the PHPSM high-deductible health plans or the BASIC benefits Health Savings Accounts, please call our Customer Service Department at

800-394-7569 or 517-787-6865.

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PHPUpdate �0

PHPSM Rolls out a New Initiative –

Healthy at HeartPHPSM is committed to helping our members receive the services they need in order to live healthy lives. According to Michigan Department of Community Health, Michigan consistently ranks high among states with the worst rates of cardiovascular disease (CVD), and four out of every ten deaths in Michigan are due to CVD. PHSPM is taking action to help members manage heart disease and control risk factors that lead to heart disease.

The Healthy at Heart initiative is designed to increase member compliance by working with physicians and helping patients become more involved in the management of their care. By identifying members with cardiac disease and providing them with educational information, to better manage their condition, we hope to decrease their risk of recurrent cardiac events or lower their risk of a first time major event. Additionally, members who are considered to be at high risk for having an acute coronary event will receive telephonic interventions from our Care Coordination nurses.

How the Initiative Works:

Members are identified from medical claims using diagnosis and procedure codes for Coronary

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Heart Disease, Acute Myocardial Infarction, Hypertension, Hyperlipidemia, PTCA and CABG.

PHPSM sends initial educational packet to members.

Members participate in a survey to receive additional educational materials specific to their condition.

Members receive an invitation to join the Healthy at Heart program, a one year free educational program, in collaboration with Pfizer.

Through out the year, high risk members receive Case Management calls from Care Coordination Nurses.

In order to smooth out the structure-process issues, a pilot will be rolled out to Foote Health System employees. The Initiative is expected to be fully implemented to all PHPSM members in March 2006.

If you have any questions, or would like more information about the program, please contact Deborah Hall-Turner, R.N., B.S.N., Director, Care Coordination and Quality, at (517) 782-7154.

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Therapeutic Alternatives ProgramPHPSM, in cooperation with United HealthCare, began participating in a “therapeutic alternatives” program this fall. The program targets members who are using selected drug products on copayment tier-3 (highest copayment) that have potential therapeutic alternatives available on lower copayment tiers. The selected agents include Lexapro, Crestor, Pravachol, Lescol, Lescol XL, and Mobic. The program also targets members using Zetia in combination with “statins”, as the combination product Vytorin is available to members for a single tier-2 copayment per month.

Similar to a generic substitution program, members receive a letter suggesting opportunities for prescription drug cost savings. The difference in this program is that the suggested options are not generic equivalents of the branded drug product, but agents within the

same therapeutic class that MAY be appropriate for the member. Interested members are invited to discuss the potential alternatives with their physicians. The correspondence SUGGESTS member opportunities for cost savings, and in no way implies that a change in therapy is mandatory or appropriate.

We sincerely hope that this explanation of the program helps you to understand why members may be asking you about alternatives to their current medications. Please contact our Care Coordination department at (517) 782-8238 or 888-807-7633 with any questions you may have.

PHPUpdate ��

Quality Improvement Program DocumentsKey Elements to Improving Quality

Evaluating, planning, acting on, and providing structure processes and resources to improve the quality of care and service our customers receive.

On an annual basis, PHPSM produces three key elements that support the Health Plan’s Quality Improvement (QI) Program. The first element, the Annual Evaluation, evaluates the prior year’s quality improvement activities. The second element, the Quality Improvement Work Plan, plans the QI activities for the upcoming year. The third element, the Quality Improvement Program Description, ensures that the structure and resources are in place to carry out these activities and to meet regulatory and accreditation standards. Outlined below are the highlights of each of these elements.

Key Element #1: The 2005 Annual QI Program Evaluation (based on 2004 QI activities)

The following represent our top five clinical improvements according to the HEDIS 2004 Effectiveness of Care measures:

17% increase in adolescent immunizations

11% increase in members following up within 7 days after a hospitalization for mental illness

10% increase in use of appropriate medications for Children ages 5 – 9 with Asthma

9% increase in diabetic members with an LDL-C <130mg/dL

PHPSM’s Annual Customer Satisfaction Survey (CAHPS®) results showed some increased percentile rankings in important satisfaction with healthcare measures. The percentile ranking is calculated by NCQA using data submitted from approximately 270 managed care plans across the nation. The highest number of points toward accreditation is awarded to measures that meet or exceed the 90th percentile nationally.

Satisfaction with Specialist Seen Most Often increased from the 61st in 2004 to the 99th percentile in 2005

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Other PHPSM accomplishments included:

In 2004, PHPSM conducted over 70 new technology assessments. Assessments were related to new diagnostic and medical procedures, surgical procedures, drugs and biologicals, and new uses of existing technologies.

The Overcoming Depression Program was implemented in April 2004.

Key Element #2: The 2005 QI Work Plan

The 2005 QI Work Plan provides PHPSM with an opportunity to plan and act upon the findings of the 2004 QI Annual Program Evaluation. Many of the 2005 QI activities address the domains of customer satisfaction, managing chronic conditions, encouraging preventive screenings, continuous monitoring of clinical and service performance, alignment with Foote Health System, and increased collaboration with Foote Managed Behavioral Health Services.

Key Element #3: The 2005 QI Program Description

The Quality Improvement Program Description ensures that the structure, processes, and resources are in place to complete the activities outlined in the 2005 Work Plan.

PHPSM strives to improve patient safety by fostering a supportive environment to help practitioners and providers deliver safe clinical practices. PHPSM welcomes participating provider involvement in our activities to improve the quality of care and service our members receive. If you would like more information about the PHPSM Quality Improvement Program, taking part in a Quality Improvement activity or a copy of any of the above referenced documents, please contact Dennis Means, M.D. at (517) 782-7154.

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PHPUpdate ��

Key Elements of the Patient Demographic FormPhysicians Health Plan of South Michigan (PHPSM) utilizes the services of Medical Site Reviewers, LLC (MSR) to conduct our Facility Site and Medical Records reviews on all of our primary care physicians and our high-volume specialists. These reviews are executed every 24 months for these practitioners and on non-accredited ancillary providers.

As a practitioner or provider preparing for a review, your patient demographics forms will be checked to ensure that they meet the standards that have been set forth by accreditation and regulatory agencies such as the Michigan Department of Community Health, the U.S. Centers for Medicare and Medicaid Services and the National Committee for Quality Assurance.

Here is a check list of the details that the MSR reviewer will be looking for:

Patient’s name or identification number on each pagePatient’s date of birthPatient’s address

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Patient’s genderEmergency contact nameEmergency contact relationshipEmergency contact telephone numberEmployer (self or spouse)Work telephone numberHome telephone numberMarital statusInformed consent

There are other details that the MSR reviewer will be auditing, for example, each patient must have an individual record, all of the pages must be attached and the record must be organized. If you are interested in seeing the entire review tool for the facility site and medical record they are available at www.msrhome.com/practitioners.

For more information, or if you have further questions please contact either Laurie Wellman or Mary Guild, R.N. at (517) 782-7154.

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Practitioner/Provider Appeals of Care Coordination DeterminationsAn appeal (or grievance) is a specific request to reverse an adverse determination and restriction of benefit coverage. Adverse determinations are based on:

Contract limitationsSpecific benefit contract exclusionsLack of medical information Failure to meet established treatment guidelines and practice parameters

An explanation of the appeals process is provided with the verbal and written notification of each denial determination. An initial determination for all appeals (other than expedited, see below) is issued within 30 calendar days from receipt. However, if further medical documentation is needed, an additional 10 days are provided.

If you disagree with a determination made by the Care Coordination Department, there are (appeal) grievance opportunities available to request reconsideration of the initial determination. Additionally, you may contact the PHPSM Medical Director or the Care Coordination

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Department with any questions you may have about the clinical criteria used in the determination or to provide further information. The Practitioner/Provider and the Member make the final treatment decision.

An expedited appeal (grievance) may be requested, prior to a Member receiving services (or during an active course of treatment) when you have received an adverse determination that seriously jeopardizes your patient’s health. When an expedited appeal is requested, the entire appeal process can be completed within 72 hours or less, however, you will need to substantiate (either orally or in writing) that the timeframe for the standard appeal process would acutely jeopardize your patient’s health, life, ability to regain maximum function or would subject your patient to severe pain that could not be adequately managed without the care or treatment that is the subject of the appeal.

PHPSM will make a determination, and notification will be made within 72 hours after receipt of your expedited appeal request.