Pay BillSCOPE | Provider Update
November 2024
Clinical Matters
Is it time for a Palliative Care or Hospice discussion?
Palliative and hospice care are designed to provide better quality of life and relief from symptoms and side effects of serious illness.
Palliative care is an approach to caring for anyone with serious illness, such as cancer. It focuses on improving the quality of life by helping patients and caregivers manage the symptoms of a serious illness and side effects of treatment.
Palliative care is appropriate for people of any age and at any stage in any serious illness. Palliative care should be used whenever the person has symptoms that need to be controlled.
Similarities and differences between palliative care and hospice care:
Similarities
- Both palliative care and hospice care provide better quality of life and relief from symptoms and side effects for people with a serious illness.
- Both have special care teams for a person's physical, emotional, mental, social, and spiritual needs.
- Hospice care often includes palliative care.
Differences
The main difference between both types of care modalities is at the stage of an individual's illness:
- Palliative care can be offered and provided at any stage of a serious illness, and can be provided while the patient is getting active treatment. In other words, it can be given at the same time as chemotherapy, radiation, or immunotherapy for cancer.
- Hospice care is offered and provided for patients during their last phase of an incurable illness or near the end of life, such as for some people with advanced or metastatic cancer. Hospice care is provided when there is no active or curative treatment being given for the serious illness. "Treatment" during hospice care means only managing symptoms and side effects.
Talk to patients about their options for palliative care or hospice and refer them to the right care at the right time. While it can a very difficult discussion, talking to the patients about their treatment options can be a relief to them and their family members.
To learn more and for additional resources:
What Is Palliative Care? | Symptom Management for Cancer | American Cancer Society
Hospice Care and Palliative Care Buffalo | Hospice Care in Buffalo (hospicebuffalo.com)
Managing Chronic Obstructive Pulmonary Disease (COPD)
There's a misperception on who's at risk for this chronic condition: one in four people who develop COPD never smoked. Learn the risk factors and how to treat it.
There is often a misconception about who is most affected by COPD. Often people think COPD is most likely to affect older adults, however anyone can develop COPD. While cigarette smoking is the leading risk factor for COPD, one in four people who develop COPD never smoked cigarettes.
Risk factors for COPD include:
- Adults aged 40 or older
- Those who currently or previously smoked
- Exposure to indoor and outdoor air pollution
- Occupational exposures like dust, chemicals, and fumes
- Changes to lung growth and/or development
- History of childhood respiratory infections
- Alpha 1 antitrypsin deficiency, a genetic form of COPD
COPD is diagnosed after reviewing the results of the patient’s medical and family history including symptoms and exposure to risk factors, a physical examination and the results from spirometry lung function testing.
Treatment options
There are many treatment options to consider.
Reduce COPD triggers that may worsen a person’s COPD: A COPD Action and Management Plan should include opportunities to reduce or eliminate exposure to COPD triggers, such as tobacco smoke, air quality, and the effect of weather.
- Tobacco smoke - Smoking causes lung function to worsen at a faster rate. Tobacco cessation is the single most important thing that can be done and should be stressed at every opportunity with resources to assist.
- Air quality - exposure to strong odors, chemicals, dust, fumes, smoke from wood burning stoves or fireplaces, and poor outdoor air quality.
- Weather - Changes in temperature, high humidity, pollen, and wind may affect a person’s COPD.
COPD medications relieve symptoms and effects.
- Bronchodilators are used to treat breathlessness by relaxing the muscles around the airways, with severity of symptoms determining if short or long-term therapy is predicted to be most effective.
- Inhaled corticosteroids or a muscarinic antagonist may be prescribed if the patient experiences frequent exacerbations.
- Combination medicines include two or three types of medications working together to relieve symptoms.
- Antibiotics may be prescribed during exacerbations, or flare-ups
Other treatment options include pulmonary rehabilitation and supplemental option.
As COPD progresses, eventually supportive care options may involve palliative care and hospice to help address physical and emotional concerns. Palliative care is a type of treatment that can be started at any stage of COPD and may improve the condition, help manage symptoms and make a patient’s treatment goals known. Hospice is support provided at the end stage of COPD that is not intended to improve the condition. (See previous article in this edition for more on palliative and hospice care).
Source: National Indicator Report COPD (lung.org), March 2024
To view COPD Clinical Practice Guidelines, please visit: 2024 GOLD Report - Global Initiative for Chronic Obstructive Lung Disease - GOLD (goldcopd.org)
Statins as a standard of care for diabetes and ASCVD
Primary care physicians should follow these recommendations, which align with Primary Value scorecard measures.
Atherosclerotic cardiovascular disease (ASCVD) remains the leading cause of morbidity and mortality in high-income countries. Statins are the drug of choice and remain one of the most used and effective drugs for reducing LDL cholesterol, the risk of mortality and coronary artery disease in high-risk groups. Because of this known benefit, the following guidelines are part of Primary Value scorecard measures which align with HEDIS and STAR quality metrics
The Primary Value Scorecard measures recommend:
- All patients with ASCVD regardless of lipid levels receive moderate to high intensity statins for secondary prevention.
- All patients aged 40-75 with diabetes regardless of lipid levels receive moderate to high intensity statins.
ASCVD includes having a history of MI, CABG, PCI or other revascularization procedures, or a diagnosis of ischemic vascular disease such as angina, atherosclerosis of an extremity, or stroke.
To assess patients for statin use, we recommend reviewing each patient’s medical record, and:
- Prescribe a moderate to high intensity statin and send a new prescription to the patient’s pharmacy.
- For any patients that have had myalgia in the past, often a retrial with a different drug or a lower dose is tolerated. Retrial with a different drug is recommended annually. If the patient continues to experience myalgia after retrial, then code appropriately.
- If the patient has tried multiple statins & cannot tolerate due to muscle pains, the patient should be assessed and coded appropriately at next visit.
At the least, a moderate intensity statin is recommended for patients with ASCVD or diabetes. Statins are generally well tolerated, however statin-associated muscle symptoms are the most common side effect associated with treatment discontinuation. It is common to experience muscle pain from one statin, and not from another. For patients that have muscle pain and symptoms, try switching to another statin such as rosuvastatin, and pravastatin. Both rosuvastatin and pravastatin are less likely to cause myalgia/myopathy and are also a zero copay or very inexpensive for most patients.
MYOPATHY EXCLUSION CODES
Patients who are intolerant to MULTIPLE statins & have a diagnosis of the following coded within the calendar year are excluded from this quality metric:
It’s important to review patient-level factors that may influence the decision to start statin therapy.
Help keep your patients informed & healthy by educating them on the benefits of statin therapy & prescribing statin therapy for them today. Independent Health supports your efforts to deliver quality, efficient care.
If you have any questions call our team of pharmacists at (716) 250-4480 or 1-844-808-1254, Monday through Friday from 8:30 a.m. to 4:30 p.m.
Office Matters
CVS Pharmacy to become non-participating pharmacy as of Jan. 1, 2025
The notification from CVS has impacted all lines of business.
CVS Pharmacy has notified Independent Health that it will no longer be a participating pharmacy as of January 1, 2025. The notification from CVS has impacted all lines of business.
This network change impacts only six percent of our members, and our pharmacy network will continue to meet network adequacy requirements with nearly 300 local chain and independent pharmacies in the Western New York region, along with 54,000 pharmacies nationwide and convenient mail-order options.
We have begun to inform our members who have recently used a CVS pharmacy about this network change so that we can give them enough time to transfer their prescriptions from CVS over to a new participating pharmacy.
For your reference, we have online resources to help answer our members' questions about switching their prescriptions and pharmacy.
We appreciate your efforts to accommodate these transfers for your patients and apologize for any inconvenience this change may cause.
If an agreement is reached with CVS after we notify our members, we will provide you with an update.
Has your practice completed its required compliance attestation?
It is imperative that participating practices attest to completing fraud/waste/abuse and cultural competency training by 12/31/2024.
Independent Health is required by state and federal agencies to ensure our participating providers complete this annual compliance training.
It is imperative that participating practices attest to completing each of the following by December 31, 2024:
Cultural Competency Training:
All providers who treat Independent Health’s commercial and state program members must attest annually that they have completed cultural competency training for all staff who have regular and substantial contact with our members. Staff must complete one of the following:
- The U.S. Department of Health & Human Services online module, “The Guide to Providing Effective Communication and Language Assistance Services,” or,
- The comparable Think Cultural Health training that corresponds with the provider’s scope of practice, and submit the electronic attestation to confirm completion.
Fraud, Waste & Abuse Training:
Independent Health requires each of its participating provider groups or practices to complete Fraud, Waste & Abuse (FWA) Training and submit an electronic attestation to confirm each of their staff members have completed this training. Staff members required to complete this training include physicians, mid-levels, ancillary providers, registered nurses, licensed practical nurses, administrative and office staff, technicians, coders and others.
Who must submit each attestation?
An authorized representative must submit each of the above attestations on behalf of all individuals under a practice’s Tax Identification Number (TIN). Therefore, each individual staff member who completes each training does not need to submit the attestation.
Have you already completed training?
If your practice has already completed 2024 Cultural Competency through another source and has a roster or spreadsheet with the dates the training was completed, you may submit the attestation through each of Independent Health’s public provider portal pages.
If your practice has already completed the 2024 FWA training and attestation through Independent Health, it is not necessary to attest to doing so again.
Clinical practice guideline provider chart review - 2024 summary
The chart review process offers the opportunity to identify improvement opportunities.
Independent Health chart reviews assess adherence to evidence-based clinical practice guidelines and are completed using available medical record documentation. All reviews were completed for 2023 dates of service.
We understand that on occasion, data may be held in parts of the patient record that are not accessible to reviewers.
Chart reviews reveal potential opportunities for improvement, not only in terms of recommended clinical activities, but also in terms of documentation of those activities.
Prenatal
A random sample of 10 charts from OB/GYN Specialty providers was utilized for prenatal chart review. The review compared chart documentation against clinical practice guideline recommendations to assess adherence to prenatal care standards. Resource: Medicaid Perinatal Care Standards (ny.gov)
Findings:
- Five of 10 charts revealed that no formal depression screening tool had been utilized, and although indicated, one record had no post-partum (PP) visit documented.
- The remainder of the charts were compliant for all prenatal care assessment components when compared to the Medicaid prenatal care standards.
Adult Preventive Health
A random sample of 10 Electronic Health Records (EHR) from adult PCP and Specialty providers was utilized for the adult preventive health review. The review compared chart documentation against clinical practice guidelines to assess adherence to adult preventive care standards. Resource: A and B Recommendations | United States Preventive Services Taskforce
Findings:
- In 10 out of 10 records, neither race nor ethnicity was documented.
- 10 out of 10 charts had no indication of HIV screening having been completed.
- Nine out of 10 chart reviews did not mention Covid-19 vaccination completion.
- Documentation of behavioral health screenings was found to be complete in all 10 records.
Pediatric Preventive Health
A random sample of 10 EHRs from pediatric PCPs was utilized for the pediatric preventive health review. The review compared chart documentation against clinical practice guidelines to assess adherence to pediatric preventive care standards. Resource: Bright Futures Guidelines and Pocket Guide
Findings:
- None of the 10 medical records reviewed had race or ethnicity documented.
- No charts referenced COVID-19 vaccination.
- Otherwise, chart documentation was concordant to clinical practice guidelines.
Heart Failure:
A random sample of 10 EHRs for patients with a diagnosis of heart failure have been reviewed. The review compared chart documentation against clinical practice guidelines to assess adherence to heart failure care standards. Resource: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines | Journal of the American College of Cardiology
Findings:
- Among the 10 charts reviewed, eight out of 10 records did not indicate race.
- 10 out of 10 records did not have documentation of a prescription for exercise/resistance training.
- One chart did not reference a diagnosis of heart failure.
- Otherwise, chart documentation was concordant with reviewed guidelines.
Upcoming member campaigns to encourage our members to take greater control of their health
Throughout the year, the Quality Management and Population Health Management Departments deploy various tactics to encourage members to take a more active role in their health.
State Member Incentive Program Campaigns
Independent Health launched three member incentive programs for State members that will run through December 31, 2024. Members received information regarding these incentive opportunities via letter and e-mail in August 2024.
- Gaps-in-Care Program - State members can earn gift cards for completing various preventive care tests and screenings included in the program.
- Non-Utilizer Program - State members with 7 or more months of continuous enrollment without a claim on file are eligible to earn a gift card for completing an annual well visit.
- Maternity Management Program - State members can earn gift cards for completing a prenatal visit during the first 12 weeks of pregnancy and postpartum visit within 11 weeks after delivery.
- Timeframe: August through December 31, 2024
Metabolic Monitoring for Children and Adolescents on Antipsychotics
The Independent Health Behavioral Health and Pediatric Case Management departments will outreach to parents or guardians of members under the age of 13 who have been prescribed an antipsychotic medication but have not received metabolic monitoring (glucose and cholesterol testing). The Case Manager will provide the parent/guardian with education on the importance of metabolic screening for the child and encourage follow-up conversation with the provider regarding testing.
- Outreach method: Outbound telephone call campaign
- Target members: Commercial and Medicaid members under the age of 13 who are prescribed antipsychotics and have not received metabolic monitoring (glucose and cholesterol testing).
- Timeframe: September through December 31, 2024
Gap in Care Reminder Calls
Independent Health’s Member Services team will perform telephonic outreach to provide education and encourage members with an open gap in care to reach out to their provider to schedule the appropriate appointments and/or get a script to complete the screening.
- Medicaid Managed Care members who have open gaps for: breast cancer, colorectal, and/or cervical cancer screenings.
- Medicare Advantage members who have open gaps for: breast cancer, colorectal, and/or eye exams for members with diabetes
- Commercial (HMO/POS) members who have open gaps for colorectal cancer screenings
- A subset of Black commercial (HMO/POS) members who have an open gap for an influenza vaccine
- Timeframe: Call campaign began in August and will run throughout 2024
Social Determinants of Health Screening
This telephonic outreach campaign will engage targeted members in a conversation around screening for social determinants of health to identify any needs the member has for food, housing, and/or transportation. If a need is identified, Independent Health will assist the member in making a connection to a community resource to address the need.
- Outreach method: Outbound telephone call campaign
- Target members: Medicare members identified with social risk factors including those with low-income subsidy or dual enrollment in Medicaid; HARP members starting SUD treatment.
- Timeframe: Call campaign began in June and will run throughout 2024
Osteoporosis Management in Woman Who Had a Fracture (OMW) Member Outreach
Independent Health’s Case and Disease Management Facilitator will outreach telephonically to Medicare members who fall into the Osteoporosis Management in Woman Who Had a Fracture (OMW) measure.
- Target population: The OMW measure focuses on females 67 to 85 years of age who had a fracture and have six months following the fracture to close the gap by having a bone density scan, filling a script for an osteoporosis medication, or receiving an injection for osteoporosis treatment.
Independent Health’s Case and Disease Management Facilitator will contact members to discuss the member’s fracture, provide education on fractures and falls prevention, and discuss options for gap closure.
The Case and Disease Management Facilitator will discuss the option of an in-home heel ultrasound with Stall Senior Medical (SSM). If the member is interested, the Case and Disease Management Facilitator will ask for consent for the member to be contacted by the SSM team and then SSM will call the member to schedule the appointment. All results will be sent to the member’s Primary Care Physician (PCP) for follow-up.
The Case and Disease Management Facilitator will also discuss other options for gap closure, depending on the member’s preference, and refer back to the member’s PCP. Each call will be individualized based on the member’s needs.
- Timeframe: This outreach is on-going. Monthly, new members are called that fall into the measure.
Eye Exam for Patients with Diabetes (EED) Member Outreach
Independent Health will be facilitating outreach telephonically to Medicare members who have a gap in care for the Eye Exam for Patients with Diabetes (EED) measure.
- Target population: Medicare members with a diagnosis of Diabetes (type 1 or 2) who have not had a retinal eye exam. An eye exam in the year prior must be negative for any type of retinopathy. If year prior eye exam is positive, then an eye exam in the current measurement year is needed.
- Outreach method: Outbound telephone call campaign.
- Medicare: Independent Health will call members and discuss the option of an in-home eye exam with Stall Senior Medical (SSM). If the member is interested, Independent Health will ask for consent for the member to be contacted by the SSM team and then SSM will call the member to schedule the appointment. All results will be sent to the member’s Primary Care Physician (PCP) for follow-up.
- Timeframe: End of October through December 2024
Pharmacy Updates
E-scribe 100-day supplies for Medicare patients
This easy switch can improve medication adherence and your patients' health
Did you know that Independent Health Medicare members can fill a 100-day supply of their Tier 1 drug? This simple switch from a 30 or 90-day prescription to a 100-day supply can increase access to medication at home, improving medication adherence and a patient’s overall health.
Especially important is facilitating the switch for Medicare members who are filling 30-day supplies of maintenance medications to treat chronic conditions. Examples include statins, ACE inhibitors, ARBs, and drugs used to treat diabetes including metformin and pioglitazone.
Lowering member drug cost is an added benefit
Tier 1 drugs are zero cost for a majority of our Medicare members most of the time. However, there are instances when a member will have a low out-of-pocket cost. The cost-share of the 100-day supply will be the same (or very close to the same) cost-share of the 90-day supply. Therefore, switching to the larger supply reduces the number of fills in a year – lowering annual drug costs for the member.
How you can help
- Write prescriptions for a 100-day supply for your Medicare members' maintenance medications. If the benefit doesn’t apply to the drug or the member, the pharmacy can always adjust the quantity.
- Choose generic alternatives over expensive brand name drugs for significant cost savings.
Medicare formularies can be viewed on our website. Tier 1 drugs listed with “EDS” (extended day supply) in the requirements/limits column can be filled for the 100-day supply.
Working together, we can improve medication adherence and clinical outcomes by increasing awareness of this valuable benefit.
Generic version of Victoza to be released in late December
Brand Victoza and liraglutide, the authorized generic, will no longer be covered
Multiple manufacturers are scheduled to release generic versions of Victoza, a GLP-1 approved to treat type 2 diabetes, in late December of this year. These drugs will be the first generic GLP-1s to come to market. Generic drugs increase access to affordable, safe, and effective therapies – often while lowering the out-of-pocket costs for our members.
Changes in Coverage
As a result of these new generic drugs, we will be removing brand Victoza and liraglutide, the authorized generic, from all drug formularies effective 1/1/2025.
Authorized Generics vs. Generics
Authorized generics are actually the brand-name medication without the brand name on the label and packaged as a generic. As such, authorized generics are typically not as cost effective as true generic medications.
If you have any questions about GLP-1 coverage, please contact Provider Relations. Thank you for your continued partnership.
Formulary and Policy Changes
Stay up-to-date on Independent Health's pharmacy policies and formulary updates.
Independent Health's drug formularies
Access Independent Health's 2024 and 2025 drug formularies here.
To obtain a hard copy, please contact Independent Health Provider Relations by calling (716) 631-3282 or 1-800-736-5771, Monday through Friday from 8 a.m. to 6 p.m.
Prime Therapeutics (formerly Magellan Rx) reviews select specialty drug prior authorization requests on Independent Health's behalf. To view Prime Therapeutics' policies for the drugs it reviews, click here.
Spotlight
Top Takeaways this Month
Keep track of all important Department of Health Public Health Bulletins here.
Registration is now open for an Office Matters webinar on Thursday, Nov. 14. Click here to register for "2025 Medicare Changes & Special Needs Plans."
Have you submitted your attestations? This is a requirement: 2024 Fraud, Waste, Abuse and Cultural Competency Awareness attestation now open. Get details on the process here.
Portal account management: Take a few minutes to review your portal account access: are all of your portal account users still employed at your practice? Does anyone need different access or their access rescinded?