February Newsletter

HEDIS^® Chart Reviews Coming Soon

Each spring, we collect data to determine how we measure up against national averages for the Healthcare Effectiveness Data and Information Set (HEDIS). This data collection and analysis indicates where we need to focus our quality efforts and is required for National Committee for Quality Assurance (NCQA) accreditation. Successfully generating our HEDIS report depends largely on the cooperation we receive from provider office staff.

In other words, we need your help. Representatives may visit your office this spring to review specific medical records or ask you to copy, fax or mail records. All individually identifiable information concerning patients will be kept strictly confidential in compliance with HIPAA regulations. If you have any questions about HEDIS, contact the Quality & Medical Management Department at 1-800-851-3379, extension 8112.

Results of the HEDIS audit will be available on our website in the fall of 2015.

HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).

CAHPS^® Results Are In

We have the results from the 2014 Consumer Assessment of Health Care Providers and Systems (CAHPS).  The CAHPS survey measures members’ satisfaction with health care they received and with their health plan. The survey was administered between January and May of 2014.

Members are asked various questions that are then grouped into composite scores. For the commercial plans a new composite measure, Shared Decision Making, was added in 2013.

The questions for this composite focus on medication use:

• Doctor discussed reasons to take a medicine?
• Doctor discussed reasons not to take a medicine?
• Doctor asked what you thought was best for you?

With continued emphasis on decreasing use of inappropriate antibiotic and decreasing prescriptions for opioids, it is important to discuss benefits and risks to all medications.

Medicare Advantage plans do not have a composite measurement for Shared Decision Making. However, the Medicare Advantage CAHPS survey asks, “In the last 6 months, how often did you and your personal doctor talk about all the prescription medicines you were taking?”

This question falls in the Care Coordination composite. Other questions under this composite ask about receiving tests results and receiving help when needed from their personal doctor’s office to manage care between different providers and services.

This composite shows the importance of following up with patients about their prescriptions and ordered tests. Evaluate if patients are taking medications correctly, and suggest pill boxes and automatic refill reminders as helpful tools available to them.

Please refer to our website for more detailed CAHPS results.

CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

Pharmacy Updates

All Plans

Specialty Preauthorization (PA)

• Going forward, all preauthorization requests for a specialty medication must be sent to Health Alliance Pharmacy Department at the fax number 217-255-4598.

Formulary Changes in Hepatitis C Treatment

• Viekira Pak – Exclusive preferred product for Hepatitis C Genotype 1 (Preferred Specialty)
  • Note: Viekira Pak is now the only Preferred product on all Health Alliance formularies for Hepatitis C.
    Sovaldi will be covered as Non-Preferred for Hepatitis C Genotypes 2–4.
  • These Hepatitis C products are now non-formulary: Harvoni, Olysio and Victrelis.
  • Members currently receiving a non-formulary or Non-Preferred product will be allowed to continue on a previously approved regimen.
• Hepatitis C Policy Updates
  • Liver fibrosis measurement equivalent to a METAVIR score of F2 or greater (previously coverage was for F3 or greater).
  • Urine toxicology screens are now required for all requests.
  • 12 months of documented abstinence is required if there has been any previous evidence of substance abuse.
  • If evidence or known diagnosis of a malignancy, the request will be reviewed by a Medical Director for medical exception.
  • Signed Health Alliance Hepatitis C treatment patient commitment letter verifying that the patient is willing to be treated, has no barriers to treatment and will be compliant with the approved regimen and labs.

Medicare

Health Alliance Connect (MMAI and SPD)

Commercial (including Exchange)

New Policies

• Keytruda (pembrolizumab) – Tier 3 with PA
• Northera (droxidopa) – Tier 5 with PA
  • Indication: For the treatment of orthostatic dizziness, lightheadedness, or the “feeling that you are about to black out” in adult patients with symptomatic neurogenic orthostatic hypotension (NOH) caused by primary autonomic failure (Parkinson’s disease (PD), multiple system atrophy, and pure autonomic failure), dopamine beta-hydroxylase deficiency, and non-diabetic autonomic neuropathy
• Ruconest (C1 esterase inhibitor [recombinant]) – Tier 6 with PA
• Tybost (cobicistat) – Tier 5 with No PA

Revised Policies

• Advair – Criteria added for documented diagnosis of asthma and COPD and exclusion of any non-FDA-approved indications
• Flovent – Criteria added for documented diagnosis of eosinophilic esophagitis and exclusion of any indication other than asthma or eosinophilic esophagitis
• Otezla – Criteria added for coverage of plaque psoriasis
• Relistor – Criteria added for coverage of opioid-induced constipation due to chronic non-cancer pain

Formulary Changes

• Omnitrope – Moved to Tier 4 (Preferred Specialty)
  • Note: Omnitrope is now the only preferred growth hormone product on the Commercial and Exchange Formularies.
• Tev-Tropin – Moved to Tier 5 (Non-Preferred Specialty)
• Exforge- Moved to Tier 3
• Myrbetriq – Moved to Tier 2
• Treximet – Moved to Tier 3

Meet with the Coding Consultant Team

The Coding Counts consultant team is beginning first-quarter rounding with our high-volume provider offices to share member-specific examples related to risk adjustment scores and Star Ratings. To find out if you’re on the list or to schedule a visit with a coding consultant, email CodingCounts@healthalliance.org or visit Coding Counts.

HealthLink Contract Ending

As of March 31, Health Alliance will no longer partner with HealthLink as an extended network. However, we are expanding our Illinois network to include many of these providers directly.

If your patients/our members currently see HealthLink providers through the extended network, they can go to Your Health Alliance and find a doctor to see if their provider will still be in-network.

Help Members Quit Tobacco

Member-reported data from the CAHPS survey shows that physicians’ discussion of treatment options and pharmacotherapy for tobacco cessation declined to below 60%. A decline in the conversation regarding tobacco cessation in general was also reported.

Health Alliance encourages physicians to discuss these issues with members. We also offer and support the Quit For Life^® tobacco-cessation program, which is available to all eligible Health Alliance members, including Medicaid.

Pharmacy options with Quit For Life include nicotine gum, lozenges, and patches without copay or Chantix or Zyban with greatly reduced copay. Members can call 1-866-784-8454 to sign up for this free program.

Other tobacco-cessation resource include:

• American Lung Association’s Freedom From Smoking^® program – Patients can get free coaching and support by calling 1-800-586-4872 or by visiting ffsonline.org.
• BecomeAnEX.org – This site offers online education and community support based on personal experience.

Whatever route you and your patient choose, please remember to discuss options and treatment for tobacco use.

Encourage Diabetes Education

Diabetes education is essential in helping patients and families learn to manage diabetes. Improved diabetes knowledge leads to better clinical outcomes, improved quality of life and lower healthcare costs. The majority of Health Alliance plans cover diabetes education under the wellness benefit.

Consider referring patients with diabetes to an in-network certified diabetes educator. Health Alliance case managers and health coaches are also available to help members. Make a referral by calling the Health Alliance Quality & Medical Management Department at 1-800-851-3379, ext. 8112.

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