Help Your Patients Save Money on Meds
When prescribing medications to our Medicare Advantage members, remember that they have no copay or deductible for Tier 1 preferred generics.
Statins – High Intensity
- Prescribe Atorvastatin
- Avoid Rosuvastatin
- Average savings of $70 per prescription
Statins – Low-to-Moderate Intensity
- Prescribe Simvastatin
- Avoid Livalo and Fluvastatin
- Average savings of $260 per prescription
- Prescribe Metoprolol Tartrate
- Avoid Bystolic
- Average savings of $200 per prescription
- Prescribe Lisinopril
- Avoid Moexipril and Enalapril
- Average savings of $75 per prescription
Calcium Channel Blockers
- Prescribe Amlodipine, Verapamil or Cartia XT
- Avoid Nisoldipine ER and Verapamil SR
- Average savings of $134 per prescription
Proton Pump Inhibitors*
- Prescribe Omeprazole
- Avoid Dexilant
- Also avoid Esomeprazole, and Omeprazole-Sodium Bicarbonate, which are both non-formulary for 2018
- Average savings of $318 per prescription
*Should be limited to 8 weeks of therapy for most patients. Recent addition to Beers List due to C. diff and bone-loss risk.
- Prescribe Levothyroxine
- Avoid Armour Thyroid (high-risk medication) and Synthroid
- Average savings of $27 per prescription
Our members can also call the number on the back of their ID cards to have a pharmacist review their medications to see if there are lower-cost options available.
Morphine Equivalent Dose (MED) and Opioid Prescribing
Q: What is the Morphine Milligram Equivalent (MME) conversion factor?
A: The MME conversion factor is a constant value which allows practitioners to convert different types of opioid products to an equivalent dose of oral morphine.
Q: What is each opioid product’s MME conversion factor?
A:Use the most recent version of the Centers for Medicare and Medicaid Services (CMS) Opioid Oral Morphine Milligram Equivalent (MME) Conversion Factors for these.
Q: What is the Morphine Equivalent Dose (MED)?
A: The MED represents a patient’s total intake of all drugs in the opioid class over a 24-hour period.
Q: How is the MED calculated?
A: This is the equation for calculating MED:
- Strength per Unit x (Number of Units / Days Supply) x MME Conversion Factor = MED
Fentanyl patches (microgram) have a MME conversion factor of 7.2.
Hydrocodone (milligram) has a MME conversion factor of 1.
A patient receives:
- A 30-day supply of 5 patches of fentanyl, 25mcg, with directions to change the patch every 72 hours
- A 30-day supply of 120 tablets of hydrocodone/APAP, 5/325mg, with directions to take 1 tablet every 6 hours
Fentanyl patch: 25mcg/patch X (5 patches/30 days) X 7.2 = 30mg/day
Hydrocodone tablet: 5mg/tablet X (120 tablets/30 days) X 1 = 20mg/day
The patient’s MED is 50mg.
Q: How does the way I write a prescription affect the MED?
A: Pharmacies will process the number of days the medication should last based on the directions written. In most cases, if a supply for a specific number of days or a note saying, “Must last X days,” is not written on the prescription, they will process the prescription assuming the member will take the highest quantity at the highest frequency allowed by the directions.
A pharmacy receives:
- A prescription for 60 tablets of hydrocodone/APAP, 10/325mg, with directions to take 1 to 2 tablets every 4 to 6 hours
Though the provider may believe the patient will only need to take 4 to 6 tablets per day, the directions will cause the pharmacy to process the prescription as though the member will be taking 12 tablets a day, which equals a MED of 120mg.
Suggestion: Place directions for the pharmacy staff on your opioid prescriptions. Adding “Must last 7 days,” (or 10 days, 14 days, etc.) is a great way to ensure that both the pharmacy and patient understand how long it should last.
- Calculation based on directions as written (maximum daily amount is 12): MED is 120mg
- With note saying it must last 7 days: MED is 85mg
- Since it’s less than 100 mg, this can also help you avoid the preauthorization requirement.
- The 2016 CDC Guideline for Prescribing Opioids for Chronic Pain advises that opioids being used for acute pain should be prescribed at the lowest effective dose and quantity needed in order to decrease the likelihood of physical dependence, withdrawal symptoms, and intentional or unintentional diversion.
- 3 days of therapy is often all that is needed. More than 7 days of therapy is rarely necessary.
Note: This is for educational or analytical purposes only and should not be used as medical guidance. Refer to the drug-specific package insert for instructions regarding dose titration and conversion from one opioid to another.
Colorectal Cancer Screening Updates
Colorectal cancer screening is an important part of preventive care for adults starting at age 50. In the June 2017 publication of the American Journal of Gastroenterology, the U.S. Multi-Society Task Force of Colorectal Cancer updated their recommendations for colorectal cancer screenings.
In an office-based practice setting, they recommend offering colorectal screenings in a tiered, sequential approach.
- Tier 1 screening tests are a colonoscopy every 10 years or an annual fecal immunochemical test (FIT) for those who decline colonoscopies
- Tier 2 tests are a FIT-fecal DNA (Cologuard) every 3 years, a flexible sigmoidoscopy every 5 to 10 years, or a CT colonography every 5 years
Multi-Society Task Force Ranking of Current Colorectal Cancer Screening Tests
|Colonoscopy every 10 years|
|Annual fecal immunochemical test|
|CT colonography every 5 years|
|FIT-fecal DNA every 3 years|
|Flexible sigmoidoscopy every 10 years (or every 5 years)|
|Capsule colonoscopy every 5 years|
|Available Tests Not Currently Recommended|
The HEDIS® Colorectal Cancer Screening measure evaluates the percentage of commercial and Medicare members 50 to 75 years old who have had appropriate screenings for colorectal cancer. Colorectal cancer screenings include:
- Fecal occult blood tests during the measurement year
- Flexible sigmoidoscopies during the measurement year or the 4 years before the measurement year
- Colonoscopies during the measurement year or the 9 years before the measurement year
- CT colonographies during the measurement year or the 4 years before the measurement year
- FIT-DNA tests during the measurement year or the 2 years before the measurement year
We strive to meet or exceed the Quality Compass 90th percentile for Colorectal Cancer Screening for our members. Our most recent HEDIS results for this were in the 75th percentile of Quality Compass for Commercial HMO-POS and within the national average for Medicare Advantage HMOs.
We cover colorectal cancer screening tests, except for CT colonography, under our wellness benefits. Check the Forms & Resources section of Your Health Alliance for providers for wellness guides, or attach to a specific member for their wellness benefits. If you have questions or need more information about specific codes and coverage, call us at 1-800-851-3379, option 3.
Thank-you for your efforts to prevent colorectal cancer in your patients and our members. Looking forward to working toward a healthier 2018!
Sleep Studies Best Practices
Sleep apnea is a serious condition, and it should not be ignored. It can lead to many serious conditions, including high blood pressure, stroke, and heart disease. Sleep studies can help you diagnose sleep apnea.
Indications for Sleep Studies
- Daytime drowsiness
- Falling asleep during daytime activities, like meetings and driving
- Changes in memory or having trouble paying attention
- Loud snoring
- Other people describing apneic spells
- Waking up frequently during the night
- Morning headaches
Most sleep studies can be done at home, which lets patients sleep in the comfort of their own bed. This also allows for a more timely study since patient and facility availability won’t be an issue.
However, there are certain criteria that might indicate a patient needs to visit a facility for their sleep study:
- Congestive heart failure or a history of heart problems
- COPD or active asthma
- History of stroke
- History of seizures
- Obesity – BMI >45
- Low oxygen levels
- Neuromuscular diseases, like Parkinson’s disease
- Someone who can properly set up the equipment
Fall Assessments and Intervention in Medicare Members
The Health Outcomes Survey (HOS) from the Centers for Medicare and Medicaid (CMS) collects member-reported health data to improve managed care and increase accountability. You can help improve these measures for Medicare members by talking to them about balance problems, falls, difficulty walking, and other risk factors for falling during their annual exams.
Talk to them about:
- The danger and risk of falls
- Factors that cause falls
- Using a cane or a walker
- Getting a vision or hearing test
- The importance of exercise and physical therapy, how to start increasing or maintaining activity, or exercise or physical therapy programs that might be right for them
You should also:
- Check blood pressure with them standing, sitting, and reclining
- Perform bone density screenings, especially for high risk members
You can also learn more about HOS and the survey questions on CMS.gov.
Talking Exercise with Patients
Exercise has been a part of daily life for John Kim, a Carle family nurse practitioner, from an early age, but he realizes that’s not the case for everyone.
Kim, who started at Carle in 2015, stresses the importance of exercise with all of his patients.
“I talk about exercise consistently to every patient because not only can it treat comorbidities, but it can also prevent future illness and disease,” Kim said. “I believe exercise along with diet is the foundation of health, and so I make it a priority to talk about exercise with each patient.”
He treats exercise like a vital sign, having his certified medical assistant ask all patients if they exercise and how much.
“Asking about exercise as a vital sign has made it extremely easy to bring up the topic of exercise to each patient,” he said.
Kim offers his patients advice about how to get started if they’re new to exercise and offers ways to increase physical activity if they aren’t active enough. He caters each plan to each patient’s individual interests and lifestyle and tries to help them take one small step at a time.
“If I have a patient that is completely sedentary, I will find out what his or her interests are and try to tailor some kind of physical activity from that,” Kim said. “I try to shoot for my patients to start off with a number they know they can do, whether it’s 5 minutes or 20 minutes a day.”
He also has patients fill out exercise logs to help hold them accountable and initially follows up with them every 2 weeks or once a month until exercise becomes more routine.
Through it all, he’s learned that being patient and nonjudgmental is key.
“New habits take time to build,” he said. “So I make sure patients know that I am not here to ridicule them, but to encourage and support them as they try to build the new habit of exercising. I have found that when patients know that their provider genuinely cares about their health, it gets to the point where it motivates the patients to push themselves a little more, and I believe this is why I have many success stories of patients going from a sedentary lifestyle to a more active lifestyle.”
- Discuss exercise along with vital signs for every patient.
- Be patient about results, and don’t ridicule.
- Set attainable goals with small steps.
- Follow up frequently until exercise becomes a habit.
- Have patients use exercise logs and bring them to each appointment.
Meet with a Coding Specialist
The risk adjustment coding consultants are continuing to request meetings with participating, high-volume provider offices. These meetings are designed to share member-specific examples of coding and quality measure needs and to update providers on the latest efforts to educate on risk adjustment. Along with member specific examples, there is information on yearly risk adjustment data validation (RADV) audits and how provider practice participation is essential in this process.
A member of the coding consultant team is willing to meet with you to discuss any coding or quality questions you may have, or to provide member-specific examples from your panel of members. If interested, contact us at CodingCounts@healthalliance.org.