spring 2010 t h e Navigator Great Lakes. Great Coverage. Great Choice. 10 Reasons to Recommend Great Lakes Health Plan to Your Patients GLHP was ranked in the 1. top 20 in the nation according to U.S. News & World Report/NCQA America s Best Health Insurance Plans 2009 10.* 2. GLHP was certified at the highest possible level Excellent by the National Committee for Quality Assurance. 3. GLHP s Disease Management Programs won the Michigan Association of Health Plan s Pinnacle Award for the second consecutive time. 4. GLHP proudly received the highest rating by consumers in 2009 in Overall Satisfaction with Health Plan, Getting Care, and Keeping Kids Healthy. Members believe they get the care they need for themselves and their children and that they get the care quickly. 5. GLHP s Pay for Performance triple compensation model rewards PCPs who are accessible, who take care of chronically ill patients, and who make sure all patients receive timely preventive care. 6. GLHP pays claims locally. Your claims are paid swiftly and accurately: i n s i d e 2 4 5 Have You Heard About Personal Care Plus? Poisonous Lead Found in Children s Toys Diagnosing Asthma 8 10 days for a clean claim. 7. GLHP set the highest service standards for our valued Provider network and has a Provider Service Representative for every network PCP and specialist practice. 8. GLHP has a Personal Care Manager Nurse to support the PCP and specialists in caring for their most challenging patients. 9. GLHP has an award-winning, continuously improving provider portal, OSCR, that supports PCP office staff in administering a busy office practice and supports PCP clinical staff with patientspecific information enabling each visit to be that much more productive for the patient and the provider. 10. GLHP continued to find new ways to reduce the administrative burden to PCPs and their staff through our paperless referral process to in-network specialists as well as minimizing procedures that need prior authorization. With all that, why would a provider or a member choose another health plan? The good David Siegel, news is they don t. MD, MPH Great Lakes Health Medical Director Plan s membership has grown to over 200,000. And with an unyielding commitment to develop personal relationships with our members and our providers, and a dedication to be an active and accountable participant in helping people live healthier lives, we will continue to grow. Grow with us; the best is yet to come. *U.S. News & World Report/NCQA America s Best Health Insurance Plans 2009 10. America s Best Health Insurance Plans is a trademark of U.S. News & World Report. Open Enrollment is Around the Corner For months, you asked when your patients can make the switch to GLHP. The entire month of May is open enrollment, the time your Medicaid patients have the opportunity to select the health plan that best suits their needs. We appreciate the support you have given GLHP, and we are asking you to continue this support through the open enrollment period. For your patients who want to choose GLHP, please ask them to call 1-888-ENROLLS (1-888-367-6557) in May.
Communication Standards Open Communication GLHP encourages and supports open communication between practitioners and members. GLHP does not prohibit or restrict a practitioner from advising members about their health status or treatment options, including medical treatment options regardless of cost or benefit coverage limitations where the practitioner is functioning within the scope of his or her practice. Provider Termination Notification To ensure proper payment and care continuity for GLHP members, GLHP provider contracts require that providers give prior written notice to GLHP when they desire to terminate their agreement with the health plan. Agreements stipulate that providers must give GLHP 90 days notice if the termination is without cause. Either GLHP or the provider may terminate the agreement with 30 days notice if the termination is with cause. Notifying Affected Members of Termination Where the provider is a PCP, GLHP will notify the members affected by the termination and assign the members to a new PCP. Members may change their PCP by calling GLHP s Customer Service department. Where the provider is a specialist or specialist group and the provider or group initiates the agreement termination, it is the specialist s responsibility to notify affected GLHP members prior to the effective date of termination. Affected GLHP members are those who have had at least three visits to the specialist in a one-year period and/or who have a chronic condition such as chronic obstructive pulmonary disease, end stage renal disease, or diabetes who have seen the provider at least three times in the previous 12-month period. If GLHP terminates the agreement, GLHP and the specialist will jointly notify the affected members. Please contact the Provider Service Department at 248-331-4296 if you have any questions. Have You Heard About Personal Care Plus? In 2008, GLHP opened a new line of business in Wayne, Oakland, and Macomb Counties with our Medicare Advantage Special Needs Product: Personal Care Plus (HMO). This year, Personal Care Plus began enrolling dual eligibles (persons who are eligible for both Medicare & Medicaid) in Kalamazoo County. Personal Care Plus members have GLHP primary for their Medicare benefits and fee-for-service Medicaid for secondary coverage. Members receive enhanced benefits including limited non-emergent transportation and podiatry. High-risk, complex patients benefit from both case and disease management programs. Additionally, Personal Care Plus providers enjoy the same provider servicing standards, including swift claims payment, that they do in GLHP s Medicaid plan. If you have any questions about Personal Care Plus, please contact your Provider Service Representative. 2
Clinical Practice Guidelines Lead Guideline www.michigan.gov/documents/provid ERSGUIDELINES_89397_7.PDF Pain Management Guideline www.michigan.gov/documents/mdch_ MI_guidelines_91795_7.pdf linical Practice and Preventive Health Guidelines have C been developed through the Michigan Quality Improvement Consortium (MQIC). The Consortium is made up of physicians, health plans, specialty groups, and researchers to implement common clinical practices and performance measures to achieve consistent delivery of evidence-based services and better health outcomes for patients. MQIC Guidelines are updated every two years and cover a wide range of common disease processes; there are also a number of tools and forms available to assist the physician with disease management. All guidelines, both new and revised, are mailed to GLHP practitioners annually; please contact your Provider Services Representative for a paper copy of any of the Guidelines or Tool kits, or they can be accessed at www.mqic.org/ guid.htm by selecting the appropriate category. Additional Guidelines Global Initiative for Chronic Obstructive Lung Disease for the Management and Prevention of COPD www.goldcopd.com Childhood and Adolescent Treatment of ADHD Full Guideline: www.glhp.com/providers/ PDF/CPG_ADHD.pdf Condensed Guideline: www.glhp.com/ Providers/PDF/CPG_Condensed_ ADHD.pdf Pediatric and Adolescent Immunization Schedule www.cdc.gov/vaccines/recs/schedules/ child-schedule.htm Adult Immunization Schedule www.cdc.gov/vaccines/recs/schedules/ adult-schedule.htm EPSDT Toolkit www.ihcs.msu.edu/epsdtclinician ToolkitNew.htm AIM Toolkit (Alliance for Immunization in Michigan) www.aimtoolkit.org Who Let The Dog Out? We did! This spring and summer, our childfriendly mascot, Dr. Health E. Hound, and his pack of GLHP employee volunteers will be in your neighborhoods at health fairs and community events. The goal of our mascot program is to support local charities, educate our members about wellness initiatives, and have fun! If you have an upcoming event you would like GLHP to participate in, please contact Kelly Rolando at 248-331-4399 or Tori Johnson at 269-552-3044. At right: Dr. Health E. Hound and area children 3
Poisonous Lead Found in Children s Toys F or years, the culprits in blood lead poisoning in children have been lead paint used in older homes and dirt tracked from industrial sites into the homes of toddlers. But the new culprit is in the toys parents buy for their children. Toys made in other countries and then imported into the U.S. put children at risk for such exposure. Lead may be used in two aspects of toy manufacturing.* Paint: Lead may be found in the paint on toys. It was banned in house paint, on products marketed to children, and in dishes or cookware in the United States in 1978; however, it is still widely used in other countries and, therefore, can still be found on imported toys. It may also be found on older toys made in the United States before the ban. Plastic: The use of lead in plastics has not been banned. It softens the plastic and makes it more flexible so that it can go back to its original shape. It may also be used in plastic toys to stabilize molecules from heat. When the plastic is exposed to substances such as sunlight, air, and detergents, the chemical bond between the lead and plastics breaks down and forms a dust. Families facing tough economic times may be more likely to purchase less expensive toys for their children and unknowingly poison them. We urge all practitioners who care for young children, particularly those in lower socioeconomic situations, to screen children for blood lead levels. The collective outcome of GLHP PCPs by county is tolled to create a blood lead screening rate. This rate is based on claims submitted for children continuously enrolled in GLHP in 2008 who turned two years old in the same year. Among all counties in GLHP s service areas, Tuscola and Sanilac counties in the thumb have the highest rates, and Wayne has the highest rate of the TriCounties, while Macomb has one of the lowest rates among all counties. GLHP will initiate improvement interventions in 2010 with those PCP offices that had 10 or more children in the denominator and whose rate was below the GLHP administrative rate of 75%. We urge lower-performing offices to contact your Provider Services Representative to learn more about in-office sampling for blood lead screening and other best practices. County HEDIS 2009 Administrative Rate County HEDIS 2009 Administrative Rate Berrien 27% n=15 Livingston 74% n=31 Branch 49% n=35 Macomb 59% n=759 Calhoun 77% n=206 Oakland 69% n=1211 Cass 70% n=23 Saginaw 76% n=170 Hillsdale 62% n=26 Sanilac 83% n=64 Huron 76% n=96 St. Clair 63% n=214 Jackson 79% n=77 St. Joseph 56% n=100 Kalamazoo 79% n=303 Tuscola 84% n=21 Lenawee 71% n=79% Van Buren 48% n=137 Wayne 74% n=1540 PCPs on GLHP s Pay for Performance contract receive $50 bonus money for a blood lead screening completed on or before a child s second birthday. *Centers for Disease Control, www.cdc.gov/nceh/lead/tips/toys.htm 4
ASTHMA: Is It Persistent or Intermittent? W hen it comes to diagnosing asthma, the difference may not be an easy call. But GLHP is on a mission. Our goal is to get all GLHP members with persistent asthma on the appropriate medication. What is persistent asthma? According to the National Heart, Lung, and Blood Institute of the National Institutes of Health s Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (EPR-3 2007), only one of the criteria below needs to be included. Rescue inhaler used > 2 days a week > 3 month Nighttime awakenings FEV1 between 60 80% of predicted Some limitations of normal activity Asthma symptoms > 2 days/week ACT score of 16 19 Treat the inflammation is the operative phrase with persistent asthma. Unfortunately, most persistent asthmatic treatment consists only of short-acting inhaled rescue medication. These beta-2 agonists are the medication of choice for quick symptom relief. This is problematic, as this drug treats constriction only. The inflammation remains. Pharmacologic management of persistent asthma consists of long-term control and quick relief. Spirometry is the new essential measure of lung function to establish the diagnosis. Moreover, the preferred treatment, according to the EPR-3, is inhaled corticosteroids. Referral to an asthma specialist may be suggested for mild persistent to severe persistent asthma. More information and treatment options, including MQIC Guidelines and an asthma action plan for patients, are available on our website: www.glhp.com. For spirometry training and reimbursement information, contact Lucille Tomei, RN, Asthma Disease Management Coordinator: 800-903-5253 or direct 248-331-4355. GLHP Employees Contribute GLHP employees and their UHG colleagues contributed to a companywide donation of more than $375,000 to Haitian relief efforts. Employees donated $175,000 to Global Impact, resulting in $100,000 in matching contributions by UHG. Global Impact funded some of the most respected charities active on the ground in Haiti, such as OxFam, CARE, Unicef, Doctors Without Borders, and many others. Charitable contributions provided meals, water, medical assistance, mobile hospitals and surgical units, and the sending of thousands of trained aid workers to assist in areas affected by the earthquake. An additional company gift of $100,000 was made to the American Red Cross. 5
PRSRT STD U.S. Postage PAID Great Lakes Health Plan PO Box 2127 Southfield, MI 48037-9955 Postmaster: Please deliver between April 19 and 23. Visit our website! www.glhp.com The Results Are In! G reat Lakes Health Plan would like to thank all the providers who participated in our annual Provider Satisfaction Survey 2009. We are pleased to share our results with you: SURVEY QUESTION 2009 SCORE 2008 SCORE 2007 SCORE Overall satisfaction 85.7% 85.2% 83.1% Rating compared to other plans 84%** 86.9% 82.9% **NOTE: The 2009 survey was fielded via a fax methodology. In past years the survey was collected through the mail. Differences in scores may in part be attributable to the change in the fielding mode. Scores represent an Excellent, Very Good, or Good rating. Providers were given a choice of Excellent, Very Good, Good, Fair, and Poor. GLHP s key strengths: Utilization review process Assistance provided by care management staff in facilitating treatment coordination Timeliness of claims payment process Ease of credentialing or re-credentialing process Assistance provided by the provider service center or 1-800 provider help line Ongoing support and services by network management Usefulness of data available through OSCR GLHP s improvement targets: Ease of the prior authorization process Timeliness of appeals process Communication of the determination of appeals Availability of disease management and health education programs for your patients Effectiveness of care management programs provided for your patients Helpfulness of the provider manual and updates We take your concerns very seriously. Look for targeted initiatives addressing areas of dissatisfaction throughout 2010. We will update you on our efforts throughout the year. Thank you for your valuable feedback. t h e NavigatOr David K. Livingston President David Siegel, MD, MPH Medical Director Melanie Osment Editor The Navigator is published by Great Lakes Health Plan, a Michigan for-profit corporation, to provide general information. It is not intended to provide personal medical advice, which should be obtained directly from a physician. 2010 All rights reserved. Printed in the U.S.A. Printed on Recyclable Paper 864M