Download Help Us Stop Lawsuits Before They Start

Issue 2, 2004
DirectLine
inside this issue:
Help Us Stop Lawsuits Before
They Start
by Sam Ho, M.D., senior vice president and chief medical officer,
PacifiCare Health Systems
ising medical malpractice
claims affect everyone,
especially physicians.
Although physicians usually prevail in malpractice suits, the average cost for defendants is more
than $77,000, according to the
Physician Insurers Association of
America. The U.S. Department
of Health and Human Services
estimates that medical liability
adds $60 billion to U.S. health
care costs each year.
PacifiCare® is working on several fronts to minimize malpractice claims. But there are also
steps you can take to help us
reduce the likelihood of lawsuits.
R
How We Make
Coverage Decisions
page 2
When a Patient’s
Claim Is Denied
page 3
Important FDA Drug
Warnings
page 4
Top Issues Facing
Health Care
back page
CLEAR EVIDENCE/CERTIFICATE OF COVERAGE
One of the best ways to avoid
potential lawsuits is to remove
any ambiguity regarding which
services are covered and which
are not. We continually track
emerging health care trends and
new procedures to determine
where they fit within benefit
plans. We also constantly reevaluate and refine evidence of
coverage and/or certificate of
coverage documentation to address any new issues that arise.
STREAMLINED PRE-CERTIFICATIONS AND APPEALS
Procedures that require health
plan approval have been a con-
www.pacificare.com
tentious public issue over the
past decade and a major contributor to malpractice claims. We’ve
taken deliberate steps to reduce
the number of procedures that
require prior-authorization in
the hopes of eliminating as
many of these conflicts as possible. In the past two years alone,
we’ve reduced the number
of procedures requiring
prior-authorization by 80
percent. Today, the only
services requiring authorization are those that
reflect the widest variation
among providers.
For those cases in
which coverage is denied, we
try to handle appeals as quickly
as possible and resolve issues
before they escalate into heated
conflicts. We process more than
95 percent of appeals faster
than regulatory standards
require. You can help by expediting any requests for clinical
information during an appeal.
BETTER COMMUNICATION
Despite our best efforts, conflicts
about denials of coverage and
other issues are bound to occur.
But conflicts don’t have to
become full-blown lawsuits. Clear
communication can go a long
way toward defusing many issues.
When a patient is denied
coverage, we try to provide a
detailed explanation. We ask
that you take the time to discuss any denials with your
patients to ensure they fully
understand the decision. For
example, a patient denied coverage for a new diagnostic test
may be understandably upset.
But the patient may not realize
Sam Ho, M.D.
senior vice president
and chief medical
officer, PacifiCare
Health Systems
that the test hasn’t been scientifically validated or hasn’t proven
to be more effective than a less
costly alternative. Patients may
still be disappointed by a denial,
but by taking the time to
explain the decision, you can
help them understand the context and defuse a more emotional response.
Disagreements are inevitable
in health care. But disagreements that result in lawsuits
ultimately raise costs for physicians, health plans and health
care consumers at large. By
working together to remove as
much friction as possible from
health care decisions, we can
help control costs and promote
patient satisfaction. ■
Formulary
Highlights
2004
The National Pharmacy
and Therapeutics
Committee at PacifiCare®/
Prescription Solutions®
continually evaluates
products for inclusion
in or deletion from the
PacifiCare formulary.
Additions and deletions
for first quarter 2004 are
listed below.
Additions:
■ Benicar® and Benicar
HCT, with restrictions
■ Diovan® and Diovan
HCT,® with restrictions
■ LexaproTM 5mg
■ PremproTM
0.3mg/1.5mg
TM
Deletions:
■ Cefzil®
Help Your Patients Take Charge
of Their Health
ost likely, you treat
PacifiCare® members
who can benefit from
one of our Health Management
programs. In fact, they may
already be enrolled.
Here’s a look at our programs:
■ Taking Charge of Diabetes®
■ Taking Charge of Your
Heart Health® for Coronary
Artery Disease
■ Taking Charge of Your
Heart Health for Congestive
Heart Failure
■ Taking Charge of Depression®
■ Taking Charge of Asthma®
Each program provides evidence-based recommendations
through educational materials,
including information about
managing health conditions,
addressing lifestyle issues, comorbid conditions and assessment of current self-care behaviors. Interventions are focused on
key topics such as preventive care
and exams or medications. To
M
How We Make
Coverage Decisions
PacifiCare® follows nationally recognized criteria when
determining whether the medical procedures and services you recommend for your patients are eligible for
coverage. PacifiCare recently began utilizing Milliman
Care Guidelines.
You may request a copy of specific criteria by contacting us. We will then fax you the criteria requested.
Medical directors, pharmacists and mental health
providers are also available to discuss denial decisions
with requesting providers at any time. You may reach
us at the following numbers for the above requests:
■ PacifiCare Medical Directors: (303) 714-2222 or
(800) 255-1189
■ Prescription Solutions® Pharmacists: (800) 711-4555
be eligible, patients
must be age 18 or
older for our diabetes, coronary
artery disease, congestive heart failure
and depression programs, and between
ages 5 and 56 for
our asthma program. Our diabetes,
coronary artery disease and congestive heart failure
programs have earned the
Quality Profile award from the
National Committee for Quality
Assurance (NCQA).
The diabetes, heart health and
asthma programs are opt-out
programs. PacifiCare identifies
members based on encounter,
claim and/or pharmacy data.
Qualified members are automatically enrolled but have the option to opt out of participating
in the program. Members can
also self-enroll, and you can refer
your patients into the program.
The depression program is an
opt-in program. Members selfenroll, and you can also refer
your patients into this program.
PacifiCare does not require
physician approval for enrollment into any of the Taking
Charge programs. However,
eligibility criteria by program
do apply.
To refer a member, fax the
PacifiCare Universal Referral
Form to us or call (800)
915-9159. ■
Notice of Affirmative
Statement Regarding
Incentives
PacifiCare® works to facilitate the delivery of appropriate care and monitors the impact of its Utilization
Management program to detect and correct potential
under- and over-utilization of services. PacifiCare
encourages appropriate decisions on the coverage of
care and service, and does not employ incentives to
encourage barriers to care and service.
■ UM decision-making is based only on appropriateness of care and service and existence of coverage.
■ PacifiCare does not specifically reward practitioners
or other individuals for issuing denials of coverage or
service.
■ Financial incentives for UM decision-makers do not
encourage decisions that result in under-utilization.
PacifiCare Behavioral Health Customer Service: (888) 777-2735
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Coming Soon: New QUALITY
INDEX Physician Profiles
®
ur QUALITY INDEX® profiles* for
physician organizations and hospitals
have been praised in the health care
industry for good reason: These report cards
empower members’ health care decision making
while raising the level of performance among our
contracted providers
and hospitals.
And because we at
PacifiCare® believe you
should never stop striving for excellence, we
are pleased to announce
that we are expanding
the scope of our
QUALITY INDEX
profiles. Beginning in
2004, we are planning
to offer QUALITY
INDEX profiles for
individual physicians
in all eight of our
service states.* This
will enable our members to further refine their search for high-caliber,
affordable health care providers and help us reward
those contracting physicians who reflect better performance in clinical quality and efficiency.
The new QUALITY INDEX profiles for individual physicians will give our members a wealth
of relevant information, including how well a
contracting physician:
O
■ scores on providing preventive health services
■ follows established guidelines for treating specific diseases
■ appropriately prescribes medications
■ efficiently uses health care resources
“Not only will our new QUALITY INDEX
profiles of individual
physicians help to
improve the care our
contracting physicians
provide, they also have
the potential to significantly reward
high-scoring physicians with more new
patients,” says Sam Ho,
M.D., senior vice
president and chief
medical officer,
PacifiCare Health
Systems. “Word-ofmouth is a powerful
marketing tool for
good doctors, but the
system we’re offering gives members tangible
proof of a physician’s performance.”
Members and contracting physicians will be
able to access the QUALITY INDEX profile of
individual physicians this summer by logging on
to www.pacificare.com. ■
Remind your patients
about the lifesaving benefits of mammograms.
You can order both
English and Spanish
materials at no cost from
the Colorado Foundation
for Medical Care (CFMC)
for your Secure Horizons®
members.
Free mammography
reminder postcards
come with postage-paid
stamps. For more information or to order, contact the CFMC at (303)
306-4482 or visit
www.cfmc.org.*
You can also order free
patient education materials for your office from
the National Cancer Institute’s Cancer Information
Service. Brochures, posters and bookmarks with
the message “Mammograms: Not just once, but
for a lifetime” are available in both English and
Spanish. To order, call
(800) 4-CANCER (226237).
*QUALITY INDEX® not currently available in all markets.
*PacifiCare is not affiliated with this
Web site.
WHAT TO DO WHEN A PATIENT’S CLAIM IS DENIED
hen a patient comes
to you upset about a
denied claim or coverage decision, you can do
more than lend a sympathetic
ear. You can help by explaining
the appeal process.
Whenever a patient disagrees
with a coverage decision, the
first step is to inform them that
they may appeal to PacifiCare®
by calling Customer Service at
(800) 877-9777. An internal
panel will review the case and
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Direct Line Issue 2, 2004 CO
Order Free
Mammogram
Materials
provide an appropriate and
timely resolution.
If your patient is not satisfied
with PacifiCare’s decision, there
are other options. If coverage was
denied because the service was
not considered medically necessary, with most plans the member can request an independent
external review. Administered by
the state Division of Insurance,
this panel provides an objective
medical review and its decision is
binding on PacifiCare.
If the original decision is
upheld, your patient still has one
more option: The case can be
reviewed through binding arbitration. If coverage was originally
denied because the service is not
included in the member’s plan,
there is no independent external
review and the appeal would go
directly to arbitration. Binding
arbitration is limited to appeals
that are not subject to ERISA.
To learn more about this
process, call Customer Service. ■
MEDSOLUTIONS TO
MANAGE OUTPATIENT
RADIOLOGY
Effective March 1, 2004,
MedSolutions® is the
new PacifiCare® vendor
to manage outpatient
radiology, including CT
scans and MRIs. If you
need further information
or have any questions,
please contact your
provider representative.
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Important FDA Drug Warnings
The FDA maintains a list of recalls, warnings and safety alerts for food and prescription drug products. You can access this list at
www.fda.gov/opacom/7alerts.html.*
For the most updated information, please visit the Healthcare Professionals section of www.rxsolutions.com and access the Drug Bulletin
Board. You may also visit www.rxsolutions.com/b/drug_bb/drug_bb.asp for an up-to-date list of drug products.
*PacifiCare® is not affiliated with this Web site.
Product
Warning
Duragesic® 75 mcg/h (fentanyl),
Janssen, 2/20/04
Health care professionals were notified of a Class I recall of Duragesic 75 mcg/h (Control Number 0327192, expiration
October 2005). A potential seal breach on one edge may allow drug to leak from the patch and could result in an
increased absorption of fentanyl, leading to increased drug effect, including nausea, sedation, drowsiness or potentially
life-threatening complications. Conversely, there may not be adequate medication to treat the patients’ pain; this may
also lead to withdrawal symptoms in an opioid-dependent patient.
Ortho-Evra,® Johnson & Johnson,
2/10/04
A warning to the public was issued about an overseas Internet site selling counterfeit contraceptive patches that contain
no active ingredients.
Permax® (pergolide), Lilly,
12/22/03
Health care professionals were informed of the possibility of patients falling asleep while performing daily activities,
including operation of motor vehicles, while receiving treatment with Permax. Many patients who have fallen asleep have
perceived no warning of somnolence.
Tamiflu® (oseltamivir), capsule and
oral suspension, Roche, 1/2/04
New preclinical safety data suggest that Tamiflu is not indicated for either treatment or prophylaxis of influenza in
infants less than 1 year of age.
Viramune® (nevirapine), tablet and
oral suspension, Boehringer
Ingelheim, 2/2/04
Severe, life-threatening and in some cases fatal hepatotoxicity, including fulminant and cholestatic hepatitis, hepatic
necrosis and hepatic failure, has been reported. These events are often associated with rash. Women and patients with
higher CD4 counts are at increased risk of these hepatic events. Women with CD4 counts >250 cells/mm3 are at considerably higher risk of these events.
Zyprexa® (olanzopine), tablet,
Lilly, 2/20/04
A letter sent out by Eli Lilly to U.S. doctors on Jan. 15, 2004, warned that Zyprexa increased the risk for death or stroke
in five clinical trials. The letter also stated that 3.5% of elderly patients with dementia taking Zyprexa in the trials died of
all causes, more than twice the death rate of 1.5% seen among those taking placebo.
MedWatch Safety-Related Drug Labeling Modifications
Product
Summary of Changes to Contraindications and Warnings
Accupril,® Accuretic,® Aceon,®
Lotensin,® Lotensin HCT,®
Monopril,® Monopril HCT,® Univasc,®
Uniretic,® 10/03
Intestinal angioedema has been reported in patients treated with ACE inhibitors. These patients presented with abdominal pain; in some cases there was no prior history of facial angioedema and C-1 esterase levels were normal.
Actos® (pioglitazone), tablet,
Takeda, 11/03
In a clinical study, Actos coadministered with insulin, CHF was reported in 0.3% of patients on 30 mg and 0.9% of
patients on 45 mg dose as an adverse event.
Advair® Diskus (fluticasone +
salmeterol), GSK, 11/03
Advair is contraindicated in the primary treatment of status asthmaticus or other acute episodes of asthma or COPD. A
large U.S. study showed a small but significant increase in asthma-related deaths in patients receiving salmeterol versus
those on placebo. Subgroup analyses suggest that risk may be greater in African-American patients compared to
Caucasians. Coadministration with ritonavir can significantly increase plasma fluticasone propionate exposure, resulting
in significantly reduced serum cortisol concentrations. Patients who are receiving Advair Diskus twice daily should not
use additional salmeterol or other inhaled, long-acting beta2-agonists.
Advil® Cold and Sinus (ibuprofen
and pseudoephedrine), Wyeth,
10/02
Taking more than recommended may cause stomach bleeding.
Alora® (estradiol), transdermal
system, Watson, 11/03
Estrogens increase the risk for endometrial cancer. Estrogens with and without progestins should not be used for the
prevention of cardiovascular disease. Women’s Health Initiative (WHI) data were added.
Altocor® (lovastatin) extendedrelease tablet, IVAX, 9/03
Lovastatin, like other inhibitors of HMG-CoA reductase, occasionally causes myopathy manifested as muscle pain, tenderness or weakness with creatine kinase above 10X the upper limit of normal. Myopathy sometimes takes the form of
rhabdomyolysis with or without acute renal failure secondary to myoglobinuria, and rare fatalities have occurred. The
risk of myopathy/rhabdomyolysis is dose-related.
Amerge® (naratriptan), tablet,
GSK, 10/03
Both peripheral vascular ischemia and colonic ischemia with abdominal pain and bloody diarrhea have been reported
with naratriptan.
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AndroGel® (testosterone), topical
gel, Solvay, 9/03
Gels are flammable. Avoid fire, flame or smoking during use.
Avelox® (moxifloxacin), tablet or
injection, Bayer, 10/03
Moxifloxacin should be used with caution in patients with ongoing proarrhythmic conditions, such as clinically significant
bradycardia or acute myocardial ischemia. The magnitude of QT prolongation may increase with increasing concentrations of the drug or increasing rates of infusion of the intravenous formulation. QT prolongation may lead to an increased
risk for ventricular arrhythmias including torsade de pointes.
Cuprimine® (penicillamine), capsule, Merck, 11/03
Because of the potential for serious hematological and renal adverse reactions to occur at any time, routine urinalysis, white
and differential blood cell count, hemoglobin determination and direct platelet count must be done twice weekly, together
with monitoring of patient’s skin, lymph nodes and body temperature, during the first month of therapy, every two weeks for
the next five months and monthly thereafter. In Wilson’s disease, liver function tests are recommended every three months,
at least during the first year of treatment. If penicillamine is administered during pregnancy to patients with Wilson’s disease,
it is recommended that the daily dosage be limited to 750 mg. If cesarean section is planned the daily dose should be reduced
to 250 mg, but no lower, for the last six weeks of pregnancy and postoperatively until wound healing is complete.
DDAVP® (desmopressin), injection,
nasal spray, tablet, Aventis, 11/03
When desmopressin is administered to patients who do not have need of antidiuretic hormone for its antidiuretic effect, in
particular in pediatric and geriatric patients, fluid intake should be adjusted downward to decrease the potential occurrence
of water intoxication and hyponatremia with accompanying signs and symptoms.
DepoCyt® (cytarabine liposome
injection), Enzon, 10/03
Following intrathecal administration of DepoCyt, central nervous system toxicity, hemiplegia, visual disturbances, deafness
and cranial nerve palsies have been reported. Symptoms and signs of peripheral neuropathy have also been observed. In the
controlled lymphoma study, the patient incidence of seizures was higher in the DepoCyt group than in the cytarabine group.
Enbrel® (etanercept), injection,
Amgen, 10/03
In clinical trials of all the TNF-blocking agents, more cases of lymphoma have been observed among patients receiving
the TNF blocker compared to control patients.
Genotropin® (somatropin, r-DNA),
injection, Pharmacia, 10/03
Growth hormone is contraindicated in patients with Prader-Willi syndrome who are severely obese or have severe respiratory impairment.
Herceptin® (trastuzumab), injection, Genentech, 10/03
In clinical trials, the per-patient incidences of moderate to severe neutropenia and of febrile neutropenia were higher in
patients receiving Herceptin in combination with myelosuppressive chemotherapy as compared with those who received
chemotherapy alone.
Micardis® (telmisartan), tablet, BI,
10/03
Fetal/neonatal morbidity and mortality warning
Orap® (pimozide), tablet, Teva, 10/03
The use of sertraline with Orap is contraindicated.
®
Peganone (ethotoin), tablet,
Ovation, 9/03
Maternal use of antiepileptic drugs, particularly barbiturates, may be associated with a neonatal coagulation defect that
may cause bleeding during the early neonatal period.
Permax® (pergolide), tablet, Lilly,
10/03
Falling asleep during activities of daily living; serous inflammation and fibrosis; and cardiac valvulopathy
Rapamune® (sirolimus) oral solution
or tablet, Wyeth, 10/03
Hypersensitivity reactions, including anaphylactic/anaphylactoid reactions, have been associated with sirolimus.
Rebetron® (ribavirin + interferon
alpha-2B), Peg-Intron® (pegylated
interferon alpha-2B), Schering,
10/03
Significant adverse events including severe depression and suicidal ideation, hemolytic anemia, suppression of bone
marrow function, autoimmune and infectious disorders, pulmonary dysfunction, pancreatitis and diabetes. Suicidal
ideation or attempts occurred more frequently among pediatric patients, primarily adolescents, compared with adult
patients during treatment and off-therapy follow-up.
Risperdal® (risperidone), tablet and
oral solution, J&J, 11/03
Hyperglycemia, in some cases extreme and associated with ketoacidosis or hyperosmolar coma or death, has been
reported in patients treated with atypical antipsychotics, including Risperdal.
Risperdal® (risperidone), tablet and
oral solution, J&J, 9/03
Cerebrovascular adverse events, including fatalities, were reported in patients (mean age 85 years) in trials of risperidone in elderly patients with dementia-related psychosis. Risperdal is not approved for the treatment of patients with
dementia-related psychosis.
Sporanox® (itraconazole), oral
solution, J&J, 9/03
If a patient with cystic fibrosis does not respond to Sporanox oral solution, consideration should be given to switching to
alternative therapy.
Symmetrel® (amantadine), syrup,
tablet, Endo, 11/03
Deaths have been reported from overdose with Symmetrel. The lowest reported acute lethal dose was 1 gram.
Tenormin,® Tenoretic® (atenolol +
chlorthalidone), tablet, AZN, 10/03
Neonates born to mothers who are receiving atenolol/atenolol plus chlorthalidone at parturition or breast-feeding may
be at risk for hypoglycemia.
Thalomid® (thalidomide), capsule,
Celgene, 10/03
The risk to the fetus from the semen of male patients taking thalidomide is unknown. Thrombotic events have been
reported in patients treated with thalidomide.
Topamax® (topiramate), tablet and
capsule, J&J, 12/30/03
Revised labeling includes a warning that topiramate causes hyperchloremic, non-anion gap metabolic acidosis.
Measurement of baseline and periodic serum bicarbonate during topiramate treatment is recommended.
Zocor® (simvastatin), tablet,
Merck, 9/03
The dose of simvastatin should not exceed 10 mg daily in patients receiving concomitant medication with gemfibrozil or
cyclosporin.
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PACIFICARE HEALTH PLANS CARDIOVASCULAR HEALTH PRACTICE GUIDELINE
MEDICATIONS
RECOMMENDATIONS
CATEGORY
Beta-Blockers
Indicated in post-MI, unstable angina and non-ST segment MI. Prescribe to all patients without a contraindication to beta-blocker
therapy, except low-risk patients (e.g., those without previous infarction, anterior infarction, advanced age or complex ventricular
ectopy). Treatment should begin within a few days of the event and continue indefinitely.
Contraindications:
■ Cardiogenic shock
■ Sick sinus syndrome
■ History of asthma/severe COPD
■ Hypersensitivity to beta-blockers
■ HR <50 bpm
■ P-R interval >.24 seconds
■ Second or third degree AV block
Precautions and Close Monitoring:
■ Diabetes mellitus
■ Severe LV dysfunction with CHF
■ SBP <100 mmHg
■ HR <60 bpm
■ Peripheral vascular disease
■ Peripheral hypoperfusion
Patients receiving beta-blockers should be advised of the following:
■ Side effects may occur during initiation of therapy but do not prevent long-term use.
■ Use is intended as long-term therapy.
■ Abrupt discontinuation should be avoided.
■ Self-monitor for evidence of hypotension and bradycardia.
Nitrates
Indicated in treatment and prophylaxis of angina. Patients should be given oral, sublingual or spray NTG and instructed in its use.
Contraindications: Concomitant phosphodiesterase type 5 inhibitors such as Viagra®
Calcium Channel
Blockers
For ischemic symptoms when beta-blockers are not successful or contraindicated. Short-acting dihydropyridine antagonists
(e.g., nifedipine) should be avoided.
Antiplatelet Drugs
Aspirin
Indicated in post-MI, unstable angina, non-ST segment MI. Prescribe 75 to 325 mg/d in the absence of contraindications.
Relative Contraindications:
Blood dyscrasias
Severe hepatic disease
Active GI bleeding
Absolute Contraindications:
Hypersensitivity to salicylates
Antiplatelet Drugs:
Prescribe clopidogrel 75 mg daily when aspirin is not tolerated due to hypersensitivity or gastrointestinal intolerance. The combination of aspirin and clopidogrel for 9 months after unstable angina/NSTEMI.
Anticoagulation
Therapy
Consider long-term anticoagulation post-MI for the following patients:
■ Post-MI patients who are unable to take aspirin daily* or other antiplatelet agents
■ Post-MI patients with persistent atrial fibrillation
■ Post-MI patients with left ventricular thrombus
*If patient is receiving antiplatelet therapy, specific formulas contain antithrombin properties that may preclude further anticoagulation requirements.
Digoxin
Indicated in patients with heart failure due to left ventricular systolic dysfunction (EF <35-40%) who are not adequately responsive
to ACE inhibitors and diuretics and in patients with atrial fibrillation or who require additional rate control.
Precautions and Close Monitoring:
■ Elderly patients
■ Patients with impaired renal function
ACE Inhibitors
Indicated in post-MI stable high-risk patients (elderly, anterior infarction, previous infarction), CHF, LV dysfunction (EF ≤40%),
hypertension or diabetes unless contraindicated.** Continue indefinitely for all patients with left ventricular systolic dysfunction
(EF ≤40%) or symptoms of heart failure. Use as needed to manage blood pressure or symptoms in all other patients.
Contraindications:
■ History of intolerance or adverse reaction to ACE inhibitors
■ Elevated levels of serum potassium (K+ >5.5 mEq/L)
■ Renal artery stenosis
■ Symptomatic hypotension
■ Shock
■ Pregnancy
Precautions and Close Monitoring:
■ SBP <90 mmHg
■ Elevated levels of serum creatinine (Scr >3) or
creatinine clearance <30 ml/min
Consider angiotensin receptor blockers (ARBs) in patients with intolerance to ACE inhibitor therapy.
**Refer to PHP Diabetes Clinical Practice Guideline.
Cholesterol-Lowering
Agents
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Advise all patients with CAD to follow the AHA Step II diet. Patients with LDL levels >125 mg/dL despite the AHA Step II diet should
be placed on drug therapy with the goal of reducing LDL to <100 mg/dL. Patients with normal plasma cholesterol levels who have a
HDL cholesterol level of <35 mg/dL should receive therapy designed to elevate the HDL level, such as increased physical activity.
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OUTPATIENT MANAGEMENT OF CORONARY ARTERY DISEASE 2003
TESTS
CATEGORY
RECOMMENDATIONS
Ventricular Function
Assess LVEF in acute coronary syndrome and coronary disease patients during hospital or outpatient evaluation, if appropriate.
Stress Test With or
Without Imaging
Perform a stress test with or without imaging in appropriate patients (e.g., adult patients with an intermediate pretest probability of
CAD based on gender, age and symptoms; undergoing initial evaluation with known CAD; before discharge for prognostic assessment,
activity prescription or evaluation of medical therapy; before and after revascularization), timing to be determined by practitioner.
Lipid Profile
Perform cholesterol profile at 4 to 6 weeks following AMI and repeat 3 months following initiation of therapeutic lifestyle changes
(TLC) and/or drug management to determine adherence and response to therapy.
Target Values:
■ Cholesterol <200 mg/dL
■ Triglycerides <150 mg/dL
■ LDL <100 mg/dL
■ HDL >40 mg/dL
Test in fasting state and include:
■ Total Cholesterol
■ Triglycerides
■ LDL
■ HDL
Category of CAD risk based on lipoprotein levels in adults:
LDL
HDL
Risk
High
>130 mg/dL
<40 mg/dL
Borderline
100-129 mg/dL
40-59 mg/dL
Low
<100 mg/dL
>60 mg/dL
Triglycerides
≥200 mg/dL
150-199 mg/dL
<150 mg/dL
Once cholesterol goal has been achieved, measure lipid profile at least every 4 to 6 months to monitor response and adherence to
drug therapy for one year. Long-term monitoring entails annual lipoprotein analyses. Consider more aggressive targets for HDL
cholesterol and triglycerides in women.
PSYCHOLOGY ASSESSMENT
Depression Screen
Routine screening for adults.**
** Refer to PHP Preventive Health Recommendations.
EDUCATION AND COUNSELING
Smoking Cessation
Assessment of smoking status at each visit. All smokers should be counseled on tobacco cessation at each visit. Refer to stop
smoking program and if necessary, recommend smoking cessation aids. Follow up on progress at each visit.
Education and SelfManagement Principles
This includes: Nutrition
Counseling, Weight
Management, Exercise/
Physical Activity
Advise all patients with CAD about symptoms of AMI and instruct how to seek help if symptoms occur. Advise patient and family on lower
sodium, lower fat, lower cholesterol and higher fiber diet. Recommend AHA Step II diet, which is low in saturated fat and cholesterol
(<7% of total calories as saturated fat and <200 mg/d cholesterol). Advise patient to achieve or maintain healthy weight (BMI of 25.0-30.0
is considered overweight, BMI >30.0 is considered obese). Advise patients on the appropriate type, level of intensity and frequency of a
regular exercise/physical activity program (e.g., walking, housework, climbing stairs). For certain patients a referral to a monitored
exercise program may be appropriate. Advise patient when to return to previous levels of activity, sexual activity, driving and employment.
Blood Pressure Control
Monitor BP every office visit.
Target adults: goal is <140/90 mmHg.
Preferred goal is ≤130/85 mmHg.
Glycemic Control
For patients who are diabetics, quarterly testing is recommended if diabetes is poorly controlled or if therapy has changed.**
Target HbA1c <7.0%.
**Refer to PHP Diabetes Clinical Practice Guideline.
Cardiac Rehabilitation
Consider cardiac rehabilitation** or a monitored exercise program for those patients who may be at higher risk for infarction or
sudden death.
**Refer to Medical Management Guideline: Cardiac Rehabilitation – Commercial or Secure Horizons®
As a guideline, this document is intended to provide information to aid health care providers and is not a substitute for clinical judgment in treating individual patients. It is subject to updates pending the release
and review of additional data, based upon changes in scientific knowledge and technology. Adopted by the Medical Management Guideline Committee, December 2003.
References:
American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee
on Management of Acute Myocardial Infarction), “ACC/AHA Guidelines for the Management of Patients
with Acute Myocardial Infarction,” Journal of the American College of Cardiology 1999; 34(3):890-911.
American College or Cardiology/American Heart Association Task Force on Practice Guidelines
(Committee on Exercise Testing),”ACC/AHA 2002 Guideline Update for Exercise Testing.” Circulation
2002; 106:1833-1982.
American College of Cardiology/American Heart Association Task Force on Practice Guidelines
(Committee on the Management of Patients With Unstable Angina),”ACC/AHA 2002 Guideline Update
for the Management of Patients With Unstable Angina and Non-ST-Segment Elevation Myocardial
Infarction.” Available at: www.acc.org/clinical/guidelines/unstable/unstable.pdf.
Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP), “Expert
Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment
Panel III),” Journal of the American Medical Association 2001; 19:2486-2497.
Direct Line Issue 2, 2004 CO
Rockville (MD): US Department of Health and Human Services, Public Health Services, AHRQ, Cardiac
Rehabilitation 1995 (Reviewed 2000) October 202p. (Clinical practice guideline: [334 reference])
Musselman, D.L., Evans, D.L., Nemeroll, C.B. (1998). The relationship of depression to cardiovascular
disease. Archives of General Psychiatry, 55, 580-592.
American Diabetes Association: Clinical Practice Recommendations. Diabetes Care 23:S1-S116
Supplement 1, 2000.
United States Preventive Services Task Force (USPSTF). May 2002.
Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure,
“The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure (JNC VII).” JAMA 2003; 289(19) 2560-2571.
American Heart Association/American College of Cardiology Scientific Statement: Consensus Panel
Statement, “Guide to Preventive Cardiology for Women.” Circulation 1999; 99:2480-2484.
7
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May 31-June 4.
W W W. PA C I F I C A R E . C O M
The Top Issues Facing Health Care
oday’s health care system
faces a number of challenges. This is the first in a
two-part series discussing the top
10 issues facing health plans,
providers and consumers, and the
ways PacifiCare® is responding.
T
1. CHALLENGE: THE
UNINSURED
With average costs of $600
per month for family coverage,
according to the PacifiCare
actuarial department, health
care coverage is unaffordable
for many individuals, especially
the self-employed and small
business employees. As a result,
according to Health Affairs and
other journals, approximately
44 million Americans have no
health insurance.
When uninsured people
delay or don’t seek care, their
health is obviously affected.
And when they finally get treatment, it is often much more
expensive than preventive or
more timely acute care would
have been, increasing health
care costs at large.
ACTION: LOWER-COST
PRODUCTS
PacifiCare has expanded its portfolio of products to offer more
affordable choices for individuals
and small businesses. Some
PacifiCare self directed health
plans (SDHPs), for example,
have individual premiums of less
than $110 per month.
Direct Line is published by PacifiCare®
Health Systems as a service to its contracted
physicians. Services and medical technologies described herein may not be covered by
all PacifiCare Health Plans or may be subject
to preauthorization. PacifiCare is a federally
registered trademark of PacifiCare Life and
Health Insurance Company.
Printed on Recycled Paper
511M-B CO
3. CHALLENGE: NEW
TECHNOLOGY
While new advances in medicine can greatly help patients,
they can also cause major
spikes in health care costs. New
diagnostic tools, disease treatments and other procedures
can cost tens of thousands of
dollars per round of treatment.
2. CHALLENGE: RISING COSTS
According to PacifiCare data,
hospital costs for commercial
health insurers have risen
12 percent to 15 percent annually for the last several years,
and pharmacy costs have risen
16 percent to 18 percent.
Overall, reports Health Affairs,
health care costs as a percentage
of gross domestic product have
risen substantially from
13.3 percent to nearly 15 percent
since 2000, and are projected
to reach 17.7 percent by 2012.
ACTION: MANAGING COSTS
DirectLine
ventable utilization and offer
members higher-quality, lowercost care.
PacifiCare uses strategies to
reduce both the cost of services
and the frequency with which
services are used. We’ve designed
new benefit plans that employ
variable copayments, preventive
medicine, patient education,
disease management and quality
profiling to identify the lowestcost, highest-quality providers,
in order for us to reduce pre-
ACTION: PRACTICING
EVIDENCE-BASED MEDICINE
PacifiCare is working to find a
fair balance between embracing
new technologies and ensuring
they provide good value. We
conduct rigorous assessments of
new technologies, both to validate new treatment guidelines
and ensure that technologies
offering real benefits are covered.
4. CHALLENGE: CHRONIC
DISEASES
Americans today are living
longer than ever before. As
people grow older, they are
more likely to suffer from
chronic diseases that require
more frequent and more costly
medical intervention.
ACTION: DISEASE
MANAGEMENT
PacifiCare continues to expand
our Disease Management programs to help patients with dia-
betes, cancer and other diseases.
Our congestive heart failure
program has increased participants’ appropriate medication
usage by 26 percent and
reduced their hospitalization
rate by more than 50 percent.
PacifiCare data shows that
these steps have given patients a
higher quality of life, while saving $69 million over the last
four years.
5. CHALLENGE: HOSPITAL
CONSOLIDATION
The number of hospital systems
has shrunk over the past several
years as many facilities have
consolidated. With less capacity
and less competition, prices for
individuals and health plans
have risen in many markets.
ACTION: INCREASING
TRANSPARENCY
PacifiCare is working to give
members and employer groups
a clearer sense of what they’re
paying for, and how those
prices compare with other
providers. Our award-winning
QUALITY INDEX® profiles*
provide hospital ratings for
both quality and cost. We also
use this information to create
benefit plans that favor higherquality, lower-cost hospitals.
Through these efforts, we can
help ensure consistent quality
while keeping costs down. ■
*May not be available in all markets.