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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 2 CO www.pacificare.com 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 W 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. 3 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. 4 CO www.pacificare.com 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. Direct Line Issue 2, 2004 CO 5 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 6 CO 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. www.pacificare.com 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 PRSRT STD U.S. Postage PAID PacifiCare P.O. Box 6006 5995 Plaza Drive Cypress, CA 90630 Postmaster: Please deliver within 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.