Help Us Stop Lawsuits Before They Start - Pacificare Health Systems

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Help Us Stop Lawsuits Before They Start - Pacificare Health Systems Powered By Docstoc
					                                                      Issue 2, 2004

     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     tentious public issue over the        detailed explanation. We ask

                          R        claims affect everyone,
                                   especially physicians.
                          Although physicians usually pre-
                                                                 past decade and a major contrib-
                                                                 utor to malpractice claims. We’ve
                                                                 taken deliberate steps to reduce
                                                                                                       that you take the time to dis-
                                                                                                       cuss any denials with your
                                                                                                       patients to ensure they fully
                          vail in malpractice suits, the aver-   the number of procedures that         understand the decision. For
                          age cost for defendants is more        require prior-authorization in        example, a patient denied cov-
                          than $77,000, according to the         the hopes of eliminating as           erage for a new diagnostic test
                          Physician Insurers Association of      many of these conflicts as possi-     may be understandably upset.
New QUALITY               America. The U.S. Department           ble. In the past two years alone,     But the patient may not realize
                          of Health and Human Services           we’ve reduced the number
INDEX® Physician          estimates that medical liability       of procedures requiring
Profiles                  adds $60 billion to U.S. health        prior-authorization by 80
page 3                                                                                                              Sam Ho, M.D.
                          care costs each year.                  percent. Today, the only                           senior vice president
                             PacifiCare® is working on sev-      services requiring authori-                        and chief medical
                          eral fronts to minimize malprac-       zation are those that                              officer, PacifiCare
                                                                 reflect the widest variation                       Health Systems
                          tice claims. But there are also
Important FDA Drug        steps you can take to help us          among providers.
                          reduce the likelihood of lawsuits.        For those cases in
Warnings                                                         which coverage is denied, we          that the test hasn’t been scientif-
page 4
                          CLEAR EVIDENCE/CERTIF-                 try to handle appeals as quickly      ically validated or hasn’t proven
                          ICATE OF COVERAGE                      as possible and resolve issues        to be more effective than a less
                          One of the best ways to avoid          before they escalate into heated      costly alternative. Patients may
Help Your Patients        potential lawsuits is to remove        conflicts. We process more than       still be disappointed by a denial,
Take Charge of Their      any ambiguity regarding which          95 percent of appeals faster          but by taking the time to
Health                    services are covered and which         than regulatory standards             explain the decision, you can
page 7                    are not. We continually track          require. You can help by expe-        help them understand the con-
                          emerging health care trends and        diting any requests for clinical      text and defuse a more emo-
                          new procedures to determine            information during an appeal.         tional response.
                          where they fit within benefit                                                   Disagreements are inevitable
Top Issues Facing         plans. We also constantly reeval-      BETTER COMMUNICATION                  in health care. But disagree-
                          uate and refine evidence of            Despite our best efforts, conflicts   ments that result in lawsuits
Health Care               coverage and/or certificate of         about denials of coverage and         ultimately raise costs for physi-
back page
                          coverage documentation to ad-          other issues are bound to occur.      cians, health plans and health
                          dress any new issues that arise.       But conflicts don’t have to           care consumers at large. By
                                                                 become full-blown lawsuits. Clear     working together to remove as
                          STREAMLINED PRE-CERTIF-                communication can go a long           much friction as possible from
                          ICATIONS AND APPEALS                   way toward defusing many issues.      health care decisions, we can
                          Procedures that require health           When a patient is denied            help control costs and promote
                          plan approval have been a con-         coverage, we try to provide a         patient satisfaction. ■
     PacifiCare Dental & Vision Update

    Is Oral Health Linked to Heart Disease?
                                       INFLAMMATION FROM                  two forms of periodontal disease     some form of periodontal dis-
                                       INFECTION?                         — periodontitis and its precur-      ease. If your patients report any
                                       There’s been much interest in      sor, gingivitis — do not raise the   of the following periodontal
                                       whether oral infections might      risk for heart events in people      symptoms, suggest that they see
                                       spark biochemical and biologi-     with existing heart disease.3        their dental provider:
                                       cal reactions that lead to            More studies are being con-       ■ Red, swollen gums that
                                       inflammation in the arteries       ducted to fully understand the       bleed easily
                                       and atherosclerosis.               relationship between periodon-       ■ Bad breath
                                          There is some evidence to       tal disease, dental infections       ■ Loose or sensitive teeth
                                       support this idea. For example,    and heart disease.                   ■ Pain during chewing
                                       researchers have found some of                                            Patients with these advanced
                                       the gram-negative bacteria that    DON’T NEGLECT PATIENTS’              symptoms may require treat-
                                       cause periodontal disease lurk-    TOTAL HEALTH                         ment, such as deep cleaning by a
                                       ing inside atherosclerotic         While research on the link           dentist, medications or surgery.
            ccording to some popu-     plaques.1 In addition, several     between oral and heart health          If your patients have more

    A       lar medical literature,
            chronic infectious dis-
    eases can increase the risk for
                                       reports have found that patients
                                       with CHD often have poorer
                                       oral health than patients with-
                                                                          continues, it’s important to
                                                                          remind patients of the role that
                                                                          oral hygiene plays in their total
                                                                                                               questions about oral health, direct
                                                                                                               them to the American Dental
                                                                                                               Association at* ■
    coronary heart disease (CHD).      out CHD.2                          health care. Encourage them to
    For this reason, researchers are      On the other hand, some         brush their teeth twice a day,       *PacifiCare® is not affiliated with this Web site.
    now trying to determine if         observational trials have not      floss once a day and see their       1. Pussinen, P.J., et al. Arterioscler Thromb
    periodontitis, untreated inflam-   found a causal relationship        dental provider regularly.           Vasc Bio 2003; 23(7): 1250-1254.
    mation and infection in the        between periodontal disease and       Also, current estimates sug-      2. Meurman, J.H., et al. Oral Surg Oral Med
                                                                                                               Oral Pathol 2003; 96(6): 695-700.
    gums, can trigger the develop-     CHD. For example, one long-        gest that four out of five           3. Hujoel, P.P., et al. J Dent Res 2002; 81(3):
    ment of CHD.                       term study concluded that the      American adults already have         186-191.

    Utilization Management                                                    Notice of Affirmative
    Criteria Available                                                        Statement Regarding
    All utilization decisions must be made in a fair, impar-
    tial and consistent manner guided by objective written
                                                                              PacifiCare® works to facilitate the delivery of appropri-
    criteria. Sources of national criteria include InterQual,
                                                                              ate care and monitors the impact of its Utilization
    Milliman Care Guidelines, American Academy of Pediat-                     Management program to detect and correct potential
    rics, U.S. Preventive Health Task Force and Medicare                      under- and over-utilization of services. PacifiCare
    Guidelines. Additionally, informational sources such as                   encourages appropriate decisions on the coverage of
    internally developed Medical Management guidelines,                       care and service, and does not employ incentives to
    Hayes Directory and published scientific evidence may                     encourage barriers to care and service.
    be used to assist in decision-making.                                     ■ UM decision-making is based only on appropriate-
       PacifiCare® has mechanisms in place for making                         ness of care and service and existence of coverage.
    Utilization Management (UM) procedures and process-                       ■ PacifiCare does not specifically reward practitioners
    es available to practitioners, providers, members and                     or other individuals for issuing denials of coverage or
    the public, upon request. This includes the criteria and                  service.
    guidelines utilized to authorize, modify, delay or deny                   ■ Financial incentives for UM decision-makers do not
    specific procedures or conditions requested.                              encourage decisions that result in under-utilization.

2    OR                                                                                                                      
   HealthCredits-Plus Gives Members
   New Reasons to Stay Healthy
           he feedback we receive      They also receive credits for mak-     HealthCredits program and                    ■ provide credits for enrolling

   T       from our contracting
           physicians tells us that
   you strongly support programs
                                       ing better diet, exercise, lifestyle
                                       and health care choices. These
                                       credits may then be redeemed for
                                                                              offer additional features and
                                                                              rewards. For example, an
                                                                              employer might choose to:
                                                                                                                           in a weight-loss program that is
                                                                                                                           popular with their employees,
                                                                                                                           instead of using PacifiCare
   that motivate our members to        discounts on health-related mer-       ■ reward members with an                     Weight & Fitness
   take charge of their health and     chandise and qualify them for          extra vacation day or personal                  “HealthCredits boosts morale
   well-being. That’s one reason       drawings to win prizes, such as        time off                                     and helps keep health care costs
   the PacifiCare® HealthCreditsSM     exercise equipment and instruc-        ■ give discounts on insurance                down by giving tangible
   program — which rewards             tional exercise videos.                premiums, which reduce                       rewards to members who prac-
   healthy behavior — has been            HealthCredits-Plus allows           members’ out-of-pocket health                tice healthy habits,” says Sam
   such a success.                     employers to customize our             expenses                                     Ho, M.D., senior vice presi-
      Now, PacifiCare is launching                                                                                         dent and chief medical officer,
   HealthCredits-Plus, a program                                                                                           PacifiCare Health Systems.
   that provides our members with                                                                                             “But it also helps us reach
   even more personal incentives                                                                                           members who normally might
   for improving their health. With                                                                                        be missed,” Dr. Ho says. “Our
   HealthCredits-Plus, members                                                                                             studies show that within our
   can redeem healthy living cred-                                                                                         commercial membership in a
   its for both PacifiCare rewards,                                                                                        given year, nearly half of our
   as well as rewards that come                                                                                            members and their dependents
   directly from their employer.                                                                                           don’t use health services. This is
      Under PacifiCare’s traditional                                                                                       one way to reach them, encour-
   HealthCredits program, members                                                                                          age their healthy practices and
   can earn credits by participating                                                                                       help physicians by involving pa-
   in our Health Management and                                                                                            tients more actively in their own
   Disease Management programs.                                                                                            health care management.” ■

   Coming Soon: New QUALITY INDEX® Physician Profiles
   Our QUALITY INDEX® profiles* for physician organizations                   ■ follows established guidelines for treating specific
   and hospitals have been praised in the health care industry                diseases
   for good reason: These report cards empower members’                       ■ appropriately prescribes medications
   health care decision-making while raising the level of per-                ■ efficiently uses health care resources
   formance among our contracted providers and hospitals.                        “Not only will our new QUALITY INDEX profiles of indi-
      And because we at PacifiCare® believe you should never                  vidual physicians help improve the care our contracting
   stop striving for excellence, we are pleased to announce that              physicians provide, they also have the potential to sig-
   we are expanding the scope of our QUALITY INDEX profiles.                  nificantly reward high-scoring physicians with more new
   Beginning in 2004, we are planning to offer QUALITY INDEX                  patients,” says Sam Ho, M.D., senior vice president and
   profiles for individual physicians in all eight of our service             chief medical officer, PacifiCare Health Systems. “Word-
   states.* This will enable our members to further refine their              of-mouth is a powerful marketing tool for good doctors,
   search for high-caliber, affordable health care providers and              but the system we’re offering gives members tangible
   help us reward those contracting physicians who reflect bet-               proof of a physician’s performance.”
   ter performance in clinical quality and efficiency.                           Members and contracting physicians will be able to
      The new QUALITY INDEX profiles for individual physi-                    access the QUALITY INDEX profile of individual physicians
   cians will give our members a wealth of relevant informa-                  this summer by logging on to
   tion, including how well a contracting physician:
   ■ scores on providing preventive health services                           *QUALITY INDEX® not currently available in all markets.

Direct Line Issue 2, 2004 OR                                                                                                                                    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*
  For the most updated information, please visit the Healthcare Professionals section of and access the Drug Bulletin
Board. You may also visit for an up-to-date list of drug products.
*PacifiCare® is not affiliated with this Web site.

Product                                              Warning

Duragesic® 75 mcg/h (fentanyl),                      Health care professionals were notified of a Class I recall of Duragesic 75 mcg/h (Control Number 0327192, expiration
Janssen, 2/20/04                                     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,                       A warning to the public was issued about an overseas Internet site selling counterfeit contraceptive patches that contain
2/10/04                                              no active ingredients.

Permax® (pergolide), Lilly,                          Health care professionals were informed of the possibility of patients falling asleep while performing daily activities,
12/22/03                                             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                  New preclinical safety data suggest that Tamiflu is not indicated for either treatment or prophylaxis of influenza in
oral suspension, Roche, 1/2/04                       infants less than 1 year of age.

Viramune® (nevirapine), tablet and                   Severe, life-threatening and in some cases fatal hepatotoxicity, including fulminant and cholestatic hepatitis, hepatic
oral suspension, Boehringer                          necrosis and hepatic failure, has been reported. These events are often associated with rash. Women and patients with
Ingelheim, 2/2/04                                    higher CD4 counts are at increased risk of these hepatic events. Women with CD4 counts >250 cells/mm3 are at consid-
                                                     erably higher risk of these events.

Zyprexa® (olanzopine), tablet,                       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
Lilly, 2/20/04                                       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,                          Intestinal angioedema has been reported in patients treated with ACE inhibitors. These patients presented with abdomi-
         ®             ®
Lotensin, Lotensin HCT,                              nal pain; in some cases there was no prior history of facial angioedema and C-1 esterase levels were normal.
          ®             ®      ®
Monopril, Monopril HCT, Univasc,
Uniretic, 10/03

Actos® (pioglitazone), tablet,                       In a clinical study, Actos coadministered with insulin, CHF was reported in 0.3% of patients on 30 mg and 0.9% of
Takeda, 11/03                                        patients on 45 mg dose as an adverse event.

Advair® Diskus (fluticasone +                        Advair is contraindicated in the primary treatment of status asthmaticus or other acute episodes of asthma or COPD. A
salmeterol), GSK, 11/03                              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                     Taking more than recommended may cause stomach bleeding.
and pseudoephedrine), Wyeth,

Alora® (estradiol), transdermal                      Estrogens increase the risk for endometrial cancer. Estrogens with and without progestins should not be used for the
system, Watson, 11/03                                prevention of cardiovascular disease. Women’s Health Initiative (WHI) data were added.

Altocor® (lovastatin) extended-                      Lovastatin, like other inhibitors of HMG-CoA reductase, occasionally causes myopathy manifested as muscle pain, ten-
release tablet, IVAX, 9/03                           derness 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,                       Both peripheral vascular ischemia and colonic ischemia with abdominal pain and bloody diarrhea have been reported
GSK, 10/03                                           with naratriptan.

4      OR                                                                                                                                            
AndroGel® (testosterone), topical       Gels are flammable. Avoid fire, flame or smoking during use.
gel, Solvay, 9/03

Avelox® (moxifloxacin), tablet or       Moxifloxacin should be used with caution in patients with ongoing proarrhythmic conditions, such as clinically significant
injection, Bayer, 10/03                 bradycardia or acute myocardial ischemia. The magnitude of QT prolongation may increase with increasing concentra-
                                        tions 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), cap-        Because of the potential for serious hematological and renal adverse reactions to occur at any time, routine urinalysis, white
sule, Merck, 11/03                      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,       When desmopressin is administered to patients who do not have need of antidiuretic hormone for its antidiuretic effect, in
nasal spray, tablet, Aventis, 11/03     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           Following intrathecal administration of DepoCyt, central nervous system toxicity, hemiplegia, visual disturbances, deafness
injection), Enzon, 10/03                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,        In clinical trials of all the TNF-blocking agents, more cases of lymphoma have been observed among patients receiving
Amgen, 10/03                            the TNF blocker compared to control patients.

Genotropin® (somatropin, r-DNA),        Growth hormone is contraindicated in patients with Prader-Willi syndrome who are severely obese or have severe respi-
injection, Pharmacia, 10/03             ratory impairment.

Herceptin® (trastuzumab), injec-        In clinical trials, the per-patient incidences of moderate to severe neutropenia and of febrile neutropenia were higher in
tion, Genentech, 10/03                  patients receiving Herceptin in combination with myelosuppressive chemotherapy as compared with those who received
                                        chemotherapy alone.

Micardis® (telmisartan), tablet, BI,    Fetal/neonatal morbidity and mortality warning
Orap® (pimozide), tablet, Teva, 10/03   The use of sertraline with Orap is contraindicated.
Peganone (ethotoin), tablet,            Maternal use of antiepileptic drugs, particularly barbiturates, may be associated with a neonatal coagulation defect that
Ovation, 9/03                           may cause bleeding during the early neonatal period.

Permax® (pergolide), tablet, Lilly,     Falling asleep during activities of daily living; serous inflammation and fibrosis; and cardiac valvulopathy
Rapamune® (sirolimus) oral solution     Hypersensitivity reactions, including anaphylactic/anaphylactoid reactions, have been associated with sirolimus.
or tablet, Wyeth, 10/03

Rebetron® (ribavirin + interferon       Significant adverse events including severe depression and suicidal ideation, hemolytic anemia, suppression of bone
alpha-2B), Peg-Intron® (pegylated       marrow function, autoimmune and infectious disorders, pulmonary dysfunction, pancreatitis and diabetes. Suicidal
interferon alpha-2B), Schering,         ideation or attempts occurred more frequently among pediatric patients, primarily adolescents, compared with adult
10/03                                   patients during treatment and off-therapy follow-up.

Risperdal® (risperidone), tablet and    Hyperglycemia, in some cases extreme and associated with ketoacidosis or hyperosmolar coma or death, has been
oral solution, J&J, 11/03               reported in patients treated with atypical antipsychotics, including Risperdal.

Risperdal® (risperidone), tablet and    Cerebrovascular adverse events, including fatalities, were reported in patients (mean age 85 years) in trials of risperi-
oral solution, J&J, 9/03                done in elderly patients with dementia-related psychosis. Risperdal is not approved for the treatment of patients with
                                        dementia-related psychosis.

Sporanox® (itraconazole), oral          If a patient with cystic fibrosis does not respond to Sporanox oral solution, consideration should be given to switching to
solution, J&J, 9/03                     alternative therapy.

Symmetrel® (amantadine), syrup,         Deaths have been reported from overdose with Symmetrel. The lowest reported acute lethal dose was 1 gram.
tablet, Endo, 11/03
Tenormin, Tenoretic® (atenolol +        Neonates born to mothers who are receiving atenolol/atenolol plus chlorthalidone at parturition or breast-feeding may
chlorthalidone), tablet, AZN, 10/03     be at risk for hypoglycemia.

Thalomid® (thalidomide), capsule,       The risk to the fetus from the semen of male patients taking thalidomide is unknown. Thrombotic events have been
Celgene, 10/03                          reported in patients treated with thalidomide.

Topamax® (topiramate), tablet and       Revised labeling includes a warning that topiramate causes hyperchloremic, non-anion gap metabolic acidosis.
capsule, J&J, 12/30/03                  Measurement of baseline and periodic serum bicarbonate during topiramate treatment is recommended.

Zocor® (simvastatin), tablet,           The dose of simvastatin should not exceed 10 mg daily in patients receiving concomitant medication with gemfibrozil or
Merck, 9/03                             cyclosporin.

Direct Line Issue 2, 2004 OR                                                                                                                                           5
                                                               PacifiCare’s Redesigned
                                                               Online Provider Directory
                                                               Makes It Easier for
                                                               Patients to Find You
                                                            online provider              to access the directory: Either              enrollment status, hospital and
                                                            directory to give            click the “Provider” link on the             languages spoken by the
                                                            our members                  home page, or select the                     provider.
                                                            quicker access               Provider tab within the “Start               ■ Members can print a person-
                                                            and more refined             with myPacifiCare” field at the              alized directory of their search
                                                            search capabilities          left of the page. PacifiCare                 results to view at their leisure
                                                            — so they can                providers can log in with their              by clicking on “Print a directory
                                                            find the health              provider ID and password.                    of these providers” or “Click
                                                            care provider that           ■ The online provider directo-               here to print a copy of the
         oes one of your patients           most closely meets their needs.              ry enables members to search                 search results.” This generates

D        need to locate you, a
         specialist or a hospital?
With the online provider direc-
                                            ■ On the PacifiCare home
                                            we’ve added a direct link to our
                                                                                         by name, address or geographic
                                                                                         area, which produces for each
                                                                                         search a maximum of 100
                                                                                                                                      an Adobe Acrobat file (pdf ),
                                                                                                                                      which can be saved to and
                                                                                                                                      printed from any computer.
tory from PacifiCare,® finding              provider directory. Click on the             provider results. From the                   ■ By clicking on the Map
this information is as easy as a            “Doctor Directory” link in the               search results page, members                 icon next to a provider’s name,
few clicks on a computer                    top right hand corner to imme-               can now refine their results by              members can generate a map
mouse.                                      diately begin a search. In addi-             choosing from such menu                      with driving directions to a
  We recently redesigned our                tion, there are two other ways               options as specialty, gender,                specific provider. ■

    Filling Your Patients’ Prescription Medication Needs
    Prescription drug benefits from PacifiCare® can help                                 and overall quality and value.
    your patients obtain the prescription medications they                                  The medications that PacifiCare covers are then
    need — at a more reasonable price. You can help your                                 listed on the formulary, which is distributed to
    patients get the most out of their pre-                                                                providers annually and is also avail-
    scription benefits by understanding                                                                    able on the PacifiCare Web site,
    PacifiCare’s pharmacy procedures.                                                             Formulary
       PacifiCare’s pharmacy and thera-                                                                    updates are published regularly in
    peutics committee — composed of                                                                        Direct Line.
    contracting providers, pharmacists                                                                        If you must prescribe medication that
    and other health care professionals                                                                    is not on the PacifiCare formulary to a
    — regularly reviews new and existing                                                                   member, be sure to send us a prior-
    prescription medications. When                                                                         authorization request form. If you can
    deciding to cover a prescription medi-                                                                 demonstrate that a nonformulary drug
    cine, the committee considers safety,                                                                  is best for your patient’s treatment, we
    effectiveness, dosage, formulation                                                                     will provide coverage for it.

    *Not all PacifiCare members have a PacifiCare prescription drug benefit, and for those that do, not all of them have a managed formulary. Secure Horizons® M+C individ-
    ual members have a prescription drug benefit that is limited to the medications listed on the Secure Horizons Covered Medications List.

6     OR                                                                                                                                    
Help Your Patients                                                                                             Helping
Take Charge of Their Health                                                                                    Patients
          ost likely, you treat     of current self-care behaviors.         The diabetes, heart health and

M         PacifiCare® members
          who can benefit from
one of our Health Management
                                    Interventions are focused on key
                                    topics such as preventive care and
                                    exams or medications. To be
                                                                         asthma programs are opt-out
                                                                         programs. PacifiCare identifies
                                                                         members based on encounter,
                                                                                                               When a patient’s claim
programs. In fact, they may         eligible, patients must be age       claim and/or pharmacy data.           is denied, she may turn
already be enrolled.                18 or older for our diabetes,        Qualified members are automati-       to you for answers. Do
   Here’s a look at our programs:   coronary artery disease, conges-     cally enrolled but have the           you know how to help
■ Taking Charge of Diabetes®        tive heart failure and depression    option to opt out of participating    her navigate the appeals
■ Taking Charge of Your             programs, and between ages 5         in the program. Members can           process?
Heart Health® for Coronary          and 56 for our asthma program.       also self-enroll, and you can refer      Step 1: You or the
Artery Disease                      Our diabetes, coronary artery        your patients into the program.       patient may initiate an
■ Taking Charge of Your             disease and congestive heart fail-      The depression program is an       appeal by calling or writ-
Heart Health for Congestive         ure programs have earned the         opt-in program. Members self-         ing to Customer Service.
Heart Failure                       Quality Profile award from the       enroll, and you can also refer        Most appeals are settled
■ Taking Charge of                  National Committee for Quality       your patients into this program.      at this step, in a timely
Depression®                         Assurance (NCQA).                       PacifiCare does not require        manner and to the
■ Taking Charge of                                                                  physician approval         patient’s satisfaction.
Asthma®                                                                             for enrollment into           Step 2: If PacifiCare®
   Each program pro-                                                                any of the Taking          denies the appeal, the
vides evidence-based                                                                Charge programs.
                                                                                                               patient may then choose
recommendations                                                                     However, eligibility
                                                                                                               to pursue an indepen-
through educational                                                                 criteria by program
                                                                                                               dent external review.
materials, including in-                                                            do apply.
                                                                                                               A state-appointed panel
formation about man-                                                                   To refer a member,
                                                                                                               will make an objective,
aging health conditions,                                                            fax the PacifiCare
addressing lifestyle                                                                Universal Referral         binding decision.
issues, co-morbid con-                                                              Form to us or call            Step 3: If the review-
ditions and assessment                                                              (800) 915-9159. ■          ers uphold the original
                                                                                                               decision, the patient’s
                                                                                                               final course of action is to
                                                                                                               have the case reviewed
   COMMUNICATION SERVICES RELATING TO                                                                          once more through bind-
                                                                                                               ing arbitration.
   UTILIZATION MANAGEMENT                                                                                         Details vary by state.
   PacifiCare® and all medical groups dele-            ■ When initiating or returning calls                    You can find out more by
   gated to make UM decisions must pro-                regarding UM issues, staff identify                     calling Customer Service
   vide the following communication servic-            themselves by name, title and name of                   or by referring to your
   es for practitioners and members:                   organization                                            Provider Policy and Pro-
   ■ Availability of staff at least eight hours        ■ A toll-free number or staff that accept               cedure Manual, Clinical
   a day during normal business hours                  collect calls regarding UM issues                       Management Manual or
   (excludes holidays) for inbound calls               ■ Access to staff for callers with ques-                Physician Orientation
   ■ Ability to receive inbound communica-             tions about the UM process                              Packet. Detailed appeals
   tion — for example, via phone, voice mail,             General inquiries may be referred to                 procedures are outlined
   e-mail or fax — after normal business               customer or member services; however,                   for members in the
   hours                                               inquiries regarding specific UM cases
   ■ Outbound communications regarding                                                                         Health Plan Companion
                                                       will be triaged to and handled by UM
   inquiries about UM during normal busi-                                                                      and in the Evidence/
                                                       staff — for example, inquiries about
   ness hours, unless otherwise agreed                 decisions beyond the confirmation of                    Certificate of Coverage
   upon                                                approval or denial of care.                             booklet.

Direct Line Issue 2, 2004 OR                                                                                                                  7
                                                                                                                                                            PRSRT STD
                                                                                                                                                            U.S. Postage
P.O. Box 6006                                                                                                                                                PacifiCare
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             have been, increasing health         ventable utilization and offer        betes, cancer and other diseases.

     T      faces a number of chal-
            lenges. This is the first in a
     two-part series discussing the top
                                                  care costs at large.

                                                  ACTION: LOWER-COST
                                                                                       members higher-quality, lower-
                                                                                       cost care.
                                                                                                                             Our congestive heart failure
                                                                                                                             program has increased partici-
                                                                                                                             pants’ appropriate medication
     10 issues facing health plans,               PRODUCTS                             3. CHALLENGE: NEW                     usage by 26 percent and
     providers and consumers, and the             PacifiCare has expanded its port-    TECHNOLOGY                            reduced their hospitalization
     ways PacifiCare® is responding.              folio of products to offer more      While new advances in medi-           rate by more than 50 percent.
                                                  affordable choices for individuals   cine can greatly help patients,       PacifiCare data shows that
     1. CHALLENGE: THE                            and small businesses. Some           they can also cause major             these steps have given patients a
     UNINSURED                                    PacifiCare self directed health      spikes in health care costs. New      higher quality of life, while sav-
     With average costs of $600                   plans (SDHPs), for example,          diagnostic tools, disease treat-      ing $69 million over the last
     per month for family coverage,               have individual premiums of less     ments and other procedures            four years.
     according to the PacifiCare                  than $110 per month.                 can cost tens of thousands of
     actuarial department, health                                                      dollars per round of treatment.       5. CHALLENGE: HOSPITAL
     care coverage is unaffordable                2. CHALLENGE: RISING COSTS                                                 CONSOLIDATION
     for many individuals, especially             According to PacifiCare data,        ACTION: PRACTICING                    The number of hospital systems
     the self-employed and small                  hospital costs for commercial        EVIDENCE-BASED MEDICINE               has shrunk over the past several
     business employees. As a result,             health insurers have risen           PacifiCare is working to find a       years as many facilities have
     according to Health Affairs and              12 percent to 15 percent annu-       fair balance between embracing        consolidated. With less capacity
     other journals, approximately                ally for the last several years,     new technologies and ensuring         and less competition, prices for
     44 million Americans have no                 and pharmacy costs have risen        they provide good value. We           individuals and health plans
     health insurance.                            16 percent to 18 percent.            conduct rigorous assessments of       have risen in many markets.
       When uninsured people                      Overall, reports Health Affairs,     new technologies, both to vali-
     delay or don’t seek care, their              health care costs as a percentage    date new treatment guidelines         ACTION: INCREASING
     health is obviously affected.                of gross domestic product have       and ensure that technologies          TRANSPARENCY
     And when they finally get treat-             risen substantially from             offering real benefits are covered.   PacifiCare is working to give
     ment, it is often much more                  13.3 percent to nearly 15 percent                                          members and employer groups
     expensive than preventive or                 since 2000, and are projected        4. CHALLENGE: CHRONIC                 a clearer sense of what they’re
     more timely acute care would                 to reach 17.7 percent by 2012.       DISEASES                              paying for, and how those
                                                                                       Americans today are living            prices compare with other
                                                  ACTION: MANAGING COSTS               longer than ever before. As           providers. Our award-winning
                                                  PacifiCare uses strategies to        people grow older, they are           QUALITY INDEX® profiles*
  DirectLine                                      reduce both the cost of services
                                                  and the frequency with which
                                                                                       more likely to suffer from
                                                                                       chronic diseases that require
                                                                                                                             provide hospital ratings for
                                                                                                                             both quality and cost. We also
 Direct Line is published by PacifiCare®          services are used. We’ve designed    more frequent and more costly         use this information to create
 Health Systems as a service to its contracted    new benefit plans that employ        medical intervention.                 benefit plans that favor higher-
 physicians. Services and medical technolo-
 gies described herein may not be covered by      variable copayments, preventive                                            quality, lower-cost hospitals.
 all PacifiCare Health Plans or may be subject    medicine, patient education,         ACTION: DISEASE                       Through these efforts, we can
 to preauthorization. PacifiCare is a federally
 registered trademark of PacifiCare Life and
                                                  disease management and quality       MANAGEMENT                            help ensure consistent quality
 Health Insurance Company.                        profiling to identify the lowest-    PacifiCare continues to expand        while keeping costs down. ■
                                                  cost, highest-quality providers,     our Disease Management pro-
        Printed on Recycled Paper   511M-C OR     in order for us to reduce pre-       grams to help patients with dia-      *May not be available in all markets.

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