Issue 2, 2004
inside this issue:
Help Us Stop Lawsuits Before
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,
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-
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-
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 www.ada.org.* ■
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 www.pacificare.com
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 www.pacificare.com.
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 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.
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,
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 www.pacificare.com
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
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
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
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. www.pacificare.com. 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 www.pacificare.com
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-
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
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.
members higher-quality, lower-
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.