Small Practice Transition to 'Paperless Practice' Gains NCQA Recognition

The following is presented to highlight medical “best practice” in the CareFirst and CareFirst BlueChoice service areas and to share with medical professionals throughout the region the innovative approaches being adopted in Maryland, Washington, D.C. and Northern Virginia. The “best practice” approach to patient care not only improves the quality of care, it also helps limit rising costs.

The first small primary care physicians’ group in the Baltimore-Washington region to offer advanced and secure Internet access to their patients’ medical records has become a model for the paperless physician’s practice.

MedPeds, a five-physician practice with a nurse practitioner, two nurses and a 16-member support staff, was an early adopter of computer technology. Last October, it received NCQA (National Committee for Quality Assurance) “Physician Practice Connections” recognition for its innovative use of new technology that offers patients superior service and care.

The NCQA’s Physician Practice Connections program is a national initiative to encourage greater use of the Internet, electronic medical records, and other new office technology and procedures to systematically expand and improve communications between primary care physicians and their patients.

MedPeds was the only new physicians group in Maryland last year to receive the NCQA’s Physician Practice Connections seal of approval. And less than 200 primary care physician practices throughout the entire United States have Physician Practice Connections endorsement from the NCQA.

The National Committee for Quality Assurance is a not-for-profit organization dedicated to improving health care quality.

The organization’s seal indicates that the medical services offered by care providers who display it have passed a rigorous and comprehensive review of their care procedures and performance.

Dr. Seth Eaton, M.D., a physician partner at MedPeds who took the lead in expanding the practice’s use of information technology, points out that small and medium sized medical practices deliver 70 percent of the health care provided in the United States. Dr. Eaton acknowledges that our system of health care is starting to make greater use of new technology, but he says the process can be accelerated if more small and mid-size physician groups adopt such innovations as electronic medical records (EMR).

“Many physicians are reluctant to adopt EMR technology if it does not mirror workflow,” Dr. Eaton says. “An intuitive, easy-to-use system is the key to adoption.”

For MedPeds, the path to expanded use of Information Technology (IT) began in 2004 when it made the transition from a practice operating with paperbased charts to one using electronic medical records. MedPeds was encouraged to build out the advantages of EMR the following year through participation in a CareFirst BlueCross BlueShield initiative called Bridges to Excellence, a three year pilot program that offered recognition and financial incentives to primary care physicians who adopt procedures that support optimum care and better outcomes for patients.

At the core of MedPeds’ solution for fully integrating what doctors do to deliver care and what patients need to conveniently access, apply and pay for that care is a computer-based system called eClinicalWorks. The system consists of four related modules that handle the workflow routines in a typical physician practice: appointment scheduling, office management – including electronic medical records, practice management (PM) that tracks the status of claims electronically and a "patient portal" that lets patients and doctors communicate on-line with ease and security.

With the introduction and growing acceptance of electronic medical records and IT applications focused on medical practice management, eClinicalWorks provides of unified end-to-end clinical information systems. The development of such systems is guided by two prime objectives — streamlining the way doctors do business and ensuring that their patients receive superior care.

MedPeds’ suite of offices in Laurel, Md., includes 15 examination rooms, each equipped with a computer terminal. A doctor treating a patient in one of the examination rooms uses a portable laptop computer to access patients’ EMR anywhere in the office and can review past treatment, medical results, referrals to specialists as well as their medical findings, medications, lab tests and other useful information.

Prescriptions can be written and forwarded via the Internet directly from the examination room to the patient’s pharmacist. Follow up appointments as well as referrals to medical specialists can be evaluated and determined “on the spot,” and appointments made and confirmed.

Chart tacks have been eliminated at MedPeds, and as a result the staff no longer searches throughout the office for patient information. Instead, those staff members who need access to records have it under a set of procedures that protects the confidentiality of personal information. The system results in patient charts that are more accurate, more complete and provide greater depth and history.

One of the biggest advantages is that the system allows the physician members to work together in ways that were not possible before. For example, a doctor “on call” when the office is closed can view from home the complete medical history of a patient who calls. The doctor can review the patient’s past visits, current medications, allergies, lab reports and other related information. He or she can recommend treatment and then send a full report of the telephone encounter with the patient to the MedPeds office where it will be waiting for the patient’s regular physician when he or she arrives for work on Monday morning.

For MedPeds patients, both the quality and the continuity of their health care are richly enhanced by the introduction of EMRs. Medical reminders and alerts become easily tagged and recognized by physicians and other care providers, lab results are tracked and available, trends can be followed and measured.

A Web-based “Patient Portal” was recently added to the MedPeds system that allows patients and doctors to communicate through the Internet easily and securely. Each patient has their own password that allows them to log into their physician’s system to see their own private set of documents, including lab results, diagnostic tests, statements and messages. Doctors can use this same portal to automatically remind patients about health maintenance and dates for procedures or treatment.

Patients also have access to a computer kiosk in the MedPeds waiting room so they can review and update their personal information, if necessary.

All of this activity, based upon EMRs and integrated through the introduction of more user friendly computers, is systematically gathered and recorded for use by MedPeds back office staff. Claims are processed, billing is managed and payments received and accounts reconciled. The system automatically reviews and confirms each patient’s insurance and co-pay information at check-in. Referral information is also checked and updated and reports easily generated to track no-shows, day charges and cash receipts for individual patients.

Significantly, the MedPeds physician partnership has seen financial benefits since adopting the electronic office model. Dr. Eaton estimates that the introduction of EMR technology has reduced the non-physician support staff by about one-third and that the office overhead has decreased by about 15 percent. The number of past due accounts is half what it was before EMRs were introduced and the income per visit has increased as doctors document more detailed progress.

The practice has also expanded. Patient volume has increased by 10 percent and new patient volume is up almost 50 percent. The partnership’s substantial investment in EMR has been recovered in the first two years of use.

Perhaps most importantly, patients are also pleased. Recent satisfaction surveys show they like the ease of access to their own medical records and the new channels of communication now open to their doctors and to the specialists to whom they are referred. EMR, IT and PM... alphabet soup that makes sense on the front line of health care – the doctor’s office.

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Cultural Diversity

CareFirst and CareFirst BlueChoice are pleased to introduce an on-line learning tool to provide health care professionals with skills and techniques to more effectively communicate with patients of various cultural backgrounds. Quality Interactions uses a patient-based approach that focuses on common clinical and cross-cultural scenarios, and includes web links to clinical guidelines, references and other relevant information.

Developed by the Manhattan Cross Cultural Group, the two-hour online course is easy and convenient, and network physicians earn 2.5 hours of Continuing Medical Education (CME) credit upon completion of the program.

Selected CareFirst and CareFirst BlueChoice physicians will be contacted this month and offered an opportunity to participate in the Quality Interactions program. For more information about the training program, please contact providercmes@carefirst.com or 410-605-2677 or 800-323-4472.

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New and Emerging Technology

CareFirst and CareFirst BlueChoice’s Technology Assessment Committee – which includes CareFirst and CareFirst BlueChoice physicians, nurses and external consulting physicians – reviews new and developing technologies. The committee relies on current medical literature, local expert consultants and physicians to determine whether those technologies meet CareFirst and CareFirst BlueChoice’s criteria for coverage. Coverage policies applicable to national Blue Cross Blue Shield accounts and Federal Employees Benefits Programs may differ from those at the local account level. The review criteria can be found in the Providers & Physicians section of www.carefirst.com by clicking on Medical Policies. The Technology Assessment Committee recently made the following determinations:

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Disease Prevention and Disease Management

Recent Literature Related to: CareFirst and CareFirst BlueChoice Disease Prevention and Management Initiatives

By Richard S. Safeer, MD, Medical Director, Preventive Medicine

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Disease Prevention

SCREENING FOR PROSTATE CANCER

Screening for cancer certainly can prove beneficial in altering the clinical outcome of the disease. Screening recommendations taken out of context though can cause a patient unwarranted physical discomfort and mental anguish. A physician has the difficult task of reconciling different screening recommendations from different medical associations and professional organizations. For example, while the American Cancer Society and the American Urologic Association favor annual Prostate Specific Antigen (PSA) screening for average-risk men aged 50 years and older, the United States Preventive Services Task Force finds there is inconclusive evidence to support an annual PSA screen. “All agree that currently there is no conclusive evidence that PSA screening reduces prostate cancer mortality at any age or life expectancy and convincing evidence of benefit is unlikely to ever exist for elderly men because ongoing randomized trials of PSA screening have excluded men older than 75 years.” The authors of “PSA Screening Among Elderly Men With Limited Life Expectancies” were interested in understanding PSA screening patterns in patients more likely to be harmed than benefit from the screening. Medicare claims and Veteran’s Affairs data from almost 600,000 veterans, aged 70 years and older, in the Veteran’s Administration Medical Care system were analyzed for inclusion of PSA testing. Fifty-six percent of those studied (median age 77) had a PSA test in 2003. Furthermore, in the very old (greater than 85 years), those in the worst health were more likely than those in best health to receive a PSA test. The authors conclude “The high PSA rates in our study, particularly among men in poor health, suggest considerably inappropriate screening in elderly veterans, with potentially harmful consequences.” Each year, CareFirst BlueCross BlueShield compiles a summary of the most recent disease prevention guidelines from more than a dozen professional medical organizations. To access this information, go to www.carefirst.com > Provider & Physicians > Clinical Resources > Preventive Services Guidelines. Where to Find it:  JAMA 2006; 296:19: 2336-2342

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Disease Management

CONGESTIVE HEART FAILURE

It’s been more than 10 years since the Scandinavian Simvastatin Survival Study illustrated the beneficial effects that hydroxymethyl glutaryl coenzyme reductase inhibitors (statins) have on the morbidity and mortality of those patients with coronary artery disease. Since then, there have been dozens of statin studies with positive outcomes and their use has become common place. The use of statins specifically in an outpatient population with congestive heart failure has not been evaluated until now in, “Statin Therapy and Risks for Death and Hospitalization in Chronic Heart Failure.” “A recent systematic review of observational studies suggested that receipt of statins is associated with lower mortality and morbidity in patients with health failure… However, these and other published observational studies largely focused on selected subgroups including patients who were hospitalized for heart failure, had advanced heart failure, and/or impaired systolic function.” More than 20,000 heart failure patients without previous statin uptake were identified for the study. Approximately half of the patients initiated statin therapy during the study. On follow up (median time of 2.4 years), there was a significantly lower rate of hospitalization and death amongst those heart failure patients who had begun statins, regardless of whether they had a previous history of coronary heart disease. Cholesterol levels were among the many variables which were controlled. Participation in our congestive heart failure disease management program can improve medication compliance and decrease the chances of your patient ending up in the emergency room. Call 800-783-4582 to refer your patient. Where to Find it: JAMA 2006;296(17): 2105-2111

CORONARY HEART DISEASE

Elevated cholesterol levels, particularly low density lipoprotein cholesterol (LDL-C), have been shown repeatedly to be a risk factor for coronary heart disease (CHD). Once an elevated LDL-C level is identified, the challenge becomes lowering the level to decrease the chances of a future coronary event. Despite the effective medications currently on the market to lower LDL-C to recommended levels, most patients with CHD and diabetes are unable to achieve these levels over long periods of time. “Improvement of LDL-C Laboratory Values Achieved by Participation in a Cardiac or Diabetes Disease Management Program” shows one way of improving LDL-C is through participation in a disease management (DM) program. This retrospective study of 67,244 patients looked at trends in LDL-C values before and aft er DM program enrollment. “DM clinicians (ie, registered nurses, dieticians) call members during the DM intervention to guide them toward healthy behaviors. Based on the clinical status of members documented in the PopulationWorks system, DM clinicians educate members on current standards of care and, with the members, develop individual action plans that guide members in taking specificactions to improve their health and achieve certain outcomes.” “Evaluation of members with elevated LDL-C values (defined as 70, 100, or 130 mg/dL or greater) revealed a significant reduction in LDL-C values.” “Additional analyses revealed that DM interventions were not only able to promote improvement in LDL-C values, but also helped members maintain these improvements over the course of three years of participation in the program.” With improved laboratory values, better clinical outcomes will follow. Where to Find it: Disease Management 2006;(9)6:360-370

DIABETES

With an increasing number of youth qualifying as obese, type 2 diabetes mellitus (DM) is on the rise in our pediatric population. As such, identification and early treatment of this population has taken on a new level of importance. The American Diabetes Association issued the following screening guidelines for children (American Diabetes Association, 2000): Age of 10 years or at onset of puberty, if puberty occurs at a younger age BMI > 85th percentile for age and gender plus any 2 of the following risk factors: Family history of type 2 DM in first or second degree relative Ethnicity/Race (American Indian, African American, Asian/Pacific or Hispanic) Associated conditions (i.e. hypertension, dylipidemia) or signs (acanthosis nigricans) of insulin resistance Frequency every two years Anand et. al. assessed the frequency and type of “Diabetes Mellitus Screening in Pediatric Primary Care.” The authors found that in a sample of 7,710 patients, aged 10 to 19, only 45.4% of those meeting ADA criteria were screened. Furthermore, although fasting plasma glucose is the preferred method of screening, it was used the least frequently, falling behind random plasma glucose, HbA1c and the oral glucose tolerance test. If you identify a newly diagnosed diabetic patient, we can provide education and support to help that patient understand their disease and assist in controlling their glucose. This service is available to adults and minors (through their parents). Please call 1-800-783-4582 to refer your patients to our Diabetes Disease Management program. Where to Find it: Pediatrics: 2006;118(5):1888-1895

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What’s the Big Deal About Coding – Besides Getting Paid?

By Beverly A. Collins, MD, MBA, MS - Medical Director, Healthcare Informatics, and Les Chalmers, RN, MS, CPC

– Manager, Health Care Policy & Technology Assessment

“It’s easier and takes less of my time to code abdominal pain, a code we use all the time, rather than look up the code for cholelithiasis.”

“I’m not going to waste my time with all these codes. I’m being paid to take care of patients, not to be an expert coder.”

These are comments from practitioners and their office staff upon hearing pleas for accurate coding from health insurance plans. The inaccurate codes are often discussed when practitioners call to learn why their claims were rejected or they were reimbursed lower than expected.

Submitting accurate claims to insurance companies for proper reimbursement is perhaps your most important reason to pay attention to the codes you use, but there are other ways code usage can have an impact on your practice.

The Problem

An article in the March 2005 Physicians Practice magazine states that the use of CPT codes is beset with a 45 to 55 percent error rate – and interventional radiologists’ coding was wrong 82 percent of the time. Since some codes change as frequently as quarterly, it is important to keep up-to-date with the CPT, HCPCS and ICD-9 codes.

Diagnosis codes (ICD-9-CM) have to be documented for each CPT/HCPCS code to verify medical necessity. The diagnosis codes should be as specific as possible to support the procedure or evaluation performed.

The current state of health care delivery demands more and better information to make decisions. The amount of information will not diminish in the near future and the mechanism for retrieving this valuable source of information -- claims -- will continue until a novel, improved method takes its place. Since practices are impacted in multiple ways by how they code claims, it is best for those practitioners to pay close attention to how this process is performed in the office.

Monitoring Trends in Care

Health insurance plans, the government and researchers are some of the entities that use claims data to monitor trends in health care utilization and costs. Plans want to make projections about medical conditions that are on the rise and cost more to support in order to adequately allocate resources. Federal and state governments undertake similar activities, and also use the information to develop programs to address community needs, such as promoting appropriate planning and space for enhanced physical activity to fight obesity in areas where heart disease and diabetes are prevalent.

Researchers use claims data in many projects to obtain large sample sizes, which are often resource prohibitive when using alternative methods like surveys and medical record reviews. Many of these studies are published in peer reviewed journals read by the community’s practicing physicians, and the findings are at times integrated into the way those practitioners deliver medicine. So how claims are coded has a greater impact on health care delivery than just providing a mechanism for reimbursement.

Quality of Care Measurement

Measurements of quality health care delivery are frequently conducted using claims data by organizations such as health insurance plans, the National Committee for Quality Assurance (NCQA) and the Centers for Medicare and Medicaid Services (CMS). The results of those measurements are used in public reporting to assist consumers in making choices about where to receive their health care (report cards), and in various programs that have an impact on practitioners’ finances, such as Pay for Performance (P4P), variable reimbursement based upon performance compared to peers and in some locations tiered network selections.

Recent focus has been upon measures that assess not only the quality of health care delivered -- such as the receipt of HbA1c tests and eye exams in diabetes patients, as well as the outcomes and complications of those patients -- but also much more on the utilization of resources in managing patients’ clinical conditions. Health Maintenance Organizations and other health plans have used this cost measure for years, and it is now being tested by NCQA and CMS for use in their programs. This measure is known by several names, like “cost efficiency” and “relative resource utilization.”

Detection of Inappropriate Billing Practices

Mining of claims is performed by health plans and government programs to detect fraud and abuse by providers filing for reimbursement. There are many software programs available that have algorithms to detect abnormal patterns and flag them for closer scrutiny by knowledgeable health care delivery personnel.

Consequently, significant sums of money have been returned to payers as a result of this activity, and providers are subject to legal ramifications if they knowingly participate in this type of activity.

Limitations of Claims Data

Claims data lack the robust clinical information found in other sources of medical information like medical records, such as physical findings and co-morbid conditions.

There are limitations to the number of diagnoses that most practitioners code. When assessing outcomes of care, risk adjustment is needed to account for the sicker patients a practice might see compared to their peers. If the severity of the illness and other co-morbid conditions are not documented in the coding, the clinical condition being studied probably will not be adequately risk adjusted using claims. Although medical records are best for the rich clinical information, mining the data is very resource intensive, requiring financial and time commitments, and qualified personnel to perform data abstraction.

Poor coding as to specificity of diagnosis and procedures is a frequent complaint of using claims data by those conducting the analysis and, indirectly by the practitioners that may be negatively impacted by the use of the ultimate analysis results. Practitioners admit to not coding well and say they have no urgent need to improve on this administrative function.

“Submitting accurate claims to insurance companies for proper reimbursement is perhaps your most important reason to pay attention to the codes you use, but there are other ways code usage can have an impact on your practice.”

Movements to Address Some Concerns

Multiple quality improvement and measurement organizations, such as the National Quality Forum (NQF), NCQA and CMS, are confronted with the dilemma of being held accountable for promoting valid quality measurements over a broad spectrum of providers, but have a lack of data to perform the measurement.

Several potential solutions have been proposed whereby more detailed information is captured through the coding process. Medicare implemented the Physician Voluntary Reporting Program (PVRP) in 2006 to promote data collection and measurement by practitioners on 36 evidence-based, clinically valid measures that have been endorsed by the physician community. This program is currently voluntary, but Medicare recently announced that eligible practitioners reporting these measures may receive a bonus. This is a Medicare program and not a commercial insurance program.

The measures in this program use Medicare developed G-codes, which are HCPCS codes that supplement the usual claims with clinical information demonstrating the quality of services delivered to Medicare beneficiaries. CPT Category II codes can also be used for some of these measures. This is considered an interim step on the way to electronic data submission through EMRs when they are widely adopted. An example of G codes that might be used for a patient with a history of a prior myocardial infarction who is being seen in the office and included in that practice’s measurement follows:

Although Medicare indicates that a bonus may be available for successfully submitting data on the measures, there is no additional reimbursement per claim for inclusion of the G codes, and many health plans, including CareFirst do not recognize these codes.

Use of more detailed diagnostic codes has also been proposed. The ICD-9 codes are being updated to the ICD-10 codes, which are alphanumeric and have seven digits. The newer codes are more specific and increase the number of codes from approximately 13,000 diagnosis codes for ICD-9 to 120,000 for ICD-10, while the number of procedure codes increases from 11,000 to 87,000. Other countries have used the updated codes for several years. One reason cited for the update was enhancing data needs for health researchers and statistical analysis.

An example is a change from the sole code used for a sports injury resulting from being struck to the new 24 codes that ist what object caused the impact – cleats, diving board, football, baseball, soft ball, soccer ball, golf ball, hockey puck, ice skate blades, etc. After protest by many concerned parties, including health insurance plans, Congress now targets the implementation of the ICD-10 codes for 2010. Training and understanding this new coding scheme will have a significant impact on practices.

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NPI Contingency Plan

The Centers for Medicare and Medicaid Services (CMS) have provided updated guidance regarding the implementation of NPI. As a result, health plans may develop contingency plans to ensure smooth provider payment cycles while working reasonably and diligently toward full compliance for up to 12 months after the May 23, 2007 NPI compliance date.

To avoid delays in claims payment and processing after May 23, 2007, CareFirst and CareFirst BlueChoice appreciate your cooperation in following our 3-step contingency plan as stated below.

1) Submit Legacy IDs and NPIs on 837 Electronic Claims CareFirst and CareFirst BlueChoice will require that electronic claims contain the provider’s legacy ID number. (A legacy ID is your provider ID number assigned by CareFirst/CareFirst BlueChoice.) Providers may also submit both the legacy ID and the NPI using a “dual use” approach until further notice.

For more information about dual use, please refer to our NPI Dual Use Companion Guide. Visit www.carefirst.com > Providers & Physicians > Electronic Services > EDI Services > EDI Manuals to find the NPI Dual Use Guide.

2) Submit Legacy IDs on Paper Claim Forms Providers are encouraged to use the current CMS 1500 (12/90) version of the professional claim form and the current UB-92 version of the institutional claim form. By doing so, you will submit paper claims with a legacy provider ID number, as you currently do. We will accept the CMS 1500 (08/05) and UB-04 versions of the forms, but they must include a legacy provider ID number. The use of NPI is optional.

3) Continue to Use Legacy ID Numbers for Inquiries and Referrals Providers must continue to use their legacy ID numbers when sending inquiries, writing referrals and accessing the BlueLine and FirstLine Voice Response Units, CareFirst Direct, iEXCHANGE and IASH.

In addition, if you haven’t done so already, providers must send their NPI directly to our Provider Information & Credentialing Department so we can include it in our systems. NPIs cannot be extracted from claims, so it is imperative that you submit your NPI information to us.

To submit your NPI, visit www.carefirst.com > Providers & Physicians > National Provider Identifi ers (NPI) > Submission Form and follow the online instructions. If you do not have Internet access, please call Provider Services to obtain a copy of the form or refer to the January/February 2007 BlueLink for other ways to submit your NPI. CareFirst and CareFirst BlueChoice will send confirmation via e-mail or by mail verifying that we received your NPI information.

Please visit the NPI section of www.carefirst.com for updates, frequently asked questions and additional resources. If you have any questions, please send an email to NPI@carefirst.com or contact Provider Services.

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InFocus is published three times a year by CareFirst BlueCross BlueShield’s Corporate Communications Department. Chief Medical Officer and Sr. Vice President of Medical Affairs Jon Shematek, M.D. Editor Robert Hilson newsletter.editor@CareFirst.com

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