I am pleased to introduce HealthInk, a new publication for the physicians and other health care professionals who serve the members of CareFirst BlueCross BlueShield (CareFirst). HealthInk will offer you information on valuable programs and services that are available for patients and practitioners through CareFirst. I am confident that HealthInk will enhance communication and strengthen partnerships between CareFirst and health care practitioners.

CareFirst's vision is to maintain its pre-eminent role in the region's health care industry and to bring the best value to its customers. To do this, we know that we must work closely with you to maintain a high quality of health care and to continually adjust to the changing marketplace.

One way that we can support you is by offering services and information that will help you in your practice. For instance, through our health education and disease management programs, we can reduce the amount of time your office has to spend on patient education and training. Since a better-informed member is a healthier member, it is important for us to promote patient education, especially for those with chronic conditions. CareFirst also offers voluntary case-management services that can help you coordinate the care for complex patient cases. These services help to ensure that our members receive the right care, at the right time, and in the right setting.

HealthInk will also highlight the findings of our various quality improvement initiatives. CareFirst's Quality Improvement Department performs studies that assist practitioners in making improvements in the delivery of health care services. By doing this, we ultimately help to improve the health status of our members.

The publication of HealthInk is consistent with my goal to promote positive relationships with you and to seek ways to achieve our mutual success. I have already met with many of you to discuss creative opportunities to work together, and I plan to continue these efforts in the months and years ahead.

We would like to hear your views on issues and topics that you would like us to address in HealthInk. It is my hope that this publication may also become a forum for you to exchange ideas relevant to your practice.

I am dedicated to our mutual success, and I am confident that if we work together, as partners, we will all succeed.

Sincerely,

Eric Baugh, M.D.
Senior Vice President of Medical
Affairs and Network Management

Eric Baugh, M.D., serves as the Senior Vice President of Medical Affairs and Network Management for CareFirst BlueCross BlueShield. A board-certified family practitioner, Dr. Baugh's primary responsibilities include the medical operations of the company's HMO and PPO products as well as care management, utilization review, medical quality assurance, preventive medicine and medical policy. Dr. Baugh received his medical degree from the University of Virginia and served with the U.S. Air Force for 21 years. Previously, he was Executive Vice President of Medical Affairs and Medical Director of Mid-Atlantic Medical Services, Inc. (MAMSI).

At CareFirst, we encourage evaluation of our HMOs by external entities such as the National Committee for Quality Assurance (NCQA). We are pleased to report that in two recent evaluations, NCQA awarded Full Accreditation to CapitalCare as well as to FreeState Health Plan. Both of these achievements followed rigorous, lengthy review processes and are the result of the hard work and dedication of many. In particular, we would like to thank all of our participating physicians and their office staffs for assisting with the medical record reviews, quality studies and interviews. The review processes for both CapitalCare and FreeState went very smoothly as a result of your help.

NCQA is an independent, not-for-profit organization dedicated to assessing and reporting on the quality of managed care plans. Its mission is to provide information that enables purchasers and consumers of managed health care to make informed decisions based on objective quality data. NCQA accreditation is something our corporate customers have come to expect.

Full Accreditation is granted for a period of three years to health plans that have excellent programs for continuous quality improvement and meet NCQA's rigorous standards. In the review process, managed care plans are evaluated in six categories:

• quality improvement;
• utilization management;
• physician credentialing;
• members' rights and responsibilities;
• preventive health services; and
• medical records.

CapitalCare's Full Accreditation status is effective April 13, 1999, to April 13, 2002, and FreeState Health Plan's is effective September 26, 1997, to September 26, 2000.

"Receiving Full Accreditation status validates that our HMOs have developed processes that will ensure our members receive the highest quality of care that is measured by a nationally recognized organization," said Jon Shematek, M.D., Medical Director of Quality Improvement.

In addition to accrediting managed care organizations, NCQA also certifies physician organizations for the delegation of categories of NCQA standards.

Congratulations to CapitalCare and FreeState Health Plan for receiving recognition for their commitments to quality!

Beta Blockers After Acute MI Literature has shown that patients who have had a myocardial infarction (MI) are at an increased risk of having another one. Beta blockers have been shown to decrease infarction size, ventricular dysrhythmias and mortality rate. In 1998, we measured the use of a beta blocker after an acute MI in patients with Maryland Point of Service coverage for the reporting year of 1997. Using the HEDIS 3.0 methodology, the compliance rate for this population was found to be 78 percent. A similar study, which was done in collaboration with the University of Maryland Cardiac Network, looked at the FreeState member population. In this study, we found that as a result of educational outreach to providers, the percentage of patients with first MI receiving beta blockers on discharge from the hospital increased from 81 percent in 1996 to 95 percent in 1997. We anticipate that through similar outreach efforts, we will be able to improve the rate of beta blocker usage after MI in our indemnity population also.

Trends in Clinical Risk Management: Diagnosing Breast Cancer in Women Under Age 40

It is recognized among physicians that the prognosis for women under the age of 40 with breast cancer is poor. Primary care physicians frequently face the challenge of appropriate management of "suspicious breast changes" in younger women _ even when the mammogram is negative and the physical exam suggests a relatively low likelihood that a lesion is cancer.

Is a "wait and see" approach the best course of action? Our Quality Improvement Practitioner Advisory Committee, composed of medical directors of medical management groups and CareFirst, recently addressed this concern. The committee suggested that all primary care practitioners refer patients with a high index of suspicion to a specialist for evaluation. In excluding cancer, particularly breast cancer in women under 40, caution is key.

CareFirst is committed to providing the highest quality of care and service to its members. The Plan's quality improvement (QI) program strives to improve clinical care and administrative services in all areas of the delivery system.

Our QI committees, with the active participation of community physicians, provide the structure needed to coordinate and integrate the QI program.

Annually, CareFirst implements a QI work plan that outlines specific clinical- and service-related improvement activities. Data are collected and analyzed for each activity. Work groups study barriers to improvement and develop targeted interventions to achieve established goals.

Examples of measures included in CareFirst's quality improvement plan for 1999 are:

• use of preventive services
• compliance with clinical practice guidelines
• continuity and coordination of care
• effectiveness of disease management programs
• availability of practitioners and access to care
• potential over- and under-utilization
• member and provider satisfaction

If you would like more information about the QI Program, including our 1998 results, please call:

• For FreeState Health Plan: Provider Networks Management at 410-528-7103 or
  800-228-8161.
• For CapitalCare: Provider Services at 202-479-3516.

Disease Management Programs Increasingly Important

An alliance of health plans, providers and members working together for everyone's benefit.

In the not too distant past, most people sought medical care only when they were sick, and physician training focused on the treatment of acute illnesses. Today, more and more patients are looking to their physicians to help them deal with chronic diseases like asthma, diabetes and heart disease.

Chronic Diseases Are Costly
According to the U.S. Centers for Disease Control and Prevention (CDC), the United States cannot effectively control escalating health care costs without addressing the prevention of chronic illnesses. It cites the following statistics to support that position:

• 90 million Americans have chronic diseases;
• Chronic diseases account for 70 percent of all deaths in the United States; and
• In 1994, an estimated $425 billion was spent to care for persons with chronic diseases _ or 61 percent of the nation's total medical care costs.

Many Chronic Diseases on the Rise
Despite advances in many areas of medicine, chronic diseases remain prevalent. In fact, the incidence of many chronic diseases is increasing.

• According to the U.S. Department of Health and Human Services, the number of people afflicted with asthma has doubled over the past 15 years to 15 million Americans. The highest increase in rates is seen in children under the age of 5. Asthma is the most common chronic disease in children, affecting an estimated 4.8 million children.
• One in four Americans has cardiovascular disease (CVD) _ the leading killer of both men and women in the United States. Nearly 1 million deaths each year (or 42 percent of all deaths) are attributed to CVD.
• Diabetes, the seventh leading killer in the United States, affects approximately 16 million Americans. It is estimated that nearly a third of those with diabetes do not know they have the disease.

Health Plans Develop Disease Management Programs Today, treatment of patients with chronic diseases has evolved so that they get the care and education they need early so they can better manage their disease and improve the quality of their lives.

CareFirst, along with many of the nation's independent Blue Cross and Blue Shield plans, is a leader in developing comprehensive disease management programs and using clinical practice guidelines to ensure that patients with chronic diseases get the most complete, effective care possible. These programs provide the intervention and professional management needed to maximize patients' health.

Programs Reap Benefits
Disease management programs are helping to forge a new type of partnership between health plans, providers and members as they all work together to improve patients' health. Not only do these programs improve patients' health, they save money as well. The CDC estimates, for example, that each $1 spent on diabetes outpatient education saves $2_$3 in hospitalization costs.

Disease management programs will continue to evolve as treatment of the chronically ill is better understood. New programs will be developed and existing ones will be refined as new and better ways of caring for patients with chronic diseases are discovered.

With disease management programs, everyone benefits _ providers, health plans and, most of all, members. Providers get support treating their patients with chronic diseases. Health plans have a cost-effective way to provide their chronically ill members with the specialized care they need. And patients get comprehensive treatment that improves the quality, and in many cases, the length of their lives.

CareFirst's Programs for Diabetes and Asthma

CareFirst is proud to offer state-of-the art disease management programs for diabetes and asthma for its HMO members. The goal of these programs is to educate members on how to avoid the preventable complications of their condition. Both programs target members and physicians through a series of educational mailings that promote effective disease management strategies. Patients with diabetes or asthma have been identified from medical and pharmacy claims data.

The mailings to members provide education about the disease and encourage members to work closely with their physicians to develop the treatment plan. As part of these programs, CareFirst sends bulletins called Asthma Control and Diabetes Control on a quarterly basis to members. These are educational tools that contain useful tips and help to promote self-care.

We have mailed physicians program overviews, our treatment guidelines and claims-based profiles of prescription patterns with recommendations. The Diabetes and Asthma Management Programs are currently being offered to our HMO members, including those in FreeState, Medi-CareFirst and CapitalCare. Plans are under way to extend these valuable programs to other members.

It is our hope that these programs will increase the health and well-being of our members. If you have any questions, please contact the Health Education Department at 410-528-7997 or 800-323-4472.

Use of ACE Inhibitors in Diabetic Patients

Clinical trials have demonstrated the benefits of ACE inhibitors in slowing the progression of renal disease, stabilizing or reducing urinary albumin excretion, and improving the glomerular filtration rate. Because they reduce the risk of diabetic nephropathy, ACE inhibitors are recommended as first line agents for all hypertensive and normotensive diabetic patients (type 1 and 2) with microalbuminuria or more advanced stages of renal nephropathy.

Much discussion is taking place in the literature concerning the appropriate place ACE inhibitors have in the treatment of diabetic patients. ACE inhibitors have been found to reduce or stabilize microalbuminuria, reduce proteinuria, and slow the progression of nephropathy in both type 1 and 2 diabetics. The American Diabetic Association and the National Kidney Foundation recommend annual screening for microalbuminuria in patients over the age of 14 who have had type 1 diabetes for at least five years. Screening in type 2 diabetics should begin upon diagnosis, with follow-ups annually. Screening for microalbuminuria can be done by three methods:

1. Measurement of microalbumin in a random spot urine collection using a microalbumin-specific test strip;
   
2. Four-hour overnight collection; or
   
3. 24-hour collection for albumin with creatinine for calculation of creatinine clearance.

Whenever protein is detected on a spot urinalysis using reagent strips, a full creatinine clearance should be determined by timed collection. While it may not be appropriate to initiate ACE inhibitor therapy in a normotensive (diastolic BP< 85mmHg) type 2 diabetic immediately, it is reasonable to use an ACE inhibitor when signs of microalbuminuria or albuminuria are noted.

In a recent drug utilization review, 27 percent of type 1 diabetics were also on an ACE inhibitor. Approximately 654 patients were identified as type 1 diabetics and not on an ACE inhibitor. We had a 36 percent response rate to our questionnaire to physicians. Of the 36 percent, over half of the responses noted that they would consider an ACE inhibitor during their patient's next visit. Approximately one-third felt that an ACE inhibitor was not indicated for their patient for a number of reasons that were stated.

A re-evaluation was conducted to determine if the percentage of patients on concurrent ACE inhibitor therapy has increased since the communication with the physicians.

Diabetes is the most common cause of end-stage renal disease in the United States. Annual screening for microalbuminuria will allow detection of patients with early stage nephropathy. In addition to aggressive glycemic control, the American Diabetes Association recommends the use of ACE inhibitors to slow the rate of progression to overt renal failure.

Innovative, Patient-Focused Programs Offered

Congestive Heart Failure
CareFirst offers a special disease management program for its Maryland region members who suffer from congestive heart failure (CHF). This program provides case management services to NYHA class III and IV CHF patients _ who often are the most difficult to manage for practitioners and the family. In this program, the patient receives home care visits and follow-up phone calls from cardiac nurses. The nurse makes an initial assessment and then works with the patient's cardiologist and/or primary care physician to establish the treatment plan. Since patient education is key to the success of this program, the case manager seeks to empower the patient and the family with knowledge of CHF. The patient and family will learn to detect the subtle early signs of CHF for early intervention. This program is being managed by two agencies: Cardiac Solutions, Inc. for members with indemnity coverage, and Network Health Systems for FreeState members.

To precertify patients for this program, please call 410-605-2661 or 800-443-5434 for indemnity members or 410-277-3900 for FreeState members.

Heparin-Coumadin Conversion Program
In the Maryland region, CareFirst offers a program that provides home-based anticoagulation services to:

• Convert coumadin-dependent patients who require invasive surgical or diagnostic procedures to heparin; and
• Convert patients back to coumadin after the procedure, administering heparin therapy in the home during the conversion process.

Experienced cardiovascular nurses screen for selected criteria prior to the patient's acceptance into the program and conduct all patient management. Standing orders are implemented at the time of evaluation, and physicians are notified of laboratory results and changes in therapy as indicated. The nursing staff is available seven days a week, 24 hours a day. We strongly recommend the use of this program for patients meeting the appropriate criteria.

Please precertify these services by calling the Precertification Department at 410-528-7029 or 800-338-3787 for FreeState patients and 410-605-2661 or 800-443-5434 for Maryland region indemnity patients.

Front-loading Program for Orthopedics
The front-loading program for orthopedics is a mandatory presurgical assessment and educational program specifically for FreeState members who are candidates for total hip or knee replacement surgery. The program is designed to improve the outcome of the surgery by physically conditioning, strengthening and educating the patient prior to surgery. The program requires a preoperative assessment by a physical therapist to determine physical therapy needs and any risks that might affect the patient's compliance with treatment after surgery. A treatment plan, which includes discharge planning, is recommended to the patient prior to the admission. Modifications to the discharge plan would be necessary only if complications occur during the admission.

In order for the program to be effective, the primary care physician's office must call 410-528-7029 or 800-338-3787 to precertify the patient at least two weeks prior to surgery. Upon completion of the physical therapy evaluation, the therapist will fax the completed assessment to the Precertification Department, the PCP and the orthopedic surgeon.

Please inform all potential patients to anticipate the initial therapy consult. If you have any questions about the front-loading program, please contact the Precertification Department at the above numbers.

Primary Care Management of HIV Disease

In 1997, the National Capital region of CareFirst initiated an HIV/AIDS project, partly in response to a report that appeared in The New England Journal of Medicine in March 1996. This report stated that patients under the care of experienced AIDS care providers had a greater survival with a decreased morbidity than with non-experienced physicians. The purpose of the project was to facilitate access to providers experienced in caring for HIV/AIDS patients. A referral network of experienced HIV/AIDS physicians was developed that can be accessed by the member with a long-term specialty referral.

In October 1998, the Plan developed guidelines for the primary care management of HIV disease. This guide incorporates two recent sets of HIV treatment guidelines, which were issued by the International AIDS Society and the National Institute of Health. Guidelines were distributed to all CapitalCare primary care physicians in November 1998.

If you would like a copy of the guidelines or have questions regarding the HIV/AIDS project, please contact:

Robert M. Thomas, MD,
Associate Medical Director
202-479-6511, or

Carol Marshall, R.N., Quality Improvement Coordinator
202-479-5541.

Do you have a patient with complex needs who could benefit from extra support? This patient might be a good candidate for case management - a voluntary service offered at no additional cost to eligible CareFirst members.

Patients who enter the case management program are assigned a case manager - a registered nurse or social worker - who helps to coordinate their care. The case manager ensures smooth delivery of care by serving as a link between the patient and providers of care.

"The case manager interacts with everyone involved in order to implement the treatment plan that was developed by the physician and agreed upon by the patient. We want to make it all happen smoothly and seamlessly," says Gloria Jimenez, Supervisor of Case Management.

Part of the job of the case manager involves making community visits. Sometimes the case manager will visit the patient at home. By assessing the home environment, the case manager can learn about other factors that may be influencing the patient's health - details that do not always show up in the chart. The case manager may also visit the patient at a facility or at the doctor's office.

The goal of case management is to maximize the quality of care, while making sure that resources are utilized appropriately. The case manager becomes a liaison for the patient with CareFirst BlueCross BlueShield. The case manager can help the patient make the best use of the benefit package and often is aware of additional benefits or community resources that may be available.

Case managers help patients to become more independent and to take better care of themselves. "My goal is to help patients manage their health appropriately," says Vanessa Nelson, R.N., case manager. "What I like most about my job is when I see patients make progress toward managing their own health care needs."

To refer a patient for case management:
In the Maryland region, please call the Central Intake-High Risk Outreach Unit at 410-605-2413 or 888-264-8648 (888-CMI-UNIT) toll-free.

In the National Capital region, please call the number for precertification printed on the back of the member's ID card. An associate care coordinator will direct your call to the appropriate case manager.

Premium rates are increasing across the country as health plans struggle to contain spiraling pharmacy costs. Pharmacy rates increased 16 to 22 percent in 1997 and again in 1998. Similar hikes are projected this year.

"Pharmacy costs have increased more than costs in any other line of business within the health care industry, due in large part to manufacturer cost increases and higher utilization," says Winston Wong, PharmD, CareFirst's Director of Pharmacy Management. "In response, health plans, including CareFirst, are implementing aggressive programs and policies to manage these costs so that health care will remain affordable to employers and members."

Manufacturer Cost Increases
From 1996 through 1998, inflation remained relatively flat with modest increases ranging from 2 percent to less than 4 percent per year. Yet, drug costs increased an average of 7 percent.

One reason for higher drug costs is that many pharmaceuticals have launched billion-dollar direct-to-consumer advertising campaigns. Not only do the drug companies raise prices to pay for the advertising, the campaigns themselves are increasing demand for these more expensive drugs.

Another reason cited for higher drug costs is greater research-and-development costs. It is estimated that expenditures for drug research topped $20 billion in 1998, and with more than 5,000 drugs in the research pipeline, those costs will continue to rise.

Despite these higher costs, pharmaceutical companies are making tremendous profits ranging from 15 to 25 percent. The major reason: more people are using prescription drugs than ever before.

Higher Utilization
For the second year in a row, the average number of prescriptions per member increased 8 percent nationwide in 1998.

"Some of the newer medications, although expensive, offer valuable treatment for which there is no substitution," says Dr. Wong. "In addition, we're seeing higher utilization because we now have a better understanding of risk factors and refined diagnoses for a number of conditions, including high cholesterol and diabetes."

Changing demographics are also affecting utilization. The aging population uses three times as many drugs as younger patients. As the baby boom generation ages, this trend, left unchecked, could have an even more serious impact on pharmacy costs.

While some of the increase in utilization may be clinically appropriate, much of it is in response to direct-to-consumer advertising. Studies show that these campaigns are causing more people to seek prescriptions and influencing the prescriptions they request.

Managing Cost Increases
Health plans are looking for innovative ways to combat higher drug prices and utilization. Many plans are now offering new types of pharmacy benefits that incorporate tier-based formularies, more aggressive copayment structures, pharmacy deductibles and maximums. Under these products, members share more of the cost of their medications. It is projected that 86 percent of employers will offer some form of a variable copayment benefit during 1999.

Health plans are also reviewing overall and provider-specific prescribing trends and making recommendations about more cost-effective alternatives when appropriate. Prior authorization programs, medical group reporting, over-utilization screening and other programs are also becoming more popular.

Physicians Provide Crucial Link
"Drug costs for CareFirst members increased last year. However, we were able to stay below the national average in terms of cost increases because we're aggressively managing our prescription benefits," says Dr. Wong. "We can have a greater impact if physicians join the effort to control drug costs and over-utilization."

He urges physicians to look at the formulary and consider cost as well as quality when prescribing mediations. Over-the-counter medications are often a reasonable first choice when choosing medications. In addition, he encourages physicians to prescribe lower-cost medications when they are as effective as more costly alternatives.

"Escalating drug costs will ultimately increase the financial burden on patients, because they will have to absorb much of these costs," says Dr. Wong. "With our providers' help, we can provide good service and quality outcomes at an affordable cost."

New guidelines for the treatment of cholesterol illustrate cases in which increased utilization is appropriate and beneficial. Five years ago, high cholesterol was defined as levels of 225 to 250 mgs. per deciliter and higher. Research, however, showed that patients with even lower levels of cholesterol were at risk of complications, including heart attacks.

Today, patients with cholesterol levels above 200 are treated for high cholesterol. Consequently, the number of patients requiring drug therapy has increased. And those with levels of 225 to 250, who are now considered at even greater risk, require more powerful and expensive medications.

This treatment can improve the health of patients and ultimately reduce the cost of future treatment.

Advance Directives Overview Advance directives are a patient's written instructions regarding medical care choices in the event that he or she becomes incapacitated and unable to communicate. The Health Education Department offers a workshop that presents the law and our policy regarding advance directives. The workshop is currently offered in the Maryland region but can be made available in the National Capital region upon request. It is recommended that medical sites have someone trained to answer patient inquiries about advance directives. The next workshops will be held on: Thursday, August 19, 1999 9:30 AM to 11:30 AM Location: Columbia Conference Center, River Parks Room Thursday, October 21, 1999 2:30 PM to 4:30 PM Location: CareFirst's Corporate Offices, Owings Mills, MD To register, or to receive a copy of the advance directives packet, please call the Health Education Department at 410-528-7997 or 800-323-4472. Please note: When a patient completes advance directives, you need to clearly document this fact in the patient's medical chart. Additionally, please display the sign stating that advance directives documents are available at your site. To obtain this sign, please call the Health Education Department at 410-528-7997 or 800-323-4472.

Judicious Use of Antibiotics Program

Just over one year ago, a major educational campaign was launched in the Baltimore Metropolitan Area to curb the unnecessary use of antibiotics. This program is a joint effort of the Maryland Department of Health and Mental Hygiene, Johns Hopkins University School of Public Health and the U.S. Centers for Disease Control and Prevention (CDC). With the support of CareFirst, the program offers one-hour seminars for pediatricians, family physicians and their staff. Educators discuss important issues about antibiotic-resistant infections in children, overuse of antibiotics and patient education in the office setting. According to Dr. Bernadette Albanese, the program director, the campaign has been extremely well received. She states, "We have conducted seminars for over 130 physician practices in the Baltimore Metropolitan Area and are still counting." In addition, grand rounds were held at 12 area hospitals and at local medical society meetings.

Education of parents and child care providers is another extremely important component of the campaign. Physicians often cite patient expectation as a common reason an antibiotic may be prescribed when the provider thought it was unnecessary. "We listened to feedback from our providers, and they asked us to be sure to talk with patients and parents about this issue," says Florence Miller in the Health Education Department. As part of the program, pediatric nurse practitioners and physician educators offer community-oriented seminars.

We have patient educational materials available for your office, including a CDC pamphlet called Your Child and Antibiotics, bookmarks and illness fact sheets on "Kids and Colds," "Kids and Sore Throats," and "Kids and Ear Infections." Also available are summary sheets developed by the CDC for health care providers on bacterial resistance, otitis media, cough illness, pharyngitis, common cold and sinusitis. To obtain any of these materials, please contact either the program office at 410-614-6034 or CareFirst's Health Education Department at 410-528-7997.

Topics: Low Back Pain, Breast Cancer - the Surgery Decision, and Benign Prostatic Hyperplasia.
These free, 60-minute, interactive educational programs help patients make more informed decisions about surgery and other treatment options they may be facing. Interactive videos are available for viewing at the following locations: Beltway Crossing Medical Center (Glen Burnie, MD), Bel Air Health Center (Belair, MD), and the Delmarva Health Plan office (Easton, MD). To view an interactive video at the Beltway Crossing Medical Center or at Bel Air, the patient may contact Sue Wingard at 410-528-7997 or 800-323-4472 or at the Easton location, Maryam Tabrizi at 410-763-6382 or 800-334-3427, ext. 6382.

CME Credit Opportunities

The Health Education Department makes available a variety of self-study programs that can be completed to earn CME credit hours. Details of these courses are outlined below. To order copies of the program materials, please call the Health Education Department at 410-528-7997 or 800-323-4472.

Geriatrics Self-Study Program

Don't miss this opportunity to improve care for your senior patients while earning 50 CME credits! More than 4,500 physicians across the nation already are using the Modules in Clinical Geriatrics in their daily practice. This program was developed jointly by the American Geriatrics Society and the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. It offers physicians the latest clinical information in geriatrics through six self-study modules. Participants will study general principles of aging and approaches to older patients, geriatric psychiatry and conditions such as malnutrition, dementia, falls, pain management, sleep disorders, osteoporosis and incontinence. The growing elderly population makes this educational opportunity advantageous for all health care practitioners.

For a minimal cost of $90 (includes shipping and handling), physicians will benefit by expanding their knowledge of the clinical and behavioral aspects of aging and earning 50 CME credits.

Domestic Violence

We realize that physicians treat victims of family violence every day, yet often it is difficult to recognize the signs and symptoms of abuse. To give you the practical tools you need to help your patients, we are offering the following self-study program, sponsored by the Maryland Physicians' Campaign Against Family Violence: Elder/Vulnerable Adult Abuse and Neglect ($10 charge). Successful completion of this program awards up to four (4) credit hours in Category I of the Physicians Recognition Award of the American Medical Association.

Working with Older Patients

To assist you in treating older patients, we offer a self-study program from the National Institutes of Health entitled "Working With Your Older Patients: A Clinicians' Handbook." This free study program describes and explains issues pertinent to older patients and offers practical and effective techniques for treating the extremely diverse elderly population. The National Institutes of Health designates this continuing medical education activity for two (2) credit hours in Category I of the Physicians Recognition Award of the American Medical Association.

Medical Aspects of Oral Contraceptive Therapy

You can earn 2 CME credit hours with this new computer-based interactive software program. Upon completion of this program, you should be able to understand the relevant pathophysiology, diagnostic evaluation and role of contraceptive therapy in management of patients with acne vulgaris, diabetes mellitus, family history of cardiovascular disease, breastfeeding, and anemia due to menorrhagia. The Dannemiller Memorial Educational Foundation is accredited by the Accreditation Council for Continuing Medical Education and designates this activity for two (2) hours in Category I credit towards AMA Physicians Recognition Award.

Natural Progesterone: Mechanisms, Effects And Safety

The College of Physicians and Surgeons of Columbia University is accredited by ACCME to provide two (2) hours in Category I credit toward the AMA Physicians Recognition Award for this program made available through a grant from Solvay Pharmaceuticals. Upon completion, the OB-GYN should be able to better understand the role and pharmocokinetics of progesterone and its analogues in the female reproductive cycle; evaluate the effects on the uterus and the central nervous system of long-term use of progesterone; appreciate the extent to which progesterone may attenuate the positive effects of hormone replacement therapy (HRT) on cardiovascular disease; and demonstrate the difference between currently available progestogenic formulations in potency, delivery mode, and clinical applications. This course is available until September 1, 1999.

The Postmenopausal Estrogen/Progestin Interventions Trial (PEPI)

The Center for Continuing Education in the Health Professions designates this activity for a maximum of five (5) hours in Category I credit toward the AMA Physicians Recognition Award provided it is completed with a minimum passing score of 70 percent. Upon completion, the reader should be able to describe the benefits of hormone replacement therapy with regard to cardiac risk factors, osteoporosis prevention, and menopausal symptom relief; identify the risk of endometrial hyperplasia with unopposed estrogen and appreciate progesterone's protective benefit; outline the risk factors for low bone mineral density and list measure to counteract bone loss; and describe the effects of aging and HRT on menopausal symptoms and sexual satisfaction in women. This program is available until June 30, 2001

The Role of Androgens in Menopause

The University of Medicine and Dentistry of New Jersey Center for Continuing Education in the Health Professions is accredited by the ACCME and designates this activity for a maximum of three (3) hours in Category I credits toward the AMA Physician's Recognition Award with a minimum passing score of 70 percent. After completing this activity, participants should be able to discuss historical data on estrogen and androgen/estrogen combination therapy in post-menopausal women; define the spectrum of menopausal symptom relief afforded by such combination therapy; discuss the efficacy and safety of such therapy; recognize the conditions for which this therapy may be considered an option; and identify approaches to improve patient communication and adherence to therapy. Support for this program is provided through a grant from Solvay Pharmaceuticals, Inc. to the Robert Woods Johnson Medical School Center for Continuing Education in the Health Professions. This program is available until June 30, 2000, and is directed toward OB-GYN and other physicians who treat menopausal women.

Philosophy of Care

We represent a philosophy of health care that emphasizes active partnerships between patients and their physicians. We believe that comprehensive health care is best provided by networks of health care professionals who are willing to be held accountable for the quality of their services and the satisfaction of their patients. We are committed to high standards of quality and professional ethics and to the principle that patients come first.

We believe that patients should have the right care, at the right time, and in the right setting. This includes comprehensive care for acute and chronic illness, as well as preventive care _ in the hospital, at the doctor's office, and at home.

We believe that all health care professionals should be held accountable for the quality of the services they provide and for the satisfaction of their patients.

We believe that patients should have a choice within their health plans of physicians who meet high standards of professional training and experience and that informed choice and the freedom to change physicians are essential to building active partnerships between patients and doctors.

We believe that health care decisions should be the shared responsibility of patients, their families and health care professionals, and we encourage physicians to share information with patients on their health status, medical conditions and treatment options.

We believe that consumers have a right to information about health plans and how they work. We believe that working with people to keep them healthy is as important as making them well.

We value prevention as a key component of comprehensive care, reducing the risks of illness and helping to treat small problems before they can become more severe.

We believe that access to affordable, comprehensive care gives consumers the value they expect and contributes to the peace of mind that is essential to good health.

Adapted from the American Association of Health Plans (AAHP)

In January 1999, we launched our new name, CareFirst BlueCross BlueShield, in cyberspace at our new Web site, www.carefirst.com. This new site introduces our new identity to any user accessing the company's site for the first time. The former Web site addresses, www.bcbsmd.com and www.bcbsnca.com, automatically take users directly to the new CareFirst home page.

The new CareFirst Web site is divided into several sections, which allow the user to easily access information. One of the main sections is titled "For Providers," and this section is further subdivided into areas for Maryland region and National Capital region providers. In both areas, providers can access phone number listings, past issues of newsletters, preventive health guidelines and links to other health care sites, as well as other useful information.

Members enrolled in Maryland-based products and their providers can access the on-line prescription drug formulary by clicking on the button on the bottom right of their screen titled "Looking for the formulary? (for Maryland members)." Clicking on this will take them directly to the introduction. Be sure to add www.carefirst.com to your list of favorites!