Table of Contents

HealthInk Has a New Name: InFocus
Our QI Program: Setting Goals for Improved Care and Service
Changes to Risk Management Program Will Help Prevent Accutane-Related Birth Defects
Council for Affordable Quality Healthcare (CAQH): Strengthening the American Health Care System
Winning the War Against Antibiotic Resistance
Review of Proposed Merger with WellPoint Continues This Fall
A New System for Reporting Pap Test Results
Recent Literature on: Coronary Heart Disease, Diabetes, Congestive Heart Failure, Asthma, Cancer and Primary Prevention
Self-Managing with Asthma Action Plan
Diabetes Guidelines Updated to Reflect New ADA Recommendations
Cardiac Guidelines
CareFirst's Medical Advisory Council: Involving Practitioners in Medical Policy Decision Making

HealthInk Has a New Name: InFocus

Welcome to your newly designed provider newsletter. The clearer, more concise format was created based on feedback we received from provider focus groups.

Just like previous issues of our newsletter, InFocus still contains information about new intitiatives, such as our Best Practice series, and articles about quality issues, preventative care reminders and recommendations and information on new trends in the field of medicine.

If you have any feedback on the new design or topic ideas, please contact Lisa Blaney via email or at 100 S. Charles St., Tower II, 6th Floor, Baltimore, MD 21201. We hope you enjoy your new InFocus.

Our QI Program: Setting Goals for Improved Care and Service

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, working closely with community physicians, develop and implement the QI Program in a coordinated effort to promote preventive health care, manage chronic illnesses and continuously improve the care and services our members receive.

Annually, CareFirst implements a QI work plan that outlines specific clinical and service-related improvement activities using the National Committee for Quality Assurance (NCQA) Standards for Performance as a framework. Data is collected and analyzed for each activity throughout the year. Work groups then study barriers to improvement and develop targeted interventions to help us achieve our established goals. For example, in order to improve childhood immunization rates, a series of age-specific letters was developed to educate parents and remind them about the immunizations due for their child.

Changes to Risk Management Program Will Help Prevent Accutane-Related Birth Defects

Earlier this year, the Food and Drug Administration (FDA) began advising consumers and health care providers about significant changes to the Accutane risk management program for pregnancy prevention called S.M.A.R.T (System to Managed Accutane-Related Teratogenicity). Accutane is now subject to greater prescribing and prescription-processing restrictions that require prescribers and receiving patients to be pre-approved through the S.M.A.R.T. program, which is administered by Roche Laboratories.

In recent years, the risk that Accutane may be inappropriately dispensed to pregnant women (or used by a patient who becomes pregnant during the course of taking Accutane) has increased with the rise in the number of women receiving prescriptions for the drug. The S.M.A.R.T. program was developed with two main goals: that no woman should begin Accutane therapy if she is pregnant, and that no pregnancies should occur while a woman is taking Accutane. S.M.A.R.T. involves Accutane prescribers, patients and pharmacists in a partnership to prevent fetal exposure. The risk management components are described fully within the boxed Contraindications and Warnings and Precautions sections of the Accutane package insert are available online.

The S.M.A.R.T. program now requires the following:

• Prescribers must study the S.M.A.R.T. "Guide to Best Practices" provided by Roche and then sign and return the Letter of Understanding certifying their knowledge of the measures to minimize fetal exposures to Accutane. Roche also has developed a Continuing Medical Education (CME) course for prescribers that includes specific, practical information about pregnancy prevention. The FDA strongly encourages prescribers' participation in this half-day course.
• Prescribers who return the Letter of Understanding to Roche will then receive special self-adhesive Accutane Qualification Stickers. The prescriber should affix one of these yellow stickers to all prescriptions for Accutane on the prescriber's regular prescription form. The sticker indicates to the pharmacist that the patient is "qualified" according to the new Accutane package insert (which states that the female patient has had negative pregnancy tests, as described below, and has been provided with education and counseling about pregnancy prevention). No prescriptions should be given for more than a one-month supply of Accutane at a time, as a pregnancy test is required every month throughout the Accutane treatment course.
• All female patients must have two negative urine or serum pregnancy tests before the initial Accutane prescription is written. For each month of therapy thereafter, they must have a negative pregnancy test result before receiving their next prescription regardless of whether they are sexually active.
• Pharmacists will dispense Accutane only upon presentation of a prescription with the special Accutane Qualification Sticker. Pharmacists will dispense a maximum one-month supply, fill each prescription within seven days of the date of "qualification," and provide a Medication Guide to patients with each Accutane prescription. Requests for refills (i.e., more Accutane without a new prescription) shall not be granted and phoned-in prescriptions shall not be filled.

Exposure of an unborn baby to Accutane is a serious adverse event and should be reported to Roche Medical Services at 800-526-6367 or directly to the FDA MedWatch Program at 800-FDA-1088. Click here to access MedWatch on the Internet.

Council for Affordable Quality Healthcare (CAQH): Strengthening the American Health Care System

CareFirst BlueCross BlueShield (CareFirst) and its fellow Council for Affordable Quality Healthcare (CAQH) members have joined forces to improve the health care experience for consumers and physicians. CAQH consists of 23 of America's largest health plans and insurers that serve more than 110 million people and 600,000 providers.

CAQH was developed in 1999 when CEOs of the largest health plans and insurers decided it was time to change the negative perceptions consumers have of the health care industry as a whole. By working together, CAQH members maintain their collective commitment of developing new programs, resources and tools to support the work of physicians and to educate consumers about health issues.

CAQH has formed three primary areas of development: Simplifying Administration, Advancing Quality Care and Safety and Improving Access to Quality Coverage.

Simplify Administration Through Technology

Single Source Credentialing
CAQH is working to reduce providers' paperwork associated with credentialing with multiple plans. CAQH's streamlined credentialing system will pull together and organize comprehensive data from more than 600,000 providers nationwide. These records will be available electronically to authorized health plans and hospitals without requiring extensive paperwork, which can result in delays.

Although CareFirst will continue to perform data verification and review as well as make independent decisions about whether a provider meets the standards for participation, CAQH's system allows each provider to submit a single application, which meets the requirements of all of the health plans and hospitals that participate in the CAQH effort. As a result, providers will not have to complete the numerous credentialing applications that each of their contracted healthcare organizations require.

"The American Medical Association (AMA) is pleased that the Council for Affordable Quality Healthcare is taking steps to lessen the morass of unproductive paperwork facing physicians in today's environment," stated AMA President Richard Corlin, M.D.

Provider applications can be submitted online, by fax or through the mail. Even if it is not time to be recredentialed, providers still benefit from filing the application; the information on the application will be used to update and maintain provider database and directory information.

There is no cost to providers to submit applications and participate in the program. Access to the system was rolled out to Maryland providers at the end of August 2002; a roll out date for Washington, D.C. providers has not been established.

Providers should update their information online or via fax and confirm every quarter that the data on file is complete and accurate. There is a system in place to automatically notify health plans and health care organizations when provider information changes.

Call the CAQH Help Desk at 888-599-1771 to request the computer software necessary to complete the credentialing application that can be faxed to CAQH. You can also call to have the application sent by mail. If you practice in Maryland and have completed the state's mandated application, call the CAQH Help Desk to get the toll-free fax number and fax the application to CAQH.

Sharing Information
There are many initiatives funded by CAQH member plans with the goal of improving the health of Americans. In order to share information and ideas about these local programs, CAQH has compiled a Knowledge Sharing database.

Access to the Knowledge Sharing database is already available to physicians, specialty societies, national health organizations and the public.

Initiatives included in the database submitted by CareFirst are Diabetes Care, Asthma Care, Childhood Immunizations and Adolescent Immunizations. Other examples of topics included are smoking cessation, breast cancer and depression.

'One-Stop-Shop Formulary'
CAQH is developing a common database of health plan formularies. Formulary DataSource reduces the amount of time that must be spent determining whether a drug is covered, as well as time spent adjusting prescriptions that do not initially meet formulary or pre-authorization requirements. Patients benefit too, since they encounter fewer complications in having their prescriptions filled.

Physicians and other providers will have easy and convenient access to Formulary DataSource to determine if a drug is included on a patient's health plan or network formulary, on CAQH's formulary Web site.

Although CareFirst and most other CAQH members do not currently have electronic prescription capabilities, providers will still be able to find information regarding clinical data and individual patient formulary coverage.

CAQH is working to post all member health plans' formularies on their Web site. Presently, CareFirst's formulary can be viewed on CAQH's Formulary Web site and is updated every two months.

Provider Directories
CAQH helps participating plans develop consumer-friendly and searchable directories on their Web sites. CAQH created a standard set of elements for its member plans so that all directories will hold the same type of information. These directories will provide consumers with information such as board certification, status, a physician's education, specialty and hospital affiliations.

CareFirst's Provider Directory can be accessed from CareFirst's Web site and offers information on physician's education, specialty, board certification and status. CareFirst's directory has recently been enhanced to require fewer steps to search and return faster results.

Consumer Web Access
CAQH is developing a glossary of common health care terms, such as "PCP" and "durable medical equipment" for consumers. This glossary will be available on all the member plans' Web sites so consumers can become more informed.

CAQH is working to ensure that all of their members' Web sites enable consumers to find benefit information and make changes online. This includes requesting primary care physician changes and additional ID cards, downloading claim forms and sending customer service inquiries via e-mail.

Advancing Quality Care and Safety

Educating About Healthy Behaviors
With the support of its members, CAQH is working to educate patients about the risks posed by current critical health issues. Presently, these topics are antibiotic resistance and cardiovascular disease. (Please see next article for information on the former)

CAQH and the Centers for Disease Control (CDC) and Prevention are working to educate consumers about the appropriate use of antibiotics. The Save Antibiotic Strength campaign is designed to inform Americans about the growing threat of antibiotic resistance due to inappropriate use of these drugs.

Cardiovascular disease is this nation's number one killer. Nearly one million Americans die each year from cardiovascular-related diseases. Congestive heart failure and coronary artery disease are two specific conditions that will be addressed by CAQH's quality health initiative.

Lessons connected with antibiotic resistance and cardiovascular disease are shared throughout the CAQH member organizations and communities with hopes to achieve improvements in quality of care and patient safety.

Improving Access to Quality Coverage

CAQH member plans promised in July 2000 to ensure consumer access to a range of care and services. Here are the cornerstones of CAQH's access-based commitment:

• open access to OB/Gyns and pediatricians because CAQH recognizes that women and children have special health care needs
• open access to ER coverage, so members feel comfortable seeking medical care in an emergency
• timely independent review in order for consumers to get the right care when they need it
• open communication between providers and patients about costs and expected outcomes
• choices so that employers and patients can pick from a wide variety of products with varying levels of coverage and costs

These are the steps that CAQH employs to continue its collective commitment to help strengthen the American health care system. More information regarding these topics can be viewed on CAQH's Web site . CareFirst will keep you updated as CAQH and CareFirst collaborate to execute new innovations.

Winning the War Against Antibiotic Resistance

By Stuart B. Levy, M.D., President, Alliance for the Prudent Use of Antibiotics

The Council for Affordable Quality Healthcare (CAQH) has launched the Save the Anitibiotic Strength campaign to raise awareness abouth the critical issue of antibiotc resistance. Joining CAQH in this effort are the Centers for Disease Control and Prevention (CDC) and the Alliance for the Prudent Use of Antibiotics (APUA). Stuart B. Levy, M.D., president of APUA, has written the following article on antibiotic resistance. Dr. Levy also serves as a professor of Medicine and of Molecular Biology and Microbiology, and director of the Center for Adaption Genetics and Drug Resistance at Tufts University School of Medicine. Since 1981, APUA has served as an objective, scientific source of information about antibiotics and as a global advocate for prudent use. Click here to learn more about APUA.

The year 2001 has been a banner year in the battle to contain antibiotic resistance. The world population has used antibiotics for more than 40 years. But the past few decades have witnessed the unprecedented rise in the spread of antibiotic resistance determinants among disease-causing bacteria.

As physicians, we are faced with patients who want or demand antibiotics. Just the other day my out-of-state relative, who had developed local swelling two weeks following the extraction of her wisdom teeth, called me at work to ask, "Please, couldn't you just prescribe an antibiotic for me?" I did not order an antibiotic for my relative. I arranged for her to see an oral surgeon in her area.

What Is Resistance? i
Bacteria can acquire resistance genes through various means. Many bacteria are inherently resistant to some antibiotics. In other bacteria, genetic mutations, which may occur spontaneously, will produce an altered target for an antibiotic or strengthen an existing efflux pump, which leads to resistance. And frequently, bacteria will gain a defense against an antibiotic by taking up resistance genes from other bacterial cells in the vicinity. Indeed, the exchange of genes is so pervasive that the entire bacterial world can be thought of as one huge multicellular organism in which the cells interchange their genes with ease.

Regardless of how bacteria acquire resistance genes today, commercial antibiotics can select for-- promote the survival and propagation of-- antibiotic-resistant strains. In other words, by encouraging the growth of resistant pathogens, an antibiotic can actually contribute to its own undoing.

i Excerpted from "The Challenge of Antibiotic Resistance," published in Scientific American, March 1998. (Stuart B. Levy)

ii This blueprint is in CME monograph form. The Annenberg Center for Health Sciences at Eisenhower is accredited by the Continuing Medical Education to provide continuing medical education for physicians. For more information on the Summit and the CME monograph, contact Annenberg Center for Health Sciences at Eisenhower, Attention: Antibiotic Resistance Monograph, 39000 Bob Hope Drive Rancho Mirage, CA 92270 or fax (760) 773-4550.

Review of Proposed Merger with WellPoint Continues This Fall

Regulators in Maryland, Delaware and Washington, D.C. are now actively reviewing the details of CareFirst Inc.'s (CareFirst) proposed conversion to for-profit status and merger with WellPoint Health Networks (WellPoint). Officials in all three jurisdictions must review and approve the merger.

Under the agreement first announced in November 2001, CareFirst would convert to for-profit status and subsequently be acquired by WellPoint for $1.3 billion. All of the proceeds from the sale would be shared by the jurisdictions - Maryland, Delaware and Washington, D.C. - in which CareFirst's primary affiliates are based. Regulators in the three jurisdictions will determine the division of the money. The $1.3 billion offers elected officials in all three jurisdictions a tremendous opportunity to expand access to health care programs and address other unmet health care needs.

The review process began earlier this year after formal applications were filed with regulators in Maryland, Delaware and Washington, D.C. Community forums at which citizens could offer their input have been held in Maryland and Washington, D.C. The Maryland Insurance Commissioner completed the first round of public hearings in May. Additional hearings are expected this fall and winter in all three jurisdictions.

In addition, as part of the established review process, the Maryland Insurance Commissioner has hired four consultants to:

• thoroughly review CareFirst's value;
• analyze the potential community benefits of the transaction;
• determine the impact of the transaction on the availability and affordability of health insurance;
• examine the process the CareFirst board used in deciding to convert and be acquired by WellPoint.

Similar reviews by outside experts will be conducted in Washington, D.C. and Delaware.

In other news related to the conversion and merger, the Maryland General Assembly enacted legislation which places the burden of proof on whether this transaction is in the public interest onto WellPoint and CareFirst. Legislation also enacted a measure requiring that the the full acquisition price be paid in cash. Legislators backed away from legislation that would have quashed the deal outright or that would have short-circuited the established regulatory review process in Maryland.

Complete information about the merger - as well as regular updates on the status of the review process - can be found by visiting CareFirst's Web site.

A New System for Reporting Pap Test Results

A revised system for reporting the results of Pap tests was published in the April 24, 2002 issue of the Journal of the American Medical Association (JAMA). The 2001 Bethesda System, which conveys laboratory findings that help physicians and patients decide how to handle abnormalities found on Pap tests, serves as the foundation for new reporting systems that appear in JAMA.

The guidelines were developed under the sponsorship of the American Society for Colposcopy and Cervical Pathology in conjunction with the 2001 Bethesda System. Key changes include:

• The incorporation of criteria to the evaluation of the adequacy of cervical cell samples that are unique to the new thin-layer, or liquid-based, cell collection method now used by many doctors;
• A new category for atypical cells at higher risk of association with precancer, called atypical squamous cells-cannot exclude a high-grade lesion (ASC-H), will be acknowledged, as well as the previous class, atypical cells of undetermined significance (ASCUS);
• The term "atypical squamous cells favor reactive" has been eliminated in order to focus attention on women at higher risk of having an abnormality;
• "Benign cellular changes" are more clearly identified as "negative".

Pap Tests for CareFirst Members
While health screening rates for female CareFirst BlueCross BlueShield (CareFirst) members are improving, they tend to remain or fall below the level of national rates and Plan goals.

The National Committee on Quality Assurance tracks the rate of cervical cancer screening as reported in Health Plan Employer Data and Information Set (HEDIS) HMO reviews. HEDIS assesses how many women between the ages of 18 and 64 years received a Pap test within the last three years.

The Maryland Health Care Commission reports that across HMOs operating in the region (which include CareFirst BlueChoice, FreeState and Preferred Health Network), the average cervical cancer screening rate for women is around 81 percent, down from 87 percent reported in 1999. Individually, Maryland HMO cervical cancer screening scores ranged as low as 76 percent and as high as 85 percent in 2001.

It is important that the primary care physicians (PCP) and their office staff establish out-reach activities and recommend annual screenings to members who have a need for this preventive care opportunity. To help encourage women and as part of the 2002 CareFirst Women's Health Initiative, CareFirst's Quality Improvement Department began sending birthday cards to all women of the appropriate age with a reminder to discuss these periodic screenings and preventive care with their PCP.

According to the American Cancer Society, an estimated 13,000 new cases of invasive cervical cancer will be diagnosed in 2002 and about 4,100 will die of the disease. Case-control studies found that the risk of developing invasive cervical cancer is three to ten times greater in women who have not been screened.

Recent Literature on:
Coronary Heart Disease, Diabetes, Congestive Heart Failure, Asthma, Cancer and Primary Prevention

By T.A. Dadisman, M.D., medical director, Preventive Medicine and Health Promotion

This article is intended to call your attention to recent information you may have missed on issues concerning primary prevention and management of coronary heart disease, diabetes, congestive heart failure, asthma and cancer.

Self-Managing with Asthma Action Plan

Implementing an Asthma Action Plan (AAP) with an asthmatic patient is the best way for physicians to provide proactive treatment and enable patients to self-manage their condition. An AAP will help patients anticipate problems and assist physicians in prescribing therapy well in advance.

After evaluating the intensity of a patient's condition, the physician can educate the patient about self-management. As a result, the patient should be able to assess the severity of an asthma attack, and with the guidance of the AAP, he or she should be able to make a responsible decision that will prevent or inhibit the attack.

A typical AAP lists controller and reliever medications, specific symptoms and instructions for the patient when the asthma attack worsens. The physician and the patient should complete "Your Asthma Action Plan" form together.

CareFirst BlueCross BlueShield has adapted an AAP form titled "Your Asthma Action Plan," which represents the colors of a traffic light. Each color on the form reflects symptoms of increasing seriousness. Peak flow measurements and attention to symptoms allow the patient to calculate the gravity of an attack and take appropriate action.

An effective AAP will help asthmatic patients to:

• know triggers of attacks and how to avoid them
• know warning signs of an oncoming attack
• use peak flow meter properly
• use inhaler and medications properly

To obtain AAP forms, please call the Quality Improvement Department at 800-323-4472 or view the Asthma Action Plan on CareFirst's Web site.

Diabetes Guidelines Updated to reflect New ADA Recommendations

Each year, the American Diabetes Association (ADA) updates their Clinical Practice Recommendations. Accordingly, CareFirst updates our Clinical Practice Guidelines for Diabetes to reflect any and all new ADA recommendations.

The following new recommendations by the ADA have been incorporated into our guidelines for 2002.

• Several studies have evidenced hypertension as a risk factor for diabetes complications. The ADA's recommendations and our Clinical Practice Guidelines for Diabetes suggest that patients with diabetes be treated to a diastolic blood pressure of <80 mm Hg and a systolic pressure of <130 mm Hg.
• Medical nutrition therapy (MNT) is an integral component of diabetes management and patient self-management education. The ADA and our Clinical Practice Guidelines for Diabetes recommend that to attain and maintain optimal metabolic outcomes for persons with diabetes, personal and cultural food preferences should be considered. The services of a registered dietitian or certified diabetes educator may also be required.
• Chronic medical conditions such as diabetes increase the risk of depression. The ADA and our Guidelines for Diabetes recommend yearly clinical assessment of a patient's emotional status for signs and symptoms of depression. More frequent assessment is recommended for high-risk patients.
• The triglyceride goal has been lowered to <150 mg/dL.

Cardiac Guidelines

CareFirst is pleased to introduce our guidelines supporting our new Cardiovascular Disease management programs for coronary artery disease and congestive heart failure.

The guidelines are based on recent publications from the American Heart Association and the American College of Cardiology.

Click here for a printable version of each guideline or call the Quality Improvement Department at 410-528-7997 or 800-323-4472 to receive a copy via mail.

CareFirst's Medical Advisory Council: Involving Practitioners in Medical Policy Decision Making

CareFirst BlueCross BlueShield (CareFirst) values its relationship with the health care practitioner community. In order to maintain its rapport with practitiojners, CareFirst established the Medical Advisory Council (MAC).

"The Medical Advisory Council provides the doctors with an avenue for input into CareFirst medical policy decision making," stated Eric Baugh, M.D., Medical Advisory Council chair and Senior Vice President of Medical Affairs.

The meetings provide an opportunity for CareFirst and the healthcare practitioner community to review and discuss CareFirst medical and/or claims adjudication policies, potential state or federal legislative mandates, credentialing, complementary medicine and ooperational modifications. They also provide an opportunity to consider relevant clinical data shared between CareFirst and the health care practitioner community.

Participation on the council is limited to CareFirst participating providers who are credentialed by CareFirst. Topics for discussion are determined by the suggestions noted on the evaluation sheets completed by the attendees at the previous meeting. The meeting coordinator then reviews the evaluation sheets for future topics.

Non-clinical representatives of medical societies may be invited to attend on a non-voting basis in order to remain informed. Some non-clinical organizations invited to attend may include Medchi, Fairfax County Medical Society and Council of Northern Virginia Medical Societies.