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The MVP Quality Improvement (QI) Committee oversees MVP's patient safety program and its initiatives. The Chief Medical Officer/Vice President of Medical Affairs chairs the committee. Several departments within MVP focus on patient safety including Quality Improvement, Utilization Management and Pharmacy. All proposals, progress reports and outcome studies from these departments' are reported to the QI Committee for feedback and recommendations.

MVP believes that review of Drug Utilization is crucial to ensuring safe and effective treatment protocols.

MVP chooses to partner with NMHCrx as its pharmacy benefits manager because we believe that the synergy of working together provides the highest quality patient care.

• Concurrent DUR: The Concurrent DUR is an on-line, real time point of service review system that identifies potentially hazardous medication problems before the prescription is dispensed. . The NMHCrx state-of-the-art online claims processing system performs a series of DUR edits before a prescription is filled. These edits include but are not limited to:
  • Duplicate Therapy - Identifies when more than one medication is being used for same condition.

  • Refill Too Soon - Verifies that the member has not exhausted a significant proportion of the previous fill before the refill can be submitted.

  • Drug-to-Drug Interaction- Identifies when the prescription presented may interact adversely with another active prescription in the patient profile.

  • Drug-To-Allergy, Age And Pregnancy Precaution - Identifies whether the prescribed medication may result in an adverse clinical outcome due to these conditions.

  • Over-Utilization - Identifies when the average daily dose of a prescription exceeds the maximum recommended dose supported by the manufacturer.

  • Under-Utilization - Identifies when a maintenance prescription has not been refilled within five days of the exhaustion of the previous fill or refill.

• Retrospective DUR: Retrospective DUR is an extension of the Concurrent DUR program. Member data collected upon adjudication of a claim is used to identify potential drug conflicts including abuse, misuse or severe drug interactions. This member information is communicated only to the prescribing physician and dispensing pharmacist who exercise their professional judgment in determining the appropriate action.

This hands-on approach to drug utilization review has a direct impact on medical care including decreased hospitalizations and increased quality of life which ultimately increases member satisfaction. It is estimated that approximately 7% of all hospitalizations, for the working age population taking prescription medicine, are related to reactions from prescribed medications. The proper analysis and appropriate action based upon drug utilization can reap additional advantages such as a reduction in sick-time, enhanced job performance and lower medical care utilization.

MVP offers Disease Management Programs for four chronic conditions, diabetes, asthma, cardiovascular disease and chronic back pain.

Asthma

Members identified to have moderate to severe asthma are enrolled into the general program and are sent mailings including a health risk appraisal, newsletters, reminder cards and asthma diaries. Results from the health appraisals allow MVP nurses to identify members in need of targeted education.

Nurses contact the high-risk patients by telephone to advocate using a peak flow meter, maintaining an asthma diary and complying with prescribed medication therapy. Physicians receive notification of their patients' progress every six months via an Asthma Informational Summary report, more frequent communication occurs when indicated.

Diabetes

Members identified to have diabetes are enrolled into the general program and are sent mailings including a health risk appraisal, newsletters, reminder cards and diabetes progress reports. Results from the health appraisals allow MVP nurses to identify members in need of targeted education.

Nurses contact high-risk patients by telephone to advocate testing and control of Hemoglobin A1c (A1c), lipid testing and control, screening for nephropathy and an annual dilated eye exam. Physicians receive notification of their patients' progress every six months via a Diabetes Informational Summary report, more frequent communication occurs when indicated.

Patients start to receive individualized education and health coaching from a Registered Nurse telephonically during the first week after discharge for a heart attack, an angioplasty or a coronary artery bypass graft (open heart surgery). The nurse ensures the member understands his/her discharge instructions, has his/her prescriptions filled and follow-up appointments scheduled. The nurse also assesses the member's stage of recovery from the event, overall health, understanding of coronary artery disease, cardiac risk factors and the member's attempts to control them. An individualized education plan for each member based on his/her needs is then developed. The nurse calls the member again at two weeks and at a minimum of once a month for the first three months, at six months and at one year.

Topics covered during the telephonic sessions include adopting healthy dietary habits, beginning an exercise regime and complying with prescribed medications. The following are key areas of education stressed with every member, cholesterol management medication, smoking cessation, blood pressure management, diet, exercise and stress management.

Upon identification, members are sent a health risk appraisal form. Upon receipt of the form, MVP scores the survey to determine an individual's risk level. The nurse calls all patients identified as high-risk to review the results and determine how the program will best meet the member's needs. Interventions in addition to the regular telephonic support include a health action plan and back care workbook. Topics covered during the coaching sessions include: physical symptomatology, barriers to compliance with recommended care, emotions, functional ability and behavior change.

MVP maintains a Physician Quality Improvement Manual that contains the health plan's preventive care and clinical guidelines. The guidelines serve as recommendations to MVP's physicians and are from nationally recognized sources such as the National Institutes of Health, the Centers for Disease Control and the American Academy of Pediatrics. All of MVP's practitioners have access to the guidelines on the MVP website. The health plan also provides CD-ROM copies of the guidelines to all primary care physicians, endocrinologists, allergists and pulmonologists.

The manual contains recommendations on the following topics: preventive care spanning from age 0-to 65 and older; asthma, high blood cholesterol, prenatal care, diabetes, hypertension, lyme disease, antibiotic usage in an upper respiratory infection, attention deficit disorder, depression, low back pain, menopause counseling, otitis media, oncology and secondary prevention of cardiovascular disease.

MVP will share individual patient drug profiles with the patient's doctors upon the doctor's request. Complete prescription profiles are supplied to the patient's primary care physician. A specialist will receive a record of the drugs that he/she has prescribed. As a component of the pre-authorization process an MVP pharmacist may discuss pertinent drug and/or medical information with the prescribing physician. Only sufficient information necessary to make a sound medical decision is shared. Additionally as a part of MVP's disease state management programs (e.g., asthma, diabetes), patient disease profiles are shared with the patient's doctors. In cases where a patient's condition requires close monitoring MVP will supply drug and disease profiles to the patient's doctors.

MVP touches upon patient safety in our QI articles and our Pharmacy and UM updates. These can range from the Disease Management program updates to the advertisement of smoking cessation programs in Vermont as well as notices in our Pharmacy Updates about potential adverse medication reactions and drugs that have been taken off the market due to ineffectiveness (e.g., Lymerix for lyme disease).

MVP's Health Promotion programs, such as Diabetes, Cardiac Care, Asthma Care and Back Care, all use the latest standards by national experts to help educate members about their particular aliment, how to control it and how to remain healthy. Our QI updates also remind practitioners when specific adult and pediatric screenings should be conducted in specific cases such as drug abuse and sexually-transmitted diseases. Such recommendations are based on the American Medical Association (AMA) or the American Academy of Pediatrics (APP).

A Copy of the Monthly Memo (May 2003 ) to participating physicians, in which we expound on the progress of the health promotion programs, is attached. Please refer to page 2.

The purpose of MVP's Physician Quality Recognition program is to identify primary care physicians providing outstanding quality of care and service to members as well as those physicians needing intensive intervention to improve the quality of care and service currently being delivered to MVP members.

Physicians with an average membership of 150 or more members are included in this review process. The following elements are used to stratify physicians: results from member satisfaction surveys, access to care issues (appointment availability including weekend and evenings), appropriate utilization of services, and results of specific quality measures such as mammography rates, immunization rates, as well as appropriate treatment for asthma and diabetes patients.

All physicians falling into the top performer category receive focused visits. The purpose of these visits is to congratulate the physician on his/her excellent performance and to identify and document practices, policies, and/or procedures that contributed to his/her performance. This information is used to establish best practices or benchmarks for other physicians.

Professional Relations staff also recognize the top providers in assorted ways when performing biannual visits to the office. All physicians in this category also receive formal recognition from MVP in the form of a plaque or certificate that can be publicly displayed in the office.

MVP's Hospital Quality Report sent to individual hospitals includes member satisfaction with hospital survey results, Leap Frog information and continuity of care data. The continuity of care data is collected from primary care physician (PCP) medical records. MVP staff members look to confirm that participating hospitals forward discharge summaries and Emergency Room reports to the PCP offices.

In addition to these reports, MVP provides its members and physicians with access to a hospital quality report on its website. MVP's Hospital Quality Report includes the Leapfrog Group's hospital survey results regarding quality of care and patient safety measures. The report features independently gathered information about hospital performance, experience, and other factors related to patient care. The individualized reports provide the user with comparable information on participating hospitals that is diagnosis specific. This information enables individuals and physicians to make informed health care decisions.