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The Quality Improvement Department (QID) of The Health Plan has continued in its efforts to identify patient safety issues to ensure better medical outcomes for our members. In 2002, the following safety initiatives were monitored and reported in the 2002 Quality Management Program Evaluation. Members may view the results of the studies on The Health Plan internet site at http://www.healthplan.org.

Inpatient Quality of Care Indicators:

Readmissions to the hospital within three (3) and thirty (30) days of an inpatient admission and any other identified potential quality of care concerns during an inpatient stay are reviewed concurrently utilizing the medical record(s). The goal of the review is to identify any quality of care and/or service issues, identify the person(s) responsible, and request a response for a corrective action plan.

Member Complaints:

Members are encouraged to file a complaint for dissatisfaction with care or service. If consent is given to retrieve appropriate medical information and notify the provider of the complaint, the QID staff performs an investigation. The goal of the review is to identify any quality of care or service issues, identify the involved entity and request a response for a corrective action plan.

Continuity and Coordination of Care:

Annually, continuity and coordination of care between providers of care is performed utilizing encounter data to identify the population and reviewing the medical record. The goal of the review is to identify appropriate written communication between physicians and facilities providing care for the member. Medical records are reviewed at the primary care physician office for evidence of communication. Data is analyzed for outliers and corrective action plans are requested when appropriate.

Drug Safety through Pharmacy Benefits Manager (PBM):

In July 2001, pharmacy benefits at The Health Plan came under the management of Merck Medco Managed Care, L.L.C. (Medco). A part of the Medco management program includes concurrent drug utilization review (DUR) at the point of sale (pharmacy dispensing level). Medco maintains software applications that evaluate a pharmacy claim submission against certain defined protocols (known as alerts). These alerts are highlighted in the list below. The protocols were developed by an independent committee of physicians and pharmacists and incorporate current medical literature and accepted current practice parameters.

• Drug interaction
• Severe drug interaction
• Excessive daily dose
• Under utilization
• Under the minimum daily dose
• Duplicate therapy
• Refill too soon
• Drug allergy
• Drug pregnancy
• Drug gender
• Drug age.

Medco maintains a report of the incidence of each alert. The report is provided to The Health Plan quarterly. Alerts are reported as a percentage of total and the outcome is recorded as a percentage of rejected or reversed claims. Rejected means that the prescription was denied for payment and corrective action needs to be taken by the pharmacist (consult with prescriber, etc.) Reversed means that the alert was due to a transmission error by the dispensing pharmacy. When the dispensing pharmacy retransmits the claim correctly the alert is resolved.

Most alerts are not of a nature that requires changing the prescription order. As an example, two medications maybe needed to treat a member's high blood pressure. Yet, the software protocol will generate an alert (duplication of therapy) prompting the clinician (pharmacist) to evaluate the appropriateness of the duplication.

During 2002, the software protocols generated nearly 169,800 alert, roughly 21% of all Health Plan claims transmitted to the Medco system. Nearly 17,690 were rejected and/or reversed to prompt providers to take corrective action. The Health Plan sees this software, as a significant tool in assisting the pharmacist is the practice of safely dispensing medications to our membership. In 2003, The Health Plan will continue to utilize the DUR alerts from Medco.

During 2001, a review of controlled substance prescription claims discovered inconsistent utilization of these medications by certain members. Some members were identified as using several physicians and several pharmacies to obtain medication. Additionally, several physicians were identified as having poor documentation of authorization for refills of chronic pain medication. With this in mind, The Health Plan in 2002 developed a procedure for appropriate prescribing and member participation in the treatment of chronic non-malignant pain. The policy allows clinician reviewers to audit member's records to determine that the member is fully aware of all the responsibilities of correctly taking chronic pain medications. Also, the reviewers determine if regularly scheduled review by the physician is documented in the patient record to assure patient compliance and progression to a positive outcome.

Starting in July 2003, Health Plan members taking drugs for gastrointestinal disorders will be enrolled in the Medco Health Positive Approaches to Digestive Health program. This program was reviewed and recommended for use by The Health Plan Pharmacy and Therapeutics committee. The program is designed to optimize therapies for various digestive conditions. The goal is to move members to a maintenance therapy regimen that includes the lowest dose needed to control symptoms and control costs of therapies.

Most patients begin therapy with either a Proton Pump inhibitor (PPI) (i.e. Nexium, Protonix) or a histamine 2 antagonist (H2RA) (i.e. Zantac) at a dose to aggressively treat acute symptoms of GERD, dyspepsia or peptic ulcer disease. Using claims history for these prescriptions, Medco Health will segment patients into acute therapy and maintenance therapy.

Those members taking acute dosing of medication will receive a series of letters starting 45 days after initiation of acute dosing. The first letter will welcome the member to the program and outlines the coverage limitations for either a PPI or H2RA. The will include a toll free number that the member's physician can call for a proactive therapy review. A second mailing will include a cover letter with a tear-off reply card for members to use to request additional educational materials for the program. These include Digestive conditions: What they are. What you can do about them. This is an overview brochure that describes general digestive conditions, such as GERD. Peptic ulcer disease, and dyspepsia. Medication treatment options for these conditions are discussed and patient self-management techniques for improved digestive health are discussed in this brochure. Also, Tracking heartburn: Your seven-day diary can be used to log the member's digestive symptoms for 7 days. This will act as a guide in discussions with the physician about self-management techniques and potential treatment changes to manage on going symptoms.

At 90 days, a therapy review/optimization edit will apply at the pharmacy. This is a hard edit and additional refills will need to be determined through a coverage review process. Optimal dosing may include altering the dose, switching to a PPI or H2RA, from a brand agent to a generic agent, or coverage for H. Pylori. A optimal therapies are derived from the American College of Gastroenteology and approved by the Medco Health Pharmacy and Therapeutics committee.

The final element of the program includes interaction with the physician. At 90 days, if the member is taking a digestive health medication at doses exceeding treatment guidelines refills of the medication will denied at the pharmacy. In order for a member to receive an additional supply of medication, their prescribing physician must call Medco Health to complete a therapy review. The number is 800 753-2851.

Confirmation letters will be sent to physicians with any therapy changes and outline review conversations.

Member Education:

The 2002 Member Newsletter is utilized to educate members on patient safety study results as well as articles pertaining to safety measures. The goal of this intervention is two-fold in notifying the member how THP intervenes to ensure that members are receiving quality care and service and to educate its members on their responsibility in becoming knowledgeable in their own health care needs.

The Health Plan offers diabetes, chronic heart failure, and chronic obstructive pulmonary disease management programs for members with these chronic conditions. We also offer a prenatal care program with outreach to all pregnant members and identification of high-risk pregnancies that are monitored by a dedicated registered nurse. Smoking cessation programs are offered telephonically and in-group sessions.

Members can expect to receive educational mailings and based on severity of illness, individual telephone contact with a dedicated registered nurse. The individual contact monitors the members and provides education to enhance the member's self-management skills.

Evidence-based guidelines:

The Health Plan uses evidence-based guidelines from nationally recognized organizations in the development and adoption of local guidelines for our physicians and members. Examples of Health Plan evidence-based guidelines include chronic heart failure, diabetes, hypertension, cholesterol management, and smoking cessation. All guidelines are updated regularly and distributed to physicians.

Drug and Disease Profiles:

Individual patient prescription drug profiles are shared with physicians upon request, or when concerns about dosage or drug interactions are identified. Patient disease profiles are shared with physicians for diabetes, chronic heart failure, and chronic obstructive pulmonary disease. In addition, childhood immunization status as well as members needing mammography and Pap testing are also shared annually with physicians.

Patient safety information to the physician:

Patient safety information is included in the provider newsletter and the pharmacy newsletter. Issues related to pharmacotherapy and safety are addressed.