Federal Employee Health Benefits

UNICARE HMO Patient Safety Initiatives

UNICARE and its parent company, WellPoint, recognize that focusing on reducing medical errors is critical to the delivery of safe and effective health care. Our goal is to work with our physician, hospital and health professional partners to promote and encourage patient safety. UNICARE's efforts target reducing medical errors through the use of guidelines and outcomes-based medicine and promoting the use of processes and systems for reducing errors. Specifically, we support the clinical care of our members through collaborative efforts with physicians and hospitals that include incentives based on quality metrics, public reporting of safety information to employers to emphasize the importance of programs to reduce medical errors, and empowering consumers with information to make informed choices.

UNICARE believes that success in improving patient safety relies on the health care community's demand for respect and attention to patient needs, clinical outcomes-based practices, and empowering patients with useful information. To maintain this demand, UNICARE and WellPoint have a variety of industry partnerships that assist in leveraging support to gather utilization and quality information. These partnerships include the Coalition of Affordable Quality Healthcare, National Quality Forum Membership, and the Joint Commission on Accreditation of Healthcare Organizations.

In addition, a committee made up of more than 100 associates from UNICARE and affiliated WellPoint companies works to promote improved patient health care and safety through reducing avoidable medical errors. National teams for Strategic Health Partnerships, Health Improvement Programs, Pharmacy Programs, Credentialing, Medical Policy, and Preventive Health Programs support the implementation of their division's patient safety initiatives. UNICARE's Corporate Medical Director, Quality Improvement (QI) Medical Director, QI Directors, Medical Operations Management, and Informatics Directors facilitate regional programs and implement and maintain UNICARE-specific initiatives.

Patient Safety Initiatives

Pharmacy Programs

Programs administered by WellPoint Pharmacy Management have several programs in place that specifically address the appropriate use of medications, decreasing medication errors and minimizing drug misadventures:

Members at Risk

The Members-at-Risk Program helps ensure safe and appropriate medication use by identifying patients who receive 20 or more prescriptions per quarter AND visit five or more physicians OR pharmacies. Member risks and increased healthcare costs are prevented through the identification of:

• drug interactions
• duplicate therapies
• member compliance
• drug-induced morbidity due to non compliance or adverse effects
• oversight of prescribing considerations such as age, allergy, or disease state
• fraud or drug abuse

Member specific reports are provided to physicians who prescribe the largest number of prescriptions for "at risk" members. The reports also include a cover letter summarizing the reports and a fax back form that the physician can use to respond to the letter.

Seniors at Risk

UNICARE has developed a member specific drug utilization review program that focuses on minimizing polypharmacy, increasing continuity of care and reducing the potential for adverse drug reactions in the senior population.

Many elderly members receive complicated medication regimens that are difficult to follow. Polypharmacy and adverse drug events are common and serious problems in the senior population. The SAR program provides physicians with member specific medication inventories detailing drug, dose, duration, and medication refill patterns. This feedback encourages physician review of entire medication regimens and allows physicians to monitor compliance.

Migraine Prophylactic Program

The migraine program seeks to increase the use of migraine prophylactic therapy by identifying members with significant migraine drug claims history. Prescribing physicians are sent letters that outline recent related medical literature and summarize drugs commonly used for migraine prophylaxis. A fax-back response form is also included.

Drug Utilization Review

Drug Utilization Review (DUR) is a structured, continuous program that reviews, analyzes and interprets medication use against established medical standards and criteria. The DUR program integrates prospective, concurrent and retrospective analysis. These methods combine to create an effective force to enhance the safety, appropriateness, and cost effective use of pharmaceuticals.

Examples of triggers as part of this program include:

• Geriatric/Pediatric Precautions - Messages alert pharmacists to significant precautions in designated age groups. Recent advances in documenting medications contraindicated in older adults have been included in the geriatric module.

• Drug/Drug Interaction - Member history is reviewed to identify potentially harmful interactions. When multiple edit messages are relayed to the pharmacist, drug/drug interaction warnings receive the highest priority. In addition, the system has enhanced edits in place for "Level 1" drug interactions that have the potential to cause serious or dangerous effects.

• Duplicate Therapy/Therapeutic Overlay - This message is relayed when multiple prescriptions for drugs in the same therapeutic class are written for one member. The message allows pharmacists to identify over utilization and monitor the dispensing of controlled substances to members already receiving drugs with a high potential for abuse. It also helps pharmacists identify fraudulent practices, such as members utilizing different doctors and different pharmacies in an attempt to obtain multiple prescriptions for the same drug.

• Drug Dosage Warning - Inappropriate prescribing is identified by comparing each prescription to clinically appropriate recommended norms. Average daily dose is compared to a minimum/maximum table comprised of data provided by First Data Bank in conjunction with recommendations from our clinical pharmacy staff. If a prescribed dosage is determined to be either excessive or sub-therapeutic, a message is sent to the pharmacy. The message outlines the recommended dosage and prompts the pharmacist to contact the prescribing physician. The system also performs maximum quantity edits for 40 drugs. Any supply in excess of the defined amount is hard-blocked; a doctor's letter is required for override.

• Drug/Age, Drug/Sex, Drug/Medical Condition - The system profiles members by combinations of characteristics including age, sex, medical condition and allergy. Pharmacists are notified of potential adverse effects for members conforming to certain profiles.

• Refill Too Soon - This message uses established tolerance criteria to prevent refills before the date when a percentage (e.g. 75%) of the previous prescription should have been used.

• Under/Over Utilization - Each time a prescription is filled, the system compares the days supply for the member's prior prescription with the time elapsed since that prior prescription was filled. If utilization falls outside acceptable levels as outlined in our minimum/maximum dosage table, a message is sent to the pharmacist. The message outlines the recommended dosage and prompts the pharmacist to counsel the member. Acceptable levels are determined using data provided by First Data Bank in conjunction with recommendations from our clinical pharmacy staff.

Additionally, letter are sent to physicians providing notification of manufacturer Drug Recalls or Withdrawals, New Black Box Warnings, Drug Interactions, etc.

The "Healthcare Advisor" tool

The new healthcare advisor tool and database on UNICARE's website, called SUBIMO, helps individuals ask better questions and make more informed decisions.

The SUBIMO Healthcare Advisor offers an array of information, in an easy-to-use format that members may find useful when preparing for a medical procedure or managing a medical condition. SUBIMO also helps members research and determine which hospital may be best suited to their personal preferences. When researching hospitals, members will be able to base their decisions on:

• Procedure being done
• Location
• Hospital characteristics
• Reputation
• Outcomes

The member will be able to find information about treatment options, complication rates, and questions to ask customized to the specific circumstances. The information is available securely online, 24 hours a day, 7 days a week. Members will also have access to information about after care and alternatives to treatment options.

The website also provides an opportunity to share information with other users through chat rooms and has access to an exhaustive resource list.

Health Improvement Programs

UNICARE's health improvement programs (HIPs), our name for disease management, target asthma, diabetes, congestive heart failure, high-risk pregnancy and cardiovascular diseases. Through the program, members may receive one-on-one intervention with a designated Health Coach who can help answer questions about appropriate medication use, treatment alternatives, and lifestyle changes needed to improve the member's health and quality of life. The Health Coach will also assist in monitoring the member's progress toward their health care goals. The programs also provide UNICARE the opportunity to track member quality and to correlate the data with individual providers. Guideline information is provided to physicians with information on which of their patients are enrolled in any one of the health improvement programs.

Additionally, each member is given a Health Risk Assessment survey to help health coaches provide the most appropriate education, information and intervention with the member. Members will also have access to a team of health coaches that may include respiratory therapists, behaviorists, pharmacists, and dietitians who can help the member address a variety of self-care needs. Many members have several comorbidities that need to be addressed simultaneously. For example, members with diabetes may also suffer from hypertension. With this team approach, we hope to address all of the member's needs.

The member's care plan is monitored closely throughout the member's participation and changed where necessary so that the member has the best chance of success. The result is an empowered member who is ready to handle difficult behavior changes with increased confidence and opportunity for success. The three key behavior change objectives are:

• understanding and following physician instructions
• complying with medication prescriptions
• making an incremental changes in lifestyle, such nutrition or exercise

Evidence-Based Protocols

UNICARE utilizes internally developed proprietary guidelines and policies as well as policies and guidelines based on the Milliman Care Guidelines^TM. This joint availability of guidelines helps to ensure our nurse and physician reviewers are equipped with a complete set of guidelines needed to assist them in making appropriate clinical decisions for our members.

WellPoint Guidelines and Policies cover more than 200 medical, surgical, diagnostic and outpatient procedures and technologies selected from our database. These clinical policies and criteria are produced through an extensive process that includes literature review, specialty physician review and review and approval by our Medical Policy and Technology Assessment Committee. Most of the committee members are physicians participating in our networks from around the United States and chaired by the Vice President/Medical Director of Medical and Credentialing Policy. The protocols are re-evaluated at least annually and more frequently when additional, significant peer review articles become available to assure they reflect clinically appropriate standards.

WellPoint Guidelines and Policies combine the integrity of physician review with evidence-based medical research. From the initial call-in stage to the final point of physician review, WellPoint Guidelines align clinical, case-specific, and special treatment data with already proven healthcare protocols that incorporate recently accepted medical advancements.

The net effect is a protocol system that captures real time advancements in medicine and distributes the information automatically through an electronic update of our on-line protocol system. The medical necessity criteria are national. WellPoint analyzes detailed utilization reports by diagnosis and by region to pinpoint "trending"and to educate physician reviewers on geographic variations-- such as limited ambulatory care facilities--so that such variations can be considered in evaluating treatment alternatives. Report information is fed back through our computer system and used by physician reviewers throughout the review process and when speaking with attending physicians.

UNICARE adopted the Milliman Care Guidelines^TM for inpatient medical and surgical. The guidelines are not meant to replace clinical judgement. These guidelines are developed from intensive literature review, and are meant to provide an additional source of evidence-based review criteria for our medical review personnel.

The Milliman guidelines span various levels of patient care and offer evidence-based best practices. Written by an experienced team of physicians, nurses, and other clinicians the Care Guidelines are reviewed against actual practices of clinical care throughout the United States and the most current medical literature. Thousands of abstracts, articles, databases, textbooks, nationally recognized guidelines and practice observations were analyzed to develop up-to-date evidence-based guidelines. The guidelines are also formally updated annually to incorporate new developments in the fast-changing medical world. In addition, these guidelines were reviewed and approved by WellPoint's Medical Policy and Technology Assessment Committee. The Milliman guidelines show effective care pathways for a given condition and the typical progress toward recovery that may be expected.

Utilizing a combined set of evidence-based guidelines and protocols, our members are less likely to be exposed to unnecessary and non-value added care. UNICARE believes having access to both guidelines will ultimately improve clinical outcomes and patient safety.

Physician Information

UNICARE wants to ensure our network physicians are aware of efforts toward monitoring, promoting and improving patient safety. Physicians can access general patient safety information through an online physician newsletter at unicare.com under the Provider link.

Council for Affordable Quality Healthcare (CAQH)

UNICARE, through its parent company, is a member of CAQH. The council is a not-for-profit alliance of America's leading health plans and networks, committed to improving the quality of healthcare and reducing administrative burdens for physicians, patients, and payers. Current CAQH initiatives address Cardiology and the under use of beta blockers post MI across the nation. WellPoint is also participating in the Save Antibiotic Strength program. The program is designed to educate individuals and to provide physicians with the information and tools needed for appropriate antibiotic use.

Demand Management - MedCall®

MedCall provides a 24-hour, 7 day a week, nurse information line accessible by phone. Members also have access to MedCall's database of information through the Internet. Callers have access to Nurse Counselors who can answer questions about procedures or symptoms, help patients prepare for office visits with questions for their providers, and provide information about appropriate care settings. MedCall empowers members with current, clinically accurate information and resources to become informed health care consumers.

Employees can ask specially trained nurses about medical procedures and their alternatives. Patients can also discuss medications and their potential side effects. MedCall and its nurses also serve as a referral source to participating doctors and medical facilities. Nurses access databases to assist the patient in finding a physician or facility in the area of the country in which they are located and in the network with which they are associated. Nurses also have information for local, state and national self-help agencies for which referrals can be made as needed.

MedCall nurses utilize guidelines provided by MedCall's system, the Healthwise® Knowledgebase™. Healthwise is organized and written to meet consumer information needs for healthcare decision making. It contains information on more than 125 complex medical problems and provides consumer information on more than 135 symptom assessments, 500 health topics, 600 medical tests and procedures, 5,000 self-help support groups, 120 CancerNet topics, 5,000 drug treatments.