Federal Employee Health Benefits

Univera Healthcare Patient Safety Initiatives

After the publication of the Institute of Medicine report on Patient Safety, there has been a proliferation of activities in the healthcare industry addressing various aspects of the report. The majority of efforts have been focused on hospitals and the inpatient setting as that was the major focus of the initial report. As a health care insurer, our role is somewhat distanced but not diminished in importance. We serve as a facilitator for our members to obtain access to the highest quality care we can identify. To this end, our role in patient safety is one of monitoring and assuring processes are in place to assure safe, high quality care. This can include the processes of assuring that the care that is provided is done so according to the current accepted guidelines and in the proper site of care. As we perform this function we are assessing whether there was over, under or mis-use of care as provided to the member.

I. Internal Corporate Initiatives

1. Univera Healthcare Case Management

   In Case Management, the medical, behavioral health and professional staff handling the member's personal health care information are sensitive to safety and well being as it relates to social, economic, demographic and psycho-social surroundings. In-house and On-site processes are in place to ensure those safety issues of members and case managers are addressed. The processes are designed to decrease risk and increased safety when conducting case management activities telephonically or in the field.

   Case Management plans for the management of incidents that may impact or compromise the safety and well being of a member and/or case manager. The guidelines assist with identification of and intervention for situations of apparent or immediate jeopardy to the health or welfare of a member. Situations covered in these guidelines include:

   • child and elder abuse
   • domestic violence
   • suicide
   • disease and infection prevention and control

   The Plan offers crisis intervention training and seminars annually. Case Management staff who communicate with members on a regular basis are encouraged to attend a session annually. This process was established to ensure compliance with CM-URAC 2.0 Standards.

2. Leapfrog and hospital initiatives

   Efforts in implementing the Leapfrog standards have been primarily focused in the Rochester region. Focus has been on the "Leaps" of Computer Physician Order Entry (CPOE) to reduce medication errors, evidence-based referrals for surgeries, and Intensivists for ICU staffing. In the other regions significant discussions have occurred with the facilities with some movement towards accepting the standards. Rochester however is the only market where the hospitals have elected to begin submitting to the Leapfrog web site for logging initiative efforts. In WNY the Kaleida Health System has begun to consolidate services around the highest volume providers in their system. We also have been identifying "best practice" in patient safety in contracted facilities and when possible, sharing this with our other contracted facilities.

   Syracuse City-wide Hospital Initiative

   Representation from each of the 4 Syracuse city hospitals has established a forum to brainstorm community wide initiatives to address safety concerns. The initial activity which will be conducted will be the development of a city-wide common list of medication and other medical documentation abbreviations which cannot be used in any medical record as well as development of a standardized set of rules and procedures to enforce the non-use of these abbreviations.

   In addition, there had been discussion regarding the development of a survey that would be administered to members who have had inpatient stays to determine if specific routine safety measures were adhered to during their stay; such as checking ID bracelets and asking the name of the patient before administering a medication, and also washing of hands by the health care practitioners before going from one patient to another.

3. FLRx Patient Safety Initiatives

   Patient safety when utilizing pharmaceuticals is important to the Health Plan.

   POINT OF SERVICE SAFETY CHECKS

   Edits: Effective in October 2000, FLRx implemented drug utilization review (DUR) messaging to pharmacists alerting them to drug-drug interactions. The nationally based program administered by First Database is utilized. Messages are displayed to pharmacists as prescriptions are being processed on line. Over 99% of all claims are processed on-line and subject to drug utilization review edits. On-line claims processing provides a series of standard safety and accuracy checks including:

   1. Drug/drug Interaction – Alerts pharmacist when a member has a potential drug/drug interaction with a new prescription. This alert reduces the chance of drug interactions when members use multiple pharmacies.

      To help reduce the noise level that has become a common occurrence with this type of messaging, FLRx only sends messages for drug-drug interactions that are considered the most severe or Level 1. A Level 1 Interaction is one in which the two drugs in question are contraindicated in ALL situations.

      Also, as most pharmacies have their own alert system, if the drug-drug interaction is such that both drugs are filled at the same pharmacy, a 'soft edit' requiring no override, will be displayed. However, it the drugs are being filled at different pharmacies, a 'hard edit' will be displayed and the claim is denied. An override may be done if the prescription is clinically appropriate. Denial override is performed by using the standard NCPDP Override Codes.

   2. Duplicate Therapy – Notifies the pharmacist when a member is being prescribed a duplicate therapy to an existing prescription.
   3. Too early refill – Prevents a member from refilling a drug prior to 75% of the current supply being exhausted. This edit helps to reduce stockpiling and waste and may be overridden for exceptions such as vacations. This edit can also alert the pharmacist that the member may be taking medications incorrectly and thus, needing a refill too soon. The edit promotes education and counseling.
   4. High dollar edit – Stops claims that exceed a normally expected dollar threshold from continuing to process without correction of data from pharmacy or override for special circumstances from the FLRx Help Desk. This alert assists in identification and correction of pharmacy keying errors.
   5. FDA guideline – Dosage checks – Specific drugs are checked for high dose/low dose, age appropriate dose. This alert provides a safety check for members.
   6. FDA guideline – Quantity checks – Limits quantities on specific drugs to either FDA recommended guidelines for maximum dosage or standards of clinical practice. This alert provides safety check for members and reduces drug stockpiling. This edit may be overridden in cases of medical necessity.
   7. Dose efficiency edits – Limits quantities for selected drugs to prevent a member from taking 2 lower strength pills when there is a single, higher strength pill available. This edit may be overridden for medical necessity.

   UTILIZATION SAFETY

   Prior Authorization: In order to assure members access to safe, effective drug therapy and to protect against waste and inappropriate use, FLRx has implemented prior authorization on selected prescription medications.

   Prior authorization medications have:

   • Clinical value for a narrowly defined population as defined by FDA guidelines and literature based evidence for use.
   • Potentially serious side effects if used inappropriately.
   • High potential for misuse or abuse due to direct to consumer advertising or a general lack of understanding on how to use the drug most safely and effectively.
   • Cosmetic uses.

   PROVIDER AND MEMBER EDUCATION INITIATIVES

   FDA Alerts: FDA alerts emerge very frequently making it practically impossible to notify everyone, all the time. Major FDA alerts, as well as new drug interactions, are addressed in the "Rx Facts - Clinical Updates." This publication is sent to pharmacies and practitioners who sign up to receive it.

   Product Recalls: Practitioners and members are notified of product recalls if the medication has been prescribed/filled for the member in the preceding four (4) months.

   Rx Facts: Monthly newsletter with the latest pharmaceutical information for providers.

4. Other outpatient initiatives

   Oral Anticoagulation Safety Principles

   Anticoagulation Safety Principles were developed and distributed in early 2002 to Rochester community physicians by an Anticoagulation Specialty Committee in response to the Rochester Health Care Forum initiative on reducing medication error and increasing patient safety.

   Physician Office Site Visits

   Offices of physicians applying to participate with the Health Plan receive a site visit to ensure compliance with physical and environmental safety requirements. Practitioners who are not in 100% compliance with the requirements are required to submit plans of correction, which must be received and approved prior to presentation to the Credentials Committee for appointment approval.

   Ongoing Monitoring of Physician Office Sites

   Member complaints regarding physician office sites are monitored in an ongoing manner to ensure that potential safety issues are identified in a timely manner. Those complaints identifying potential physical safety concerns are investigated through the quality review process.

   Patient Specific Automated Office Reminders

   Many clinical offices, in the WNY region currently, receive patient specific time of service reminders outlining preventative health screenings that have not been performed as well as listings of medications recently refilled to compare with those prescribed for frequency and compliance. This information ensures that the PCP is aware of all medications the patient is on that may have been prescribed by other practitioners in efforts to reduce the risk of a medication being prescribed that would interact harmfully with another medication the member is currently on.

   Rate Based Indicator Reports

   Clinical indicators and sentinel events for outpatient and inpatient care are tracked and trended on a quarterly basis against thresholds to monitor for patterns of care provided. Data points falling outside of thresholds are drilled into for further analysis to determine potential care patterns that may cause undue risk to members with regards to care complications, misdiagnosis, etc. Indicator reports are produced for the CNY, Utica, and Rochester regions currently with expansion to the WNY region anticipated.

   Clinical Quality Concerns

   Individual quality of care concerns regarding practitioners that are forwarded to Quality Management are investigated and reviewed against established acceptable standards and patterns of care through the established peer review process. Concerns are provided a severity level based on review outcome to identify the level, if any, that the care provided did not follow the acceptable standards. In addition, practitioner trends or significant digression from acceptable clinical and safe practices are further reviewed for presentation to the Credentials Committee as necessary.

   Disease Management Programs

   Population based disease management programs provide targeted reminders and educational programs to identified members and their treating practitioner. These reminders and educational programs notify the member and practitioner of screenings/tests/or medication refills which are due according to the evidenced-based clinical guidelines which support the chronic illness program. These screenings/tests/medications have been proven to reduce and/or prevent harmful complications to members with chronic illness. By raising awareness and encouraging use of these needed services and medications, the Plan addresses the safety of these individuals through avoidance of detrimental complications. The disease management program using the evidence-based guidelines designs interventions shown in the literature to offer the maximal opportunity for the member to receive the appropriate care intervention.

   Quality Based Incentive Programs

   There are several initiatives aimed at providing incentives to providers for the delivery of quality care. In Rochester the RIPA profiles use their internally developed "Value of Care" measures to incent proper prescribing and patient care activities. In Western NY there are several separate initiatives that focus on proper prescribing practices, a pilot to provide financial incentives for meeting predefined quality goals, as well as provision of efficient care. There are ongoing discussions to expand the pilot program for quality based measures into the general provider population.

   Continuity and Coordination of Care

   The Plan monitors for exchange of information between PCPs and specialists and also between institutional providers and PCPs to ensure that the PCP maintains awareness of all care and treatment, including all medications, provided to his/her patient across the continuum.

II. Patient Safety Products and Tools

1. Active Health Management^®

   Founded on the principal of promoting clinical excellence, ActiveHealth fosters an environment in which payers, providers, physicians, and consumers become partners in treatment planning and care delivery.

   • Identify and stratify potential high-risk, high-cost patients
   • Generate evidence-based recommendations for improving clinical outcomes
   • Communicate these recommendations to the patient's treating physician - in time to help
   • Provide targeted preventive and wellness recommendations directly to patients
   • Deliver customized disease and care management services

   ActiveHealth couples established medical knowledge with actual patient data to identify opportunities for improving patient care. The proprietary software tool is a relational database that continuously reviews data received regarding members against multiple knowledge bases for interactions, screenings and other quality and safety issues.

   Many payers have initiated use of this including Empire BCBS and Aetna. Here at Univera Healthcare Health Plan we have internalized the different aspects of the program and deliver a similar product using our internal resources without the additional expense. The periodic patient reminders sent to providers includes many of the elements seen in this product as well as using evidenced based decisions in medical policy and program development. Using these tools in WNY we have been able alert our providers to issues that may indicate sub-optimal care. Data is obtained from our internal PBM, FLRx, as well as the other claim databases.

III. External Associations and partnerships

1. JCAHO

   Univera Healthcare health Plan hospital contracts require maintenance of certification, if certified and if not a review process to assure compliance with similar guidelines.

   On January 1, 2003, compliance with JCAHO's six National Patient Safety Goals became mandatory. Aggregate data on organization compliance with the requirements will be published at the end of 2003. Individual organization performance data will become available approximately one year later. As of February 21, 313 surveys were completed and most health care organizations were found to be in compliance with the Goals. However, some of the Recommendations have proved more challenging than others.

   JCAHO has announced a new accreditation process beginning January 2004, which will assume continuous accreditation readiness. The new accreditation process, referred to as Shared Visions - New Pathways focuses on quality and safety of care and strives to provide strong incentives for organizations to provide safe, high-quality care at all times. The expectation is that accredited organizations will be in "compliance with 100 percent of the Joint Commission's standards 100 percent of the time."

   As an outgrowth to the new accreditation process, beginning in 2006, all regular accreditation surveys by JCAHO will be unannounced. Currently the regular accreditation surveys are scheduled in advance. Unannounced surveys will be pilot-tested in volunteer organizations during 2004 and 2005

2. URAC

   URAC has taken an active approach to promote patient safety standards through its accreditation standards. In addition, URAC is involved in qualitative research to identify effective patient safety practices in medical management programs as noted below.

   Patient Safety in Utilization Management (UM) Systems: URAC has initiated a research project, funded by the Robert Wood Johnson Foundation, that examines how UM programs identify and address possible patient safety issues. URAC is analyzing how UM information technology (IT) systems are programmed to flag patient safety problems and how program staff respond to flags through investigation or intervention. URAC's study will establish baseline information on UM IT practices relating to patient safety, and identify preliminary "best practices" in UM information management and follow up strategies

   Patient Safety in Disease Management Programs: URAC recently announced a second project to showcase Disease Management Practices for Employers and Health Plans funded by a grant from AdvancePCS. URAC is seeking information on approaches to improve patient safety through disease management (DM) programs. In February 2003, URAC issued a "call for innovative practices," and organizations are invited to submit information on how their DM programs contribute to improved patient safety. Selected programs will be published on URAC's Web site as brief case studies and distributed to employers, purchasers, health plans, and other organizations as a tool to educate on effective DM practices.

   Innovative DM practices will be categorized into the five areas of patient safety practices outlined by the National Quality Forum (NQF) (also noted on page10 of this report):

   1. Improving Patient Safety by Creating a Culture of Safety
   2. Matching Healthcare Needs with Service Delivery Capability
   3. Facilitating Information Transfer and Clear Communication
   4. Adopting Safe Practices in Specific Clinical Settings or Specific Processes of Care Increasing Safe Medication Use

3. AMA

   The AMA convenes the Physician Consortium for Performance Improvement (The Consortium). Its' mission is to improve patient health and safety by:

   • Identifying and developing evidence-based clinical performance measures that enhance quality of patient care and that foster accountability;
   • Promoting the implementation of effective and relevant clinical performance improvement activities; and
   • Advancing the science of clinical performance measurement and improvement.

   The Consortium includes methodological experts, clinical experts representing more than 50 national medical specialty societies, the Agency for Healthcare Research and Quality (AHRQ), and the Centers for Medicare and Medicaid Services (CMS). The Consortium is partnering with physicians, insurers, and payers from both the private and public sectors to improve the quality of chronic care.

   BCBSA is a partner in the physician performance measurement project and 3-4 Blue Plans will initially pilot the national measures on diabetes, major depressive disorder and coronary artery disease.

4. LEAPFROG

   As a result of new research and concern from providers, Leapfrog has soften its standards - hospitals should have an easier time demonstrating progress toward meeting the criteria: computerized prescribing, handling minimum volumes of certain high-risk procedures, and the use of intensivists in critical care. Hospitals were given an additional year (until 2005) to begin using prescription-ordering information systems (alerting physicians to drug interactions and allergies). Leapfrog also simplified its definition of full implementation of computerized prescribing and will give partial credit for systems implementation in at least one area of the hospital. They also broadened their definition of intensivist to include physicians who have a long record of full-time experience in intensive care (but may not be board-certified in the specialty). Finally, Leapfrog eliminated a volume-based measure of proficiency for carotid endarterectomy after research countered previous findings of better outcomes at higher-volume hospitals.