Volume 17 Issue 2: 2013

For additional information, visit us at Provider.MedMutual.com. | 1

The American College of Obstetricians and Gynecologists (ACOG), the March of Dimes

and the Leapfrog Group all agree that elective deliveries between 37 and 39 weeks can

be detrimental to the health of both mother and child. These organizations and others,

such as the American Hospital Association (AHA) and the Centers for Medicare and

Medicaid (CMS) “Partnership for Patients,” are seeking to re-educate patients and

providers about early elective delivery. Elective, non-medically necessary inductions

are estimated to comprise 10-15 percent of deliveries.

Reasons cited for early elective inductions and cesarean sections include:

] Convenience (both for the healthcare provider and the patient) ] Patient preference (an earlier end to the discomfort of pregnancy or delivery on a certain day) ] Provider preference (efficiency in scheduling, to ensure adequate staffing and bed availability) ] Patient belief (incorrect) that it is safe to deliver as early as 36 weeks

Near-term infants appear physically “at term” but are physiologically and developmentally less mature and at increased risk for temperature instability, hypoglycemia, respiratory distress, apnea, clinical jaundice and feeding difficulties, which may necessitate Neonatal Intensive Care Unit (NICU) placement. Preterm infant cost can be 17.4 percent higher than the normal delivery cost. An estimated $1 billion dollars and one-half million NICU days could be saved annually in the US if the rate of early term delivery was reduced to 1.7 percent.

To elevate patient awareness, Leapfrog conducts a voluntary hospital survey about preterm delivery rates and posts the results on the Leapfrog Group website in the consumer section at www.leapfroggroup.org\cp. The AHA recently adopted a position statement regarding the elimination of early-term, non-medically necessary deliveries. Suggested strategies and best practices can be viewed in the webinar “Eliminating Elective Deliveries Before 39 Weeks” on their Hospitals in Pursuit of Excellence www.hpoe.org/resources website.

Physicians and midwives are encouraged to educate prospective parents about the advantages to mother and baby of delivery at term. Hospitals can adopt interventions to encourage physicians to provide a medical indication before performing an early-term delivery.

Early Elective Deliveries are Bad Medicine

2 | Eye on Quality Volume 17 Issue 2

New Guidelines to Help Manage COPD COPD is the third leading cause of death and the twelfth leading cause of morbidity in the U.S. Guidelines for COPD recommend that spirometry testing should be performed to diagnose airflow obstruction in patients with respiratory symptoms such as wheezing, shortness of breath and chronic cough.

Tools Available to Reduce Inappropriate Antibiotic Use

To help educate your patients about appropriate antibiotic utilization, we developed, and made

available, various member educational tools. According to the Centers for Disease Control and

Prevention (CDC), antibiotics should not be administered for viral infections such as acute bronchitis

and upper respiratory infections.1

Medical Mutual measures antibiotic dispensing rates on an annual basis. Our most recent rate for:

] Appropriate antibiotic use (not dispensing antibiotic) for adults diagnosed with acute bronchitis is 20.31 percent, which is well below the benchmark of 56 percent.

] Dispensing antibiotics to children diagnosed with upper respiratory infection is 80.16 percent, which remains below the benchmark of 96 percent.

Available tools include:

Antibiotic Brochure — Contains information about antibiotic resistance, appropriate antibiotic use and non-pharmaceutical options for treating colds and coughs for both pediatric and adult populations.

Viral Infection Checklist — Consists of a tear-off checklist of treatments for your patient with a viral infection. There are 50 checklists per pad.

To request an antibiotic tool, or any of our Company’s provider tools, complete and submit the enclosed Provider Order Form, or complete our form online by visiting Provider.MedMutual.com and selecting Tools & Resources, Forms, Clinical Supply Form.

Source:1 Centers for Disease Control and Prevention (CDC). U.S. Department of Health and Human Services. Fast Facts about Antibiotic Resistance.

Once spirometry is performed it will be easier to diagnosis and manage stable COPD, prevent and treat exacerbations, reduce hospitalizations and deaths and improve the quality of life for those living with COPD. For more information, visit http://www.ama-assn.org/amednews/2011/08/15/hlsb0816.htm

Respiratory Highlights

A significant number of Medical Mutual’s Quality Improvement initiatives and measures involve members with chronic respiratory conditions. In this issue, we devoted a section of the newsletter to presenting a number of informative articles addressing various components of our members’ respiratory health and well-being.

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Engage Asthma Patients to Improve AdherenceAsthma affects more than 6 million children in the United States and accounts for approximately $20 billion dollars in healthcare costs annually. Pediatric asthma medication adherence is important. The condition has been shown to improve when providers ask caregivers for input into their child’s treatment plan and when provider-patient communication takes place during the medical visit. National asthma guidelines recommend that providers ask for child and caregiver input into the asthma treatment plan. This represents a patient-centered approach that has been developed to involve and motivate the patient. For more information, visit http://www.medscape.com/viewarticle/770257.

Tools for Tobacco Cessation Providers continue to encourage tobacco users to quit. Results from a recent member survey are shown in the table below:1

Provider Action 2009 2010 2011

Advising Tobacco Users to Quit 77.9% 75.8% 74.1%

Discussing Tobacco Cessation Medications 45.7% 46.1% 46.8%

Discussing Tobacco Cessation Strategies 39.8% 39.8% 40.5%

Our tools to help with tobacco cessation include:

] Smoking Cessation Fact Sheet — A tear-off handout providing information to encourage smoking cessation.

] Chart Stickers for Identifying Tobacco Dependent Patients — With 16 stickers per sheet, this compact tool allows easy tracking of tobacco dependent patients.

] SuperWell® QuitLine Brochure — A handout describing the benefits of smoking cessation and how to enroll in our smoking cessation program.

] QuitLine Fax Referral Form — Enroll patients in our telephonic smoking cessation program with this convenient fax form.

To request a tobacco cessation tool, or any of our Company’s provider tools, complete and submit the enclosed Provider Order Form, or complete our form online by visiting Provider.MedMutual.com and selecting Tools & Resources, Forms, Clinical Supply Form.

Sources:1 Medical Mutual Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey 2010-2012. Medical Assistance with

Smoking and Tobacco Use Cessation (MSC).2 National Committee for Quality Assurance. 2012. Healthcare Effectiveness Data and Information Set (HEDIS®). Avoidance of Antibiotic

Treatment in Adults with Acute Bronchitis (AAB) and Appropriate Treatment for Children With upper Respiratory Infection (URI).

Respiratory Highlights

4 | Eye on Quality Volume 17 Issue 2

2013 Quality Measures for Respiratory ConditionsMedical Mutual is collecting data on the following respiratory conditions to report to the National Committee for Quality Assurance (NCQA), a nationally recognized accrediting agency.

Pharmacotherapy Management of Chronic Obstructive Pulmonary Disease (COPD) Exacerbation

To measure the percentage of COPD exacerbations for which appropriate medications were dispensed

Denominator Members aged 40 and over with a diagnosis of COPD exacerbation. An exacerbation is defined as an acute inpatient discharge or emergency department visit with a primary diagnosis of COPD

Numerator 1 Members who filled a prescription for a bronchodilator within 30 days of the COPD exacerbation

Numerator 2 Members who filled a prescription for a systemic corticosteroid within 14 days of the COPD exacerbation

Use of Spirometry Testing in the Assessment and Diagnosis of COPD

To measure the percentage of members with a new diagnosis of COPD, or newly active COPD, who received appropriate spirometry testing to confirm the diagnosis

Denominator Members aged 40 and over with a new or newly active diagnosis of COPD

Numerator At least one claim with a spirometry test in the 2 years before the first diagnosis to 6 months after the first diagnosis

Asthma Medication Ratio — New Measure for 2013To measure the percentage of members with persistent asthma who had a ratio of controller medications to total asthma medications of 0.50 or greater during the measurement year

Denominator Members aged 5-64 with persistent asthma (defined as one claim for asthma in the last two years)

Numerator For each member, calculate the ratio of controller medications to total asthma medications (see equation below). Then sum the total number of members who have a ratio of 0.50 or greater.

Unit of Controller MedicationsUnit of Total Asthma Medications

Medical Management for People with Asthma — New Measure for 2012

To measure the percentage of members with persistent asthma who remained on the appropriate asthma medication during the treatment period.

Denominator Members aged 5-64 with persistent asthma (defined as one claim for asthma in the last two years).

Numerator 1 Members who remained on an asthma controller medication for at least 50% of their treatment period.

Numerator 2 Members who remained on an asthma controller medication for at least 75% of their treatment period.

Appropriate Testing for Children with Pharyngitis

To measure the percentage of children who were diagnosed with pharyngitis, dispensed an antibiotic and received a group A streptococcus (strep) test for the episode. A higher rate represents better performance (i.e., appropriate testing).

Denominator Members aged 2-18 with a diagnosis of pharyngitis who received an antibiotic.

Numerator Members who received appropriate group A streptococcus (strep) test.

Respiratory Highlights

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Appropriate Treatment for Children with Upper Respiratory Infection

To measure the percentage of children aged 3 months –18 years of age who were given a diagnosis of upper respiratory infection (URI) and were not dispensed an antibiotic prescription. The measure is reported as an inverted rate [1 – (numerator/eligible population)]. A higher rate indicates appropriate treatment of children with URI (i.e., the proportion for whom antibiotics were not prescribed).

Denominator Members aged 3 months –18 years of age with a diagnosis of upper respiratory infection.

Numerator Members who received an antibiotic medication on or three days after the upper respiratory diagnosis.

Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

To measure the percentage of adults with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription. The measure is reported as an inverted rate and a higher rate indicates appropriate treatment of adults with acute bronchitis (i.e., the proportion for whom antibiotics were not prescribed).

Denominator Members aged 18-64 with a diagnosis of acute bronchitis.

Numerator Members who received an antibiotic medication on or three days after the acute bronchitis.

Medical Assistance with Smoking and Tobacco Use Cessation

Below are three components of this measure used to assess different facets of providing medical assistance with smoking and tobacco use cessation. All are based on a rolling average of results from the current measurement year and the prior year. This data is obtained from a member survey.

1. Advising Smokers and Tobacco Users to Quit

To measure the percentage of members who are current smokers or tobacco users and who received cessation advice during the measurement year.

Denominator Members 18 years of age and older who are current smokers or tobacco users.

Numerator Members who received cessation advice from a healthcare provider.

2. Discussing Cessation Medications

To measure the percentage of members who are current smokers or tobacco users whose healthcare provider discussed or recommended cessation medications.

Denominator Members 18 years of age and older who are current smokers or tobacco users.

Numerator Members who stated their healthcare provider discussed or recommended cessation medications.

3. Discussing Cessation Strategies

To measure the percentage of members who are current smokers or tobacco users who stated their healthcare provider discussed or provided cessation methods or strategies.

Denominator Members aged 18 and older who are current smokers or tobacco users.

Numerator Members who stated their healthcare provider discussed or provided cessation methods or strategies recommended cessation medications.

2013 Quality Measures for Respiratory Conditions(continued from page 5)

Respiratory Highlights

6 | Eye on Quality Volume 17 Issue 2

Medical Policy Update

Carpal Tunnel, Tendon Sheath, Ligament, Tendon and Trigger Point Injections

Policy Number: 200218Initial Effective Date: 02/28/2002

Carpal tunnel, tendon sheath, ligament, tendon and trigger point injections involve the injection of local anesthetic with or without steroid into the identified painful area. Injection of therapeutic drugs is indicated when painful or inflammatory conditions of soft tissues have not responded to conventional measures.

Effective October 10, 2012: The Company considers the following injection(s) medically necessary and eligible for reimbursement when the painful or inflammatory condition has not responded to conventional measures:

] Tendon sheath, ligament or tendon injection(s) (CPT Codes 20550 and 20551); and

] Trigger point injection(s) (CPT Codes 20552 and 20553)

The Company considers trigger point injections not containing a corticosteroid and/or local anesthetic not medically necessary and not eligible for reimbursement.

Frequency limitations may apply. Please refer to Provider.MedMutual.com Tools & Resources, Care Management, Corporate Medical Policies for the most current version of Corporate Medical Policy 200218.

Corporate Medical Policy Update

Policy Title Policy Title

200104 Bone Growth Stimulation: Electrical and Ultrasound

200218 Carpal Tunnel, Tendon Sheath or Ligament, Tendon and Trigger Point Injection

200233 Skin Substitutes 200611 Vagus Nerve Stimulation 200803 Scleral Shell Contact Lens200913 Certolizumab pegol (Cimzia)

2009-H Transcranial Magnetic Stimulation 201001 Golimumab (Simponi)201007 Light Therapies for Treatment of Vitiligo 2011-D Applied Behavioral Analysis 201202 FerriScan – NEW201210 Pegylated Interferon Antiviral Therapy – NEW94007 Evaluation of Vestibular Disorders

The following Corporate Medical Policies were developed or revised between October 1, 2012, and December 31, 2012:*

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According to the American Institute for Cancer Research (AICR) fewer patients

than ever are aware of lifestyle factors that can decrease cancer risk. The AICR

conducted a random sample telephone survey to over 1,000 Americans aged 18 and older,

to mark World Cancer Day (February 4, 2013). The findings showed “alarming downturns” in

patient response to questions about factors that they believe have “a significant effect on

whether or not the average person develops cancer.”

The AICR reported that thousands of studies show that healthier lifestyles could cut cancer incidence by as much as one-third and could result in about 400,000 less cases of cancer in the U.S. every year. Unfortunately, their survey results revealed that fewer Americans than ever are aware of six cancer risk factors.

When asked the question, “Which of the following do you believe has a significant effect on whether or not the average person develops cancer?” the following results were obtained:

Lifestyle Choice Answered “Yes”

Diets low in fruits and vegetables 43%

Alcohol intake 38%

Lack of physical activity 36%

Obesity 48%

Diets high in red meat 35%

Cured meats 36%

More respondents were concerned about food additives (56 percent) and pesticide residue on produce (72 percent), neither of which has undergone sufficient research to prove an increase in cancer risk. Tobacco use was correctly identified as a risk factor by 92 percent and excessive sun exposure by 84 percent.

The message that patients need to hear is to act on factors they can control and not to worry about what they cannot control. The simple decision to eat smart and move more every day can make a difference, both in cancer risk prevention and in overall health.

Visit aicr.org/assets/docs/pdf/education/aicr-cancer-awareness-report-2012.pdf for more information or to download the complete report.

Are Your Patients Aware of Cancer Risks?

8 | Eye on Quality Volume 17 Issue 2

Clinical Practice Guidelines

Medical Mutual is committed to partnering with our network providers to

provide the highest quality of care to our members. This effort includes adopting

nationally recognized professional organization peer-reviewed clinical practice

guidelines and making them available on our provider website. All published

guidelines have been carefully reviewed by a panel of actively practicing,

board-certified Medical Mutual physician reviewers and can be found on

Provider.MedMutual.com by selecting Tools & Resources, Care Management,

Clinical Quality, Guidelines.

The following Clinical Practice Guidelines have been updated and are available for providers to access on our website:

] Asthma ] Hypertension

] Cholesterol ] Major Depression: Behavioral Health Provider

] Continuity and Coordination of Care: ] Tobacco Dependence Medical Surgical Provider

] Diabetes

It is our hope that you will find these guidelines useful in your daily practice:

] Behavioral Health ] General Surgery

] Cardiology ] Geriatrics

] Family Practice ] Internal Medicine

] General Practice ] Pulmonologists

Below is a list of additional guidelines that can be accessed on our website:

] Alcohol Screening ] Chronic Obstructive Pulmonary Disease (COPD)

] Attention Deficit/Hyperactivity Disorder ] Heart Failure

] Cardiology ] Low Back Pain

] Chronic, Non-Malignant Pain ] Major Depression: Primary Care Physicians

] Continuity of Care Behavioral Health Provider ] Preventive Care

Do you have a comment or suggestion you would like to share with us? We are always interested in hearing from providers regarding our efforts to partner with you to provide the highest quality of care to our members. Contact the Clinical Quality Improvement (CQI) department at 800.586.4523, email us at ClinicalQuality@MedMutual.com, or write to us at the address listed to the right.

We Would Like to Hear from YouMedical MutualMZ: 01-5B-75012060 East 9th StreetCleveland, OH 44115

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2013 Immunization Schedules Update

Each year, the Advisory Committee on Immunization Practices (ACIP) develops

recommendations for routine use of vaccines in children, adolescents and adults

in the United States. This year, for the first time, recommended immunization

schedules for persons aged 0 through 18 years and adults ages 19 years and older

were published together, and both child and adolescent were combined into one

comprehensive schedule.

Healthcare providers are encouraged to use both the recommended schedules and the catch-up schedule in combination with their footnotes and not as stand-alone documents. Highlights of the changes for 2013 include:

] The meningococcal conjugate vaccine (MCV4) for high-risk children has been expanded to age 6 weeks to reflect licensure of Hib-MenCY vaccine.

] Abbreviations for influenza vaccine were updated: Trivalent influenza vaccine (TIV) has been changed to inactivated influenza vaccine (IIV) in anticipation of use of the quadrivalent vaccine for the 2013-2014 influenza season.

] Tetanus and diphtheria toxoids and acellular pertussis (Tdap) vaccine footnotes have been updated to reflect changes, including administration of Tdap to pregnant women during each pregnancy (preferred during 27-36 weeks gestation), regardless of number of years since prior Td or Tdap dose.

Footnotes were combined, and vaccine recommendations were standardized as related to routine vaccination, catch-up vaccination, and vaccination of persons with high-risk medical conditions or special circumstances. Complete information is available at cdc.gov vaccines, or consult Tools & Resources, Care Management 2013 ACIP Immunizations Schedule Resources on our website.

Contacting Care ManagementThe Care Management department is available to address inquiries about utilization management functions, such as inpatient admissions, denials, appeals and referrals (including Behavioral Health services), Monday through Friday, excluding holidays, from 8:15 a.m. to 4:15 p.m. EST. Please refer to the phone numbers on the member’s ID card.

Case Management services are available to help coordinate care, provide information on community resources and provide patient education. Call 800.258.3175 for more information.

10 | Eye on Quality Volume 17 Issue 2

To assist members that are pregnant or those diagnosed with certain chronic diseases,

Medical Mutual offers the SuperWell Disease and Maternity Management Program. In

addition to maternity, this program is available for eligible members diagnosed with one

or more of the following conditions:

] Heart failure ] Chronic obstructive

pulmonary disease ] Diabetes

] Coronary artery disease ] Asthma ] Chronic pain conditions ] Depression

Because many of the above conditions coexist in the same individual, this program can provide the intensive support necessary to make your management more effective. Enrollment in the program provides structured education and support by specially trained Health Coaches. Patients benefit from routine monitoring, education on complication management and following the prescribed treatment plan.

To enroll a patient in the SuperWell Disease and Maternity Management Program, call 800.861.4826.

SuperWell® Disease and Maternity Management Program

Great Way to “Go Green”

Medical Mutual offers network providers access to a secure, safe and simple way to communicate with us online by using our Provider ePortal. The ePortal simplifies many of the services we provide, such as streamlining the reimbursement process with real-time claims adjudication, immediate access to funds through electronic funds transfer, and the

ability to check member eligibility, benefits, claims status and coverage details. Access to online fee schedules, the complete Provider Manual and electronic communication enrollment, as well as the ability to conveniently update accounts and service locations are also featured on the ePortal.

For more information, visit Provider.MedMutual.com and browse through the convenient online demo of the Provider ePortal features and highlights. Enrolling is just as simple and can be done using the same website.

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For Your InformationWe remain committed to supplying you with the programs, information and support needed to ensure the health and well-being of our members and the communities we serve. Access Provider.MedMutual.com, for the following:

Select Tools & Resources/Forms for: ] Online Provider Services ] Forms

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EyE On Quality is publishEd fOr nEtwOrk physicians sErving MEdical Mutual and its faMily Of cOMpaniEs

PCAT-2180 05/23/13

Medical Spotlight

Early Elective Deliveries are Bad MedicineNew Guidelines to Help Manage COPD

Are Your Patients Aware of Cancer Risks?

In This Issue1 Early Elective Deliveries are Bad Medicine2 New Guidelines to Help Manage COPD 2 Tools Available to Reduce Inappropriate Antibiotic Use3 Engage Asthma Patients to Improve Adherence3 Tools for Tobacco Cessation 4 2013 Quality Measures for Respiratory Conditions7 Are Your Patients Aware of Cancer Risks?8 Clinical Practice Guidelines9 2013 Immunization Schedules Update10 Great Way to “Go Green”