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Tennessee | Fourth Quarter 2018

Practice Matters: TN – Fourth Quarter 2018 Provider Services Center: 800-690-1606

Important information for health care professionals and facilities

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In This Issue...• Recommended Metabolic Testing for Behavioral Health HEDIS® measures

• TennCare Kids Screenings and Components

• Thank You to Our Care Providers

• TennCare Policy on Third Party Liability

• Our Quality Management Program

• Preventive Health Care Screenings for Adults

• Care Coordination and Follow-ups Help Address Member Physical and Mental Health Needs

• Flu and Pneumonia Reminder

• Summary of 2018 Medical Record Review

• Cultural Competency Training for Care Providers

We hope you enjoy this edition of Practice Matters. In this issue, you can read about our quality management program, a summary of the 2018 medical record review, care coordination to address physical and mental health needs, and more.

Practice Matters: TX - Summer 2013 Customer Service Center: 888-362-33681 Practice Matters: TN – Fourth Quarter 2018 Provider Services Center: 800-690-16061

Important information for health care professionals and facilities

Recommended Metabolic Testing for Behavioral Health HEDIS® measuresMany studies have shown individuals with schizophrenia or affective disorders are 1½ – 2 times more likely than the general population to have diabetes or obesity. It’s unclear whether this is due specifically to the psychiatric condition or if other factors, such as medication, lifestyle or family history also contribute. Research has noted a pattern of metabolic issues with people taking certain antipsychotic medications. These issues include obesity, diabetes and dyslipidemia.

While adverse effects should be considered when prescribing antipsychotic medications, many industry experts say an individual’s psychiatric condition, symptoms, history of drug response and patient preference, among other things, also should be taken into account. Given these risks, it’s important that patients who take antipsychotic medications be monitored regularly for metabolic abnormalities.

In addition to a baseline measure, the National Committee for Quality Assurance (NCQA) has several recommendations for ongoing testing. NCQA’s Healthcare Effectiveness Data and Information Set (HEDIS®) measures on the use of antipsychotic medications and metabolic testing are listed in the following chart with the recommended tests and timelines for each measure:

Name of measure Recommended Testing Frequency

Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM)

• Fasting blood glucose / HbA1c

• LDL-C / cholesterol

Annually

Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD)

• Fasting blood glucose / HbA1c

Annually

Diabetes Monitoring for People With Diabetes and Schizophrenia (SMD)

• HbA1c

• LDL-C

Annually

If you have patients receiving antipsychotic medications, the following guidelines for metabolic testing are an excellent resource:

• aafp.org/afp/2010/0301/p617.html• ncbi.nlm.nih.gov/pubmed/16933585• cqaimh.org/pdf/tool_metabolic.pdf

TennCare Kids Screenings and ComponentsEarly, Periodic Screening, Diagnosis and Treatment (EPSDT), known in Tennessee as TennCare Kids, is a program aimed at providing children early access to preventive services and timely intervention when medical needs are identified. Network care providers are expected to employ active outreach to help ensure that children are seen according to a prescribed, age-appropriate schedule. To maintain and improve the health status of our members, it’s crucial they receive well-child checkups and necessary follow-up treatment.

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Practice Matters: TX - Summer 2013 Customer Service Center: 888-362-33682 Practice Matters: TN – Fourth Quarter 2018 Provider Services Center: 800-690-16062

Important information for health care professionals and facilities

A complete TennCare Kids screening consists of the following age-appropriate components, required to be done at each visit:

• Comprehensive health history• Complete unclothed/suitably draped physical

examination• Vision and hearing screenings• Developmental/behavioral screenings• Appropriate laboratory tests, according to age and

health history• Immunizations per current American Academy of

Pediatrics (AAP) recommendations• Health education/anticipatory guidance

TennCare Kids members are encouraged to receive their comprehensive health checkups and immunizations on a regular schedule. In addition, remember to do dental referrals no later than age 3 or earlier if necessary. Offering health education and anticipatory guidance to parents is an important component of these visits. Remind your TennCare Kids members and their parents that early detection and treatment can avoid or reduce the effects of many childhood conditions.

Thank You to Our ProvidersAll of us at UnitedHealthcare Community Plan would like to thank the care provider offices who have recently joined in and helped us bring our non-compliant members up-to-date with their EPSDT screenings. Your support of this effort made a tremendous difference and we appreciative your cooperation. Our goal is to make sure every eligible child receives routine EPSDT screenings, and we appreciate your assistance in helping us to achieve this goal.

If your office is interested in collaborating with us to get your non-compliant members in for their EPSDT screenings, we would like to partner with you. Contact your Provider Advocate.

TennCare Policy on Third Party LiabilityTennCare recently issued a policy (number CON 09-001 (Rev. 5)) to clarify responsibilities for identification and billing of third parties for TennCare-covered services. This means care providers must meet the requirement of attempting to determine at the point of service whether a patient has medical coverage other than TennCare. If you learn that your patient’s access to a third party insurance has changed and it’s not reflected in TennCare Online Services, you should complete the TPL Update Request Fax Form and submit it to TennCare.

The policy also noted a change to the list of services for which the “pay and chase” approach is required. This method is no longer used with claims for prenatal care for pregnant women. Instead, they now require the use of the “cost avoidance” approach, in which the state or its agents withhold payment to the care provider until the third party payer has paid its share.

To read the TennCare policy, go to tn.gov/content/dam/tn/tenncare/documents2/con09001.pdf.

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Practice Matters: TX - Summer 2013 Customer Service Center: 888-362-33683 Practice Matters: TN – Fourth Quarter 2018 Provider Services Center: 800-690-16063

Important information for health care professionals and facilities

• Improve patient safety• Make sure members are happy with the plan• Help ensure care providers meet our standards

We use national standards to see how well our QM program works. The National Committee for Quality Assurance (NCQA) writes the standards and compares the quality programs of health plans. We measure our progress meeting our goals using NCQA’s Healthcare Effectiveness Data and Information Set (HEDIS®) Consumer Assessment of Healthcare Providers & Systems (CAHPS®). HEDIS® and CAHPS® results are given in a national report card. Following are 2018 TennCare HEDIS® and CAHPS® highlights that compare our results to national averages:

Our Quality Management ProgramUnitedHealthcare Community Plan wants you to get the best care and service. That’s why we have a Quality Management (QM) program that helps us learn what we can do better and make improvements

Our QM efforts:

• Aid people with health conditions like asthma,diabetes, heart disease, depression, bipolar disorderand schizophrenia

• Help pregnant women have healthy babies• Assist members in staying healthy with shots,

screenings and tests

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Measure

UnitedHealthcareCommunityPlan Middle Tennessee

UnitedHealthcareCommunityPlan East Tennessee

UnitedHealthcareCommunityPlan West Tennessee

HEDIS® 2017 National 50th percentile**

2018 Adult CAHPS® Highlights

Rating of Health Plan* 64% 68% 65% 60%

Rating of Personal Doctor* 64% 70% 66% 67%

Rating of all Health Care* 58% 61% 59% 55%

Rating of Specialist* 64% 75% 70% 67%

How Well Doctors Communicate‡ 91% 93% 91% 92%

2018 Child† CAHPS® Highlights-General Population

Rating of Health Plan* 80% 80% 79% 71%

Rating of Personal Doctor* 79% 77% 76% 77%

Rating of all Health Care* 72% 74% 70% 70%

Rating of Specialist* N/A 78% 70% 73%

How Well Doctors Communicate‡ 96% 93% 93% 94%

†Population eligible members were age 17 and younger as of Dec. 31, 2017.*Percentage reflects members who rated their plan/provider 9 or 10 on a scale of 0-10, 10 being best.N/A assigned when number of respondents total less than 100.‡Percentage reflects respondents indicating ‘always’ or ‘usually.’**National Average is based on the HEDIS® 2017 NCQA 50th percentile.HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

Practice Matters: TX - Summer 2013 Customer Service Center: 888-362-33684 Practice Matters: TN – Fourth Quarter 2018 Provider Services Center: 800-690-16064

Important information for health care professionals and facilities

Preventive Health Care Screenings for AdultsRecommended preventive health care services and screenings for adults is as important as performing TennCare Kids exams. Preventive benefits help adults detect problems early and take an active role in maintaining good health.

The choices our members make about the way they live are important to their health. As their care provider, you can talk to them about the importance of preventive services and the prevention they might need. Remind them that it’s important to follow your advice about checkups, healthy lifestyle choices and medications to prevent health problems. Always encourage regular screenings and assist in keeping our members healthy.

To learn more about our quality health programs, visit UHCprovider.com/tncommunityplan. A paper copy of our QM program description is available on request by calling Customer Services at 800-690-1606.

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2018 HEDIS® Measures

UnitedHealthcareCommunityPlan Middle Tennessee

UnitedHealthcareCommunityPlan East Tennessee

UnitedHealthcareCommunityPlan West Tennessee

HEDIS® 2017 National 50th percentile**

Women’s Health

Breast Cancer Screening 52% 57% 51% 59%

Timeliness of Prenatal Care 70% 85% 77% 84%

Postpartum Care 57% 68% 54% 64%

Diabetes Care

A1C Level Testing 86% 87% 84% 87%

Retinal Eye Exam Performed 44% 57% 49% 55%

Diabetic Blood Pressure Control <140/90

65% 68% 57% 61%

Monitoring for Kidney Disease 90% 93% 89% 90%

Behavioral Health

Antidepressant Medication Management – Effective Continuation Phase Treatment

28% 28% 26% 36%

Practice Matters: TX - Summer 2013 Customer Service Center: 888-362-33685 Practice Matters: TN – Fourth Quarter 2018 Provider Services Center: 800-690-16065

Important information for health care professionals and facilities

Care Coordination and Follow-ups Help Address Member Physical and Mental Health NeedsStudies have shown that more than 68 percent of adults with a mental health disorder reported having at least one general medical disorder, and 29 percent of adults with a medical disorder had a comorbid mental health condition. Since there’s a complex relationship between mental and physical health and there are many ways comorbid disorders can develop, coordination of care among care providers is extremely important.

Patients with mental illness are increasingly benefiting from coordination of medical and behavioral health care. People who experience physical and mental health problems may not always receive appropriate care. Primary Care Providers (PCPs) may attribute symptoms of depression or anxiety to physical illness, while mental health practitioners may overlook physical symptoms or consider them psychosomatic. Understanding the interaction between physical and mental health and providing care that recognizes both is essential.

PCPs who recognize a patient has a need for mental health care may refer that patient to a behavioral health provider. However, studies have shown there are high rates of unrecognized and untreated medical disorders in individuals with mental illness, and many receive psychiatric treatment but don’t have a primary care

physician. Behavioral health professionals may be the first to identify a physical health issue. It’s important for inpatient care providers to be aware that many patients with comorbid disorders say the last physical exam they had was during a psychiatric hospital admission.

UnitedHealthcare Community Plan annually reviews the number of inpatient hospitalizations and PCP referral/appointment outcomes for members. While the percentage of members attending appointments in each region is improving, there’s still a high percentage of members who don’t attend the follow-up appointment or refuse the services entirely. With the high number of individuals affected by comorbid disorders, care providers must take opportunities to educate members about the importance of follow-up medical care and the benefits of sharing information and coordination of care.

REFERENCESDruss, B. & Walker, E. Mental disorders and medical comorbidity. February 2011Williams, D., Health Business Blog, March 11, 2011Kertesz, L., Here’s to Your (Mental) Health, AHIP Coverage (September/October 2006)Lunnay, B. & Bywood, P., Co-morbidity of mental and physical illness: Meeting unmet care needs, Research Roundup Issue 18, August 2011Hahm, H. & Segal, S., Failure to Seek Health Care Among the Mentally Ill. American Journal of Orthopsychiatry, 2005, Vol 75, No. 1, 54-62

Flu and Pneumonia ReminderCare providers should take advantage of each office visit to talk with patients about the flu and pneumonia and their risks for complications. Encourage patients to get their vaccines. It’s their best defense against combating the flu and pneumonia this season. And care providers can also protect themselves and staff by getting vaccinated, too.

Practice Matters: TX - Summer 2013 Customer Service Center: 888-362-33686 Practice Matters: TN – Fourth Quarter 2018 Provider Services Center: 800-690-16066

Important information for health care professionals and facilities

Summary of 2018 Medical Record ReviewThe annual internal 2018 Early and Periodic Screening, Diagnostic and Treatment (EPSDT) medical records review was conducted for each of the three Tennessee regions. Forty five care providers were included in the review, with 135 individual charts reviewed. The average score of all three regions combined was 93 percent. The elements most frequently not documented and identified as opportunities for improvement: were vaccines; TB screening; dyslipidemia testing; and hematocrit/hemoglobin screening/testing. Refer to the 2018 American Academy of Pediatrics and Bright Futures Recommendation for Preventive Pediatric Health Care for current guidelines.

VaccinesVaccines are expected to be given during the EPDST screenings at the appropriate ages according to the Centers for Disease Control and Prevention Immunization Schedule unless there’s a contraindication or parent refusal noted. Any dose not administered at the recommended age should be administered at a subsequent visit, when indicated and feasible.

TB Screening TB screening should be performed at various ages. Testing should be performed on recognition of high-risk factors. You should refer to the 2018 American Academy of Pediatrics and Bright Futures Recommendation for Preventive Pediatric Health Care for current TB guidelines for all youths through age 21. Screenings for our TennCare Kids members are covered up until their 21st birthday.

Dyslipidemia Screening/TestingA dyslipidemia risk assessment should be performed with appropriate action to follow, if positive. It should occur at 24 months, age 4, age 6, age 8 and then yearly from age 12–16, according to American Academy of Pediatrics and Bright Futures. Testing is to be performed once between ages 9–11 and once between ages 17–21. Screenings for our TennCare Kids members are covered up until their 21st birthday.

Hematocrit/Hemoglobin Screening/TestingThe risk assessment should be performed at four months, 15 months, 18 months, 24 months, 30 months, and yearly from age 3–21, according to American Academy of Pediatrics and Bright Futures. Hematocrit or hemoglobin testing should be done at 12 months and at other times if indicated for other reasons (i.e., extensive menstrual or other blood flow, strict vegetarian diet, and diagnosis of anemia in the last two years). This is covered for our TennCare Kids members up until their 21st birthday.

In addition to documenting those elements, dental referrals are to occur no later than age 3 or earlier if necessary. Each of the elements should be addressed during a TennCare Kids well-child exam when appropriate, and all findings should be documented.

Cultural Competency Training for Care ProvidersCultural competency is a set of skills we’re required to disclose about care providers who see Medicaid members. The training for cultural competency covers a broad range of topics.

You may not be aware that you may already have completed cultural competency training as part of requirements for obtaining privileges at the hospital/facility where you practice. The good news is that training counts toward cultural competency training for UnitedHealthcare Community Plan as well.

We request information from the following areas from our network care providers to have updated cultural competency information, which we include in provider directories:

• Communications Skills: Interpreter Services (CS)• Communications Skills: Language Availability (CLA)• Communications Skills: Soft Skills (CSS)• Financially Challenged Patients (FCP)• Homeless (HL)• LGBT communities (LGB)

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Practice Matters: TX - Summer 2013 Customer Service Center: 888-362-33687 Practice Matters: TN – Fourth Quarter 2018 Provider Services Center: 800-690-16067

Important information for health care professionals and facilities

• People with disabilities (PWD)• Refugee or Immigrant Patients (RIP)• Senior Care (SC)• Unspecified (UNS)

We also ask care providers to attest to cultural competencies that are available to their patients and update this information as it changes. Care providers with access to My Patient Profile can update this information online.

Periodically, you may receive a request from us to update your demographic information. The information we request includes a section for cultural competency skills and services you provide to certain populations.

Resources on cultural competency For more information — including quick reference guides and videos to help with using My Practice Profile — visit UHCprovider.com/mpp.

If you need information about cultural competency, please visit UHCprovider.com or the Health and Human Services website at cccm.thinkculturalhealth.hhs.gov.

If you have questions, please call Provider Services at 877-842-3210.

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UnitedHealthcare Community Plan complies with the applicable federal and state civil rights laws, rules, and regulations and does not discriminate against members or participants in the provision of services on the basis of race, color, national origin, religion, sex, age, or disability. If a member or a participant needs language, communication, or disability assistance or to report a discrimination complaint, call 1-800-690-1606. Information about the civil rights laws can be found at https://www.uhccommunityplan.com/tn/medicaid/community-plan.html or from the U.S. Department of Health and Human Services at http://www.hhs.gov/ocr/index.html.

8 Cadillac Drive Suite 100Brentwood, TN 37027

Practice Matters is a quarterly publication for physicians and other health care professionals and facilities in the UnitedHealthcare network.

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