WIXLIB

IN T H IS ISSUE :PUBLISHED FOR INTER VALLEY HEALTH PLAN PHYSICIANSHEDIS 2004 ResultsBenefits for 2005Info-LinkFA L L 2 0 0 4Disease Management UpdatePharmacy UpdateBrands Soon to be GenericsQuality Measures forTreatment of DepressionKudos CornerVolume V Issue 2HEDIS 2004 RESULTSIt is that time of the year again! Every year since 2000 Inter Valley Health Plan has shared its HEDIS scores withour physician network. HEDIS is a set of standardized measures designed to compare the performance of managedhealth care plans.The goal is to effectively use HEDIS measures to improve quality.Old MeasuresIn 2004 Inter Valley showed improvement in eight out of eleven Effectiveness of Care Measures (see graphbelow). Two Comprehensive Diabetes Care measures are of concern to the Plan, i.e. the rate of annual dilated retinalexamination decreased by seven percent, and the percentage of LDL testing in diabetics decreased by two percent.The good news is that we showed improvement in controlling high blood pressure, in HgbA1C values indicatingbetter glycemic control in diabetics, and in nephropathy screening.Of equal concern are low results on the following new 2004 HEDIS measures:LDL value 100 mg % after an acute cardiac event.37%Colorectal Cancer screening .45%LDL 100 mg% in diabetics .40%continued on page 32002 – 2003 EFFECTIVENESS OF CARE holesterolManagementLDL 60 -365CholesterolManagementLDL Level 130ControllingHigh 210090 98 97% %90 889088 %8085% %83%80%77 7782757074 %%72% %70% %%% 676064 %6460%59%%55 %50%%403020100Comprehensive Comprehensive Comprehensive Comprehensive Comprehensive tesDiabetesHbA1C level RetinopathyHbA1CLDLLDL LevelNephropathy 9.0 130

D I S E A S EM A N A G E M E N TInter Valley Health Plan’s Disease Management Programhas identified 1,383 members with Congestive HeartU P D AT Etheir self-management efforts.Case Managers collaborate with the PCPs and otherFailure (CHF) and stratified them according to risk factorsstaff to develop effective coordination strategies andbased upon the following criteria:patient care plans based on patients’ clinical, emotional,HIGH RISK: any emergency room visit/hospitaland psychosocial needs, and in accordance with theadmission and two or more co-morbidities,practice guidelines. In addition, other methods ofMEDIUM RISK: at least two office visits and two ormore co-morbidities, orengaging and retaining members in an active program ofeducation, support, and advocacy are utilized to reduceLOW RISK: office visit only—no inpatient orcost, and facilitate health status improvements.emergency room visit and no co-morbidities.Inter Valley Health Plan believes that the PCP plays anThe CHF members were identified through:important role in the success of our Disease ManagementHealth Risk Assessment for new enrolleesProgram.This program is designed to support you, theHospital/Physician/Member ReferralsPCP, with the care of your patients.The process beginsEncounter datawhen you refer patients to our program and continuesQAPI ProjectChart ReviewA packet was mailed to the High-Risk members whichincluded educational materials, a SF-36 Health Statusthrough our updates about your patients’ health status.If you have any questions, please contact CindyQuestionnaire, and a welcome letter. Although thisNinofranco, CHF Case Manager, at (909) 623-6333,program is voluntary, we strongly encourage members toextension 298. Please send any referrals of CHF patientsjoin so we may help coordinate their care and improvefor inclusion in the Program by fax at (909) 620-8092.BENEFITSFOR20052005 is fast approaching and Inter Valley will be notifying our Service To Senior members about our annualchange of benefits. Member should receive this information by November 1. This year we are delighted toreport that there will be very minor changes. The benefit changes are enhancements to the overall benefitpackage. In addition, we have added several Brand Name Drugs to our approved list.You will find thosepharmacy enhancements on the Pharmacy Update insert of this newsletter.Below is a list of the benefit highlights most important to the physician offices and the members.Los Angeles CountyHealth Plan PremiumPCP VisitSpecialist VisitHospital CopayOutpatient Surgery2004 Copay 0 5 10 75 a day – max 375 1002005 Copay 0 5 10 75 a day – max 375 100Members in Los Angeles County will receive a Part B Premium refund of 10 every monthfor being a member of Inter Valley Health Plan.San Bernardino & Riverside CountiesHealth Plan PremiumPCP VisitSpecialist VisitHospital CopayOutpatient Surgery22004 Copay 0 5 10 100 a day – max 500 1002005 Copay 0 5 10 75 a day – max 600 100

Q U A L I T Y M E A S U R E S F O R T R E AT M E N T O F D E P R E S S I O NThe point prevalence for major depressive disorder in the Westernindustrialized nations is 2.3% - 3.2% for men and 4.5%-9.3% forwomen. Risk factors for major depression include femalegender, a history of depressive illness in first-degreerelatives, and prior episodes of major depression. Patientswith major depressive disorder have substantialamounts of physical and psychological disability, aswell as occupational difficulties.One of the HEDIS* measures is “AntidepressantMedication Management (AMM)”. Consumers,purchasers and providers consider this measureimportant and valuable as an indicator for the qualityof care given the patients with depressive disorders.This standard consists of the following threedifferent measurements.123Optimal Practitioner Contacts forMedication ManagementMembers who are diagnosed with a new episode of depression and treatedwith antidepressant medication should have at least three visits with either a mental health provider or nonmental health provider during the 84-day (12 week) Acute Treatment Phase.Ef fective Acute Phase TreatmentMembers who are diagnosed with a new episode of depression and treated with antidepressantmedication, and who remained on an antidepressant drug during the entire 84-day (12 week) AcuteTreatment PhaseEf fective Continuation Phase TreatmentMembers who are diagnosed with a new episode of depression and treated with antidepressantmedication, and who remained on an antidepressant drug for at least 180 days (6 months)In this age of quality measurements, physicians not only should provide quality care, but they should documentthis by using the appropriate codes.When treating depression in conjunction with other medical disorders, amental health diagnosis or service code must be used with the Evaluation and Management Codes.The mentalhealth codes for depression are as follows: ICD-9 Codes: 296.2, 296.3, 298.0, 300.4, 309.1, 311 or DRG 426.*HEDIS is a registered trademark of NCQAHEDIS 2004 RESULTS CONTINUEDInter Valley Health Plan strives to improve theOsteoporosis Management in womenwho had a fracture .17%quality of care received by members based onAntidepressant management .11%by working with physicians for necessaryAlcohol and other drug dependencyfollow-up with a provider.11%interventions, such as patient education, physicianevidence-based guidelines.This we hope to accomplishreminders, case management and disease management.3

K U D O SC O R N E RAs talked about in the last issue of InfoLink, Inter Valley has started a ProviderAppreciation Program designed torecognize our providers for all they do tofurther the success of the Plan. As such,we would like to recognize the followingProvider Groups and/or Hospitals forsuccessfully passing their audits ofdelegated functions with a score of 95%or above:Combined Management Services forCitrus Valley Physicians Group, EastlandMedical Group and West CovinaMedical Clinic — Credentialing AuditHeritage Victor Valley — ClaimsProcessing AuditSt. Mary Medical Center — ClaimsProcessing AuditPrime Partners IPA Medical Group —Claims Processing AuditRiverside Medical Clinic — UtilizationManagement, Quality Management andCredentialing AuditsAdditionally, we would also like totake this opportunity tocongratulate the following physicianand/or staff for obtaining theircertification in Older Adult Sensitivityby attending one of the training sessionsco-sponsored by Inter Valley Health Planand Pfizer Pharmaceuticals:Physicians attending the workshopTiffany Endo M.D.Craig Endo M.D.Richard F. DiThomas M.D.Redemption Geronimo M.D.Sudath Jeereddi M.D.Hedy Loa M.D.Glenn Miya M.D.Claudia Pena M.D.Physician staf f attending the workshopMohamed Ali M.D. OfficeMario Diaz M.D. OfficeFamily Foot CenterHerman M. Geller M.D. OfficeSudath Jeereddi M.D. OfficeKing-Yee Yu M.D. OfficeEwa Konca M.D. OfficeAlaa Latif M.D. OfficeLa Verne Medical Group PhysiciansSadiq Mandalawi M.D. OfficeYogesh K. Paliwal M.D. OfficePVHMC Family MedicineStephen Rathbun M.D. OfficeGerald Rude M.D. OfficeDaryoosh Valamanesh M.D. OfficeCongratulations to all and keep up the good work.CONTRIBUTING EDITORSRemedios L. Amirante, M.D. Medical DirectorCyndie O’Brien CommunicationsFidel Valenzuela, Pharm. D. Health ServicesSusan Tenorio, BSN,R.N. Health ServicesJeannie Lauppe, R.N. Health ServicesInfo-LinkEDITOR’S NOTE: We value youropinion. If you have anycomments on thisissue of Info-Link or have atopic suggestion for futureissues, please contact CyndieO’Brien at 909/623-6333 ore-mail cobrien@ivhp.com.300 South Park AvenueP.O. Box 6002Pomona, CA 91769-6002Dual GraphicsPAIDU.S. POSTAGEPRESORTED STD

pharmacyUP H A R M A C YPDB E N E F I TATEC H A N G E SI N2 0 0 5Inter Valley strives to provide its members with a pharmacy benefit (Brand-Generic) in all counties.We are alsocommitted to maintain an easy to understand benefit and have chosen to minimize the changes to the pharmacybenefit for 2005. Please note the few changes in 2005, which may impact some of your patients.LOS ANGELES COUNTYDrug2004 Benefit2005 Benefit ChangeACTOSCovered on tier 3Not Covered (Use Avandia)CIPROCovered on tier 2Not Covered Use generic Cipro (Ciprofloxacin)KETEKNot coveredCovered on tier 2LANTUSCovered on tier 3Covered on tier 2LORATADINE (OTC)Not coveredCovered on tier 1 generic ClaritinMIACALCIN NASALNot coveredCovered on tier 3NOVOLOGHUMOLOGCovered on tier 3Covered on tier 2ZITHROMAXCovered on tier 3Covered on tier 2RIVERSIDE/SAN BERNARDINO COUNTIESDrug2004 Benefit2005 Benefit ChangeACTOSCovered on tier 3Not Covered (Use Avandia)ARAVANot CoveredCovered on tier 3CIPROCovered on tier 2Not Covered Use generic Cipro (Ciprofloxacin)KETEKNot coveredCovered on tier 2LANTUSCovered on tier 3Covered on tier 2LORATADINE (OTC)Not coveredCovered on tier 1 generic ClaritinMIACALCIN NASALNot coveredCovered on tier 3NOVOLOGHUMOLOGCovered on tier 3Covered on tier 2ZITHROMAXCovered on tier 3Covered on tier 2