Clinical Care & Research
Women's Preventative Health Care - New Free Screenings
As of August 1st, women will receive free access to eight key preventative services under the Affordable Care Act. These free services include well-woman visits; contraceptives and counseling; gestational diabetes screenings; human papillomavirus testing; counseling for sexually transmitted infections; counseling and screening for Human Immunodeficiency Virus; breast-feeding supplies; support and counseling; and domestic violence counseling.
Health insurance companies must now provide these services to women free of charge with no deductible or copay on their plan's next renewal date. This component of the health care act is estimated to help up to 47 million women.
Geriatric Resources on Your SmartphoneYou know the scenario, you are seeing one of your patients who has social needs but you do not know where to turn or refer them. Now the resource is just clicks away in the palm of your hand. You can browse the www.Georgia4seniors.org site for information about senior housing, adult day care, home delivered meals, waiver programs, advocacy assistance and much more. The Georgia Aging and Disabilities Resource Connection maintains this extensive database of services of interest to seniors and persons with disabilities.
Antidepressant Medication Management: Treatment Compliance ImprovingBy Dr. Larry Baker, Associate Medical Director of United Behavioral Health
Primary care doctors are on the front lines of treating depression, as such, they have more capacity to reduce the morbidity associated with depression more than any other professional group. While depression is the most common behavioral health condition affecting adults, it is also one of the most treatable.
However, the patient medication compliance figures for depression indicate that patient non-compliance is considerable and needs to be addressed by primary care physicians with the patient. The National Committee for Quality Assurance (NCQA) provides two measures to monitor medication compliance for patients with depression that are prescribed antidepressant medication. Compliance is monitored for the percentage of patients that stay on their antidepressant medication for at least three months and those that stay on their antidepressant medication for at least six months. Using NCQA's measures the national data shows that nearly 30 percent of primary care patients who initiate antidepressant treatment discontinue treatment within one month of diagnosis and 40 percent to 50 percent discontinue treatment within three months.
So how do primary care physicians improve treatment compliance with depression? One way to increase patient medication compliance is with education at the beginning of the treatment episode.Patients should receive information related to the following key areas:
- How antidepressants work and how long the medication takes to reach therapeutic levels.
- Benefits of antidepressant treatment.
- Expectations regarding the remission of symptoms.
- How long the medications should be used.
- Coping with side effects of the medication.
- Speak to their health care professional often about the side effects of the medication;
- Tell their health professional about all current medical conditions and medications they are taking, including nonprescription drugs, herbs, and supplements to support assessment of potential drug interactions;
- Schedule regular follow-up appointments so their health care professional can monitor progress to determine whether a particular medication is working for them;
- Consider that they may need to try several different medications before finding the one that works best;
- Continue to take medication as prescribed for at least 6 months after they feel better in order to reduce the chances of feeling depressed again. Patients should understand that some people need to remain on medication for several months or years (maintenance therapy); and
- Others need medication for the remainder of their lives, especially those who have had several episodes of major depression.
- Depression is a medical illness, not a character flaw or a weakness.
- Recovery with treatment is the rule, not the exception.
- Treatments are effective and treatment options are available.
- The goal of treatment is complete remission and staying well.
- Ending treatment early increases the chance of symptom reappearance.
- Take your medications every day.
- Psychotherapy/counseling is an effective addition to medication.
- Take your medications for a month; the meds may take this long to work.
- Continue to take your medications even if you feel better.
- Call me if you have side effects that you can't accept.
- If you have any questions about our treatment, let me know at once.
Questions about Georgia Pain RuleThe Georgia Composite Medical Board established new regulations for physicians in relation to managing their patients with chronic pain. The regulations can be found on their website at this link: http://medicalboard.georgia.gov/recently-passed-rules
The Composite Board also posted some frequently asked questions in regards to the new pain regulations that are reprinted below:
- Who must perform the physical exam of a patient enrolled in a licensed hospice setting?
According to rule 360-3-.06.2(c) a physician shall have a medical history of the patient, a physical exam of the patient shall have been conducted and informed consent shall have been obtained. This implies that the physician does not personally have to perform this physical examination. The physical examination may be performed prior to the referral to hospice by the referring physician and documentation of such would be adequate. If a completely new physical exam is required that physical exam must be performed by a licensed healthcare provider and that must be within the scope of practice of that licensed health care provider in the State of Georgia.
- How often do patients need to be tested for compliance under the new board rule?
The rule states that the patient must be seen at least every 90 days when they are being prescribed chronic opiate therapy for greater than 90 days in the one year period. The patient should be checked for compliance during this evaluation. The patient may be seen more often than every 90 days. Evaluations for compliance include physical exam, laboratory evaluation to include serum, sweat, urine or blood testing, pill counts, and interviews. Sweat, serum, urine and blood testing should be done on a random basis. A random basis is defined as a basis which the patient cannot predict ahead of time. It would be difficult to test a patient randomly if they were only seen every three months as the requirement is for them to be tested every three months. In this setting the patient may be called in for a nonclinical visit to be tested as one possible solution to this dilemma or the patient may be seen on a more frequent basis.
- When may a hardship exception to the required patient visit be made?
An exception may be made to seeing the patient at least every 90 days, because of hardship, as long as this is clearly documented in the chart. Hardship is determined by the physician using the physician's judgment in individual cases.
- A patient asks if they have to comply with the new state law on pain management when being prescribed Concerta, a schedule II prescription for ADD.
The new rule applies to schedule II and III substances prescribed for pain or chronic pain. The use of schedule II substances for the management of ADD is not included under the purview of this rule.
- If I prescribe schedule II or III substances to ANY patient more than 90 days, am I required to perform further monitoring?
The rule states that ANY patient prescribed schedule II or III substances 90 days or greater in a calendar year MUST be monitored. The definition of monitoring in the rule states this MUST include serum, urine, saliva or sweat testing EXCEPT in cases of hardship. Any hardship exception must be clearly documented in the patient record. There are no further requirements unless a physician's practice is composed of greater than 50% annual patient population of chronic pain receiving schedule II or III substances.
Resources for Improving Patient Cardiac Health
While clinicians are well informed of the evidence based guidelines to care for patients, often the translation of those guidelines into clinical practice is challenging. Two free programs in Georgia are actively recruiting primary care practices interested in improving the cardiac health of their patients. The projects support the mission of the Department of Health and Human Services Million Hearts Campaign – blood pressure control, lipid management, tobacco cessation and low dose aspirin therapy.
Both programs provide education, onsite technical support, assistance with data collection, interpretation and monitoring. Including:
- Establishing workflows to allow efficient and consistent data capture;
- Developing routine reports that allow quarterly monitoring of measures;
- Implementing a continuous quality improvement program to improve performance.
Alliant/GMCF, the Georgia Medicare Quality Improvement Organization – This project supports practices to successfully submit PQRS and achieve the 2012 financial incentive of 0.5 percent and avoid future penalties for non-reporting. Recruitment is statewide for practices caring for Medicare FFS members.
The COSEHC AT GOAL PI-CME Program - Each physician completing the CME Process Improvement Program will receive 20.0 AMA PRA Category 1 Credit(s)™. The Georgia Department of Public Health, Heart Disease and Stroke Prevention has identified the following high-risk districts to target in recruiting practices for this program: Dublin, Waycross, Macon, LaGrange, Valdosta, and Columbus.
For more information about these resources or the program please contact Adrienne Mims, MD, with Alliant/GMCF at 678-527-3492 and email: Adrienne.firstname.lastname@example.org or Debra Simmons at 336-716-1130 or email@example.com
Accountable Care Final Rule: Much Progress, Casts a Wide Net
By Justin Barnes, vice president with Greenway Medical Technologies and co-chair of the national Accountable Care Community of Practice (ACCoP)
Our nation's shared goal of a sustainable healthcare system of decreased costs and increased care quality through coordinated and accountable delivery took a positive, inclusionary step with the Centers for Medicare and Medicaid Services (CMS) Shared Savings Final Rule.
Consider that this final structuring of Accountable Care Organizations (ACOs), though still built upon primary care providers and their beneficiary patients, has broadened its scope to allow provisions for specialists and nurse practitioners to become ACO members, encourages home health agencies to participate, and embraces eligible critical access hospitals, federally qualified health centers and rural health clinics.
It maintains minimum patient levels at 5,000 and a three-year commitment, but offers logistical and logical flexibility such as allowing providers to participate in more than one ACO when billing from more than one hospital setting.
While the lowering of the number of quality measures (from 65 to 33), the flexibility of 2012 start dates through early summer, and the relaxing of financial risk was all expected, arguably the biggest news of the day was the co-announcement of the Advanced Payment Model, done to bring much of the broader participation into the program.
With Advanced Payment, CMS is putting its own level of financial risk into the program by offering three tiers of startup funding options to healthcare organizations with limited or no inpatient facilities and annual revenue below $80 million, though the startup fees would be paid back out of future shared savings. And there is some fine print: only ACOs entering the program in April or July of 2012 can benefit, also provided there is no health plan ownership in the organization.
CMS is also funding the first two years of patient engagement surveys required of an ACO as a further incentive to participate and further its own financial and programmatic commitment.
The Final Rule also clearly maintains and speaks to the key component of electronic health records (EHRs) as the data sharing connectivity and clinical support core of necessary health information technology. On one hand CMS understood that the still-maturing EHR adoption rates by healthcare providers nationally being fueled by meaningful use – while very encouraging with more than 114,000 eligible providers registered and more than $870 million granted so far in year one - did set an initial high bar by requiring that 50 percent of ACO participants be meaningful users by year two.
Instead, the Final Rule placed EHR adoption as its highest scoring Quality Measure, consistently rewarding increased adoption with higher sharing rates, which "signals the importance of EHR adoption in ACOs," according to the document.
The other quality measures, aligned in four domains of Care Coordination/Patient Safety (in which the EHR measure is rightly placed), Preventive Health, At Risk Population, and Patient/Caregiver Experience, continue to crossover with those of meaningful use and the Physician Quality Reporting System (PQRS). This again promotes EHR adoption, and the Final Rule provides for Shared Saving and PQRS reporting and reward to overlap as well.
Still, there is work to do. CMS must establish national benchmarks for the majority of the quality measures and must finalize the compilation and availability of shared claims data, for example, to do so. For providers and healthcare organizations, there is much to consider. Prior to the issuance of the Final Rule, CMS announced the Pioneer Model, the Bundled Payments for Care Improvement Initiative, and the Primary Care Initiative, all offering additional routes and choices for the pursuit of incentivized care coordination. And even here too, the Final Rule allows for some dual participations as a further incentive.
And as commercial payers, employers and health plans are increasingly entering the conversation and shaping other forms of accountable care models, it is clearly time to determine your own best practice inclusion into models being discussed and planned in your region. Care coordination took a big step toward reality with the issuance of the Final Rule, and as these organizations form, providers, like patients, should not be left out.
New Tobacco Cessation Resources for Family Physicians
The Georgia Tobacco Use Prevention Program of the Georgia Department of Public Health (DPH) has new educational materials available at no cost to all healthcare professionals throughout Georgia. These free materials include posters and brochures for physician offices.
The new Georgia Tobacco Quit Line/Tobacco Cessation brochures are also available beginning this month. These new brochures are available in 4 versions. Healthcare professionals can order all 4 versions and free shipping is provided throughout the entire state of Georgia. In addition, free Georgia Tobacco Quit Line prescription pads are available.
The Georgia Tobacco Quit Line: 1-877-270-STOP (7867) is a free and confidential professional cessation counseling, support and referral service for tobacco users trying to quit. Established since 2001, the Georgia Tobacco Quit Line is operated by a national tobacco cessation vendor.
Regardless of insurance status, the Georgia Tobacco Quit Line services (i.e. professional telephone counseling, referral and educational support) are free to all Georgians. To obtain more information about the Georgia Tobacco Quit Line, physicians can access the "Be Smoke-Free" section of the Live Healthy Georgia website at: http://www.livehealthygeorgia.org.
EHR Incentive Program – Clinical Quality Measures Webinar Now Available
Recently, CMS held a webinar to discuss the clinical quality measures (CQMs) and how to successfully report them during Stage 1 of meaningful use for the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs.
A PDF of the webinar presentation is now available online. Go to the Spotlight and Upcoming Event section at https://www.cms.gov/EHRIncentivePrograms/50_Spotlight.asp#TopOfPage of the Medicare and Medicaid EHR Incentive Programs website to download this presentation.
The presentation includes information on:
- An overview of the CQMs
- How to report CQMs during attestation
- Why CQMs are included in the EHR Incentive Programs
The webinar also includes an hour-long question-and-answer session with CMS subject matter experts. CMS plans to host another CQM webinar soon. Stay tuned for updates on how you can join this informational session.
Want more information about the EHR Incentive Programs?
Make sure to visit the Medicare and Medicaid EHR Incentive Programs website at https://www.cms.gov/ehrincentiveprograms/ for the latest news and updates on the EHR Incentive Programs or the local Georgia Health Extension Center at www.ga-hitrec.org.
Childhood Obesity Program – Strong4Life
Children's Healthcare of Atlanta (CHOA) has launched Strong4Life, a statewide movement to raise awareness of the childhood obesity crisis in our state and to offer solutions through programs, partnerships and clinical interventions. Strong4Life includes a large-scale public awareness campaign and programs that reach kids and families in schools, early childhood centers, physicians' offices, communities and more. With nearly 40 percent of Georgia's children being overweight or obese, Georgia has the second highest childhood obesity rate in the U.S.
CHOA sees it on the front lines in their hospitals every day: children who are overweight are now suffering from diseases once seen only in adults such as heart disease, hypertension, liver and kidney disease and Type 2 diabetes. CHOA knows that many physicians face this challenge in their practices, understanding that the issue is not just with the child, but in creating long-lasting behavior change that encompasses the entire family and community. One of the greatest hurdles physicians face is denial from both parents and our society, and addressing the health of the child often demands parents and caretakers think about their own health decisions. The studies showed that children want for those around them to be frank and open with them about the issue of obesity.
In Atlanta, you likely have seen some powerful advertising on billboards and TV. Strong4Life's "Warning" campaign, similar to other public health campaigns, is designed to alert parents about the health crisis and get people talking about the issue. CHOA's experience in launching Strong4Life in Columbus and Macon this spring demonstrated that this approach sparked critical conversation within those communities and an overwhelming majority reacted positively to the campaign's message.
Visit http://www.choa.org/Child-Wellness/Strong4Life-Programs/Providers to learn more and to get engaged in the Strong4Life movement. Together, we can make Georgia a leader in childhood wellness, instead of a leader in childhood obesity.
Behavioral Aspects of DementiaBy Adrienne Mims, MD
There have been recent concerns regarding the appropriate use of antipsychotic medications for patients in nursing homes. Boxed warnings were implemented for antipsychotic drugs in 2005 and the FDA expanded this warning to conventional antipsychotics in 2008. In May 2011, the Office of the Inspector General put out a report on Medicare Atypical Antipsychotic Drug Claims for Elderly Nursing Home Residents. The report used Medicare claims data from Part B and D and the Minimum Data Set to identify Medicare claims and payments for atypical antipsychotic drugs for elderly patients (age 65 and older) residing in nursing homes from Jan 1 through June 30, 2007.
- 14 percent of residents had claims for atypical antipsychotic drugs
- 38 percent were associated with off-label use
- 88 percent were associated with a condition in the FDA boxed warning (i.e. dementia)
- 22 percent were not administered in accordance with CMS standards (see below)
More recent CMS data, from a CMS Report for 3rd quarter calendar year 2010, noted that 39.4 percent of nursing home residents who had cognitive impairments and behavior problems, but no diagnosis of psychosis or related conditions, received an antipsychotic. 15.6 percent who had no cognitive impairment or behavior problems also received antipsychotics.
Code of Federal Regulations stipulates in 42 CFR 483.25 that:
- Antipsychotic use should treat specific condition as diagnosed and documented in chart
- Antipsychotic used should be accompanied by gradual dose reductions and behavioral interventions
To address this concern, the American Geriatric Society (AGS) has produced a resource to assist clinicians who care for patients with dementia that exhibit psychotic symptoms. This resource describes the appropriate diagnostic and therapeutic management of such patients and makes recommendations for when atypical antipsychotics can be used. The resource emphasizes the importance of a thorough evaluation of neuropsychiatric symptoms as they may be due to reversible conditions. Also, the use of non-pharmacologic treatments is addressed and the consideration for time limited use of antipsychotic drugs to reduce rather than eliminate the distressing symptoms. This resource is available at: http://dementia.americangeriatrics.org/AGSGeriPsychConsult.pdf
Additionally, the AGS has created a free companion tool application from iTunes called GeriPsych Consult. This app has been developed to assist healthcare providers in managing psychotic symptoms and disorders in older adults. This tool is available at: http://itunes.apple.com/us/app/geripsych-consult/id451511117?ls=1&mt=8
The Effective Healthcare Program: Helping You Make Better Treatment ChoicesPosted by Evelyn L. Lewis, MD, MA, FAAFP
The Effective Healthcare Program was created by Congress in Section 1013 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003. The program is administered by the Agency for Healthcare Research and Quality (AHRQ), which is part of the U.S. Department of Health and Human Services. Under that legislation, the Agency for Healthcare Research and Quality (AHRQ) is authorized to conduct and support research with a focus on comparing the outcomes and effectiveness of different treatments and clinical approaches. Priority topic areas of study include arthritis and non- traumatic joint disorders, cancer, cardiovascular disease including stroke and hypertension, dementia including Alzheimer's disease, depression and other mental health disorders, developmental delays, ADHD, autism, diabetes, disability, pregnancy and preterm birth, substance abuse, pulmonary disease, infectious diseases and HIV/AIDS, and obesity.
It allows patients and their clinicians to work better together to choose the best treatment for an illness or condition. Comparative effectiveness research also helps patients and families understand the effectiveness and risks of different treatment options while allowing for choices based on the circumstances of the individual patient.
How is Comparative Effectiveness Research Used?
Every patient is different – with different circumstances, different medical histories, and different values. Comparative Effectiveness Research (CER) doesn't tell patients and clinicians which treatment to choose. Instead, CER reviews the benefits and harms of options and serves as a useful tool for everyone participating in the decision making:
- Patients face complicated choices: Which test will help most? Which medicine is best? Is surgery the best option? By providing more information, CER helps patients work with their clinicians to make the best possible choices.
- Doctors and other healthcare providers use CER to keep up on the best available scientific evidence on a particular healthcare topic, such as treatments for a chronic condition like diabetes. CER assists providers in learning how well a particular group of medications works in specific categories of patients. It also describes the strength of evidence behind scientific findings.
- Policymakers, business leaders, and others strive to make healthcare decisions based on the best available information. CER helps decision makers plan public health programs, design health insurance coverage, and initiate wellness or advocacy programs.
Hallmarks of the Effective Healthcare Program
There are four key hallmarks of the program. First and foremost, the program is aimed at practical issues. The reports that are produced do not make treatment recommendations but instead address practical questions about the potential harms of treatment options. The condensed summary guides that are produced contain "bottom Line" findings to help patients, clinicians, and policymakers make the best possible decisions.
Secondly, the program involves the public. Research ideas are requested from all sources – physicians, clinicians, educators, the private sector, disease advocacy groups, patients and others. Once draft research questions regarding recommended topics are formulated, they are posted online for public comment. In addition, the volunteer Effective Healthcare Program Stakeholders Group provides input in important areas. They provide guidance on improving the overall quality and impact of the Program and its products.
Thirdly, the program protects against conflict of interest. Any of the researchers participating in the program must disclose any potential conflicts of interest. All published research as well as treatment data that are available, but not yet published, is reviewed by researchers. In addition, all reports are peer reviewed before publication.
Lastly, the program pushes research forward. Each of the reports identifies relevant and specific clinical issues where reliable information is lacking. Unanswered questions as well as gaps in the research are often addressed in future projects.
The Research Process
Any individual or organization can submit a suggestion for research under the Effective Healthcare Program Web site. Topic nominations are reviewed by AHRQ staff for factors such as, how widespread and serious is the disease; what are the costs and available treatments; the amount of controversy regarding the treatment and the potential for improving and impacting care. Accepted suggestions are then sent to independent research teams to refine the research questions. The teams then either conduct a research review or produce a new research report.
Who Conducts the Research for the Effective Healthcare Program?
Networks of research and clinical teams produce the Effective Healthcare Program reports and publications across North America. For example, evidence-based practice centers perform the comprehensive research reviews of existing evidence. New scientific evidence and analytic tools are generated by DEcIDE (Developing Evidence to Inform Decisions about Effectiveness). Centers for Education & Research on Therapeutics or CERTs conduct research and provide education on the best use of drugs, biologics, and medical devices. The John M. Eisenberg Clinical Decisions and Communications Science Center converts the research results into summary guides and other resources. New evidence is generated from original research by individual investigators and their research groups located at academic institutions.
To learn more about the program and how you can get involved go to the Effective Healthcare Program website at www.effectivehealthcare.ahrq.gov to view publications, listen to audio-casts, suggest topics or comment on draft key questions. You can also contact Evelyn L. Lewis, MD, MA, FAAFP, and the Patient Centered Outcomes Consultant Regional Manager by email at firstname.lastname@example.org to schedule a visit to your practice.
Prevent Blindness Georgia Trains Physician Practices
in Vision Screening
Prevent Blindness Georgia vision screened more than 33,000 four-year old children in Georgia in 2010. The screenings are offered free of charge and are funded by grants and donations. Although most of these children are required to have EED (ear/eye/dental) screenings prior to entering school, about six percent of them fail the vision screening and are referred to an eye care professional for further evaluation. In many cases, the children failed the screening at their well-child checkups, but the parents had not followed up with an eye care professional. In other cases, the previous vision screening did not detect vision problems.
Physicians are the first line of defense in preventing vision loss in children. Prevent Blindness Georgia is making it a priority to ensure that the staffs of Georgia's family physicians and pediatricians are trained in the best evidence-based method of vision screening children, using a manual jointly published by Prevent Blindness America and the American Academy of Pediatrics. This methodology uses simple, but effective tools such as the Lea Symbols Chart with child-friendly shapes and the Random Dot "E" test with 3-D stereopsis glasses to identify children at risk for such childhood vision issues as amblyopia, strabismus, or refractive errors and refer them for an eye exam.
The Kid's Health First Pediatric Alliance and The Children's Health Network have sponsored trainings conducted by Prevent Blindness Georgia to ensure that physicians are familiar with this method. For more information visit www.pbga.org or call Prevent Blindness Georgia at 404-266-2020.