Provider Resources

October 2019

Table of Contents

Network Health Outscores National Averages in Quality Ratings
Ascension Doctor Chooses Local Hospital for Life-Changing Surgery
Detecting Breast Cancer Early with Mammograms
Educating Patients on Appropriate Antibiotic Use
Network Health’s Behavioral Health Committee
Screening Needs for Patients Prescribed Antipsychotic Medications
Challenges in Managing Urinary Incontinence


Network Health Outscores National Averages in Quality Ratings

Network Health earned a 4.5 out of 5 overall Star rating for its Medicare Advantage PPO plans from the Centers for Medicare & Medicaid Services (CMS), outperforming the national average of 4 Stars. Every year, Medicare evaluates plans based on a 5-star rating system. In addition, the National Committee for Quality Assurance (NCQA) awarded Network Health a 4.5 out of 5.0 rating for both Medicare and commercial lines of business for 2019-2020. Network Health is one of only four health plans in Wisconsin receiving this score for Medicare and commercial plans, and no other plans in Wisconsin are rated higher.

The Medicare Advantage Five-Star Quality Rating System was implemented to drive improvements in quality of care and to help consumers make plan comparisons. CMS evaluates plans annually and bases the Five-Star ratings results on clinical data, customer survey responses and plan performance scores spanning the previous two years. This information is timely as consumers start evaluating available health plans during open enrollment for 2020 insurance coverage.

“These ratings recognize the satisfaction of our Network Health members and the excellent care they receive from our providers,” said Kimberly Swanson, MPA, vice president, quality and clinical integration of Network Health. “Our primary goal is to take care of our members by providing high-quality health care. Network Health has the hometown advantage, we know how to serve our members, because we live and work in the same communities.”

NCQA ratings are based on clinical quality, member satisfaction and NCQA Accreditation survey results. Ratings emphasize care outcomes and how members rate their care. Ratings are also given on a scale of zero to five, with five being the highest rating. Network Health is ranked in the top 38 commercial plans and top 25 Medicare plans of the more than 1,000 plans that are NCQA rated.

The health care industry is striving to make improvements in the delivery of high-quality care and the overall member and patient experience. Network Health has always partnered with local providers, including provider owners Ascension and Froedtert, to offer high-quality coverage. With this 4.5 Star rating, Network Health is currently the largest provider-owned Medicare Advantage plan in Wisconsin outranking the national average.


Ascension Doctor Chooses Local Hospital for Life-Changing Surgery

In December 2018, Senior Regional Director of Clinical Informatics for Ascension, Dr. Peter Sanderson started having pain in his hip joint. He is based in Stevens Point where he’s had practicing privileges at St. Michael’s since 1980. He saw a local orthopedic doctor for an x-ray. The results showed slight degenerative arthritis, which he knew was common for someone his age. Ove the next few months, his symptoms persisted to the point where he was walking with a cane and couldn’t walk more than 20 feet without having to stop. A repeat x-ray showed a significant change. The femoral head joint was dying due to lack of blood supply. Ultimately, Sanderson was diagnosed with avascular necrosis of the femoral head.

At this point, Sanderson knew he’d have hip replacement surgery. As a provider with a clinical informatics background, he had a unique perspective. He said, “If it concerns my health and the health of my family and I think there’s a better place to have a procedure, I’ll go to that place and pay more out-of-pocket.” But Sanderson knew about the high-quality, integrated care he would receive at his local Ascension hospital. He said, “I knew there was no place that was going to provide me a better outcome, so why would I go anywhere else?”

Sanderson had detailed information about the team that would do his hip replacement surgery. “I was aware of the surgical success rate, which is high. I was aware of the infection rate, which is incredibly low. In fact, I knew the efforts that were taken in the past whenever there was a post-op infection, which was aggressively treated. The team sat down and said, ‘how can we prevent this in the future?’” He continued, “The service I received was beyond my expectations. And, I don’t think I received special care. I received the same care that everyone else does.”

Sanderson spoke to colleagues who had orthopedic issues or joint replacements and heard the same thing from them. He said, “As an organization, you can advertise all you want, but there’s no better statement about the type of care you provide than when your caregivers, your staff and your physicians stay with you for their care,” he said.

Four months post-op, you wouldn’t know Sanderson had a hip replacement surgery by watching him. He is back to doing the things he enjoys, like playing with his grandchildren, landscape photography and caring for his four dogs. He said, “I know I’m improving all the time. The surgery has been life-altering.”


Detecting Breast Cancer Early with Mammograms

Breast cancer is one of the most common cancers among American women. Mammograms are the best way to detect breast cancer early, when it is easier to treat and before it is big enough to feel or cause symptoms. Working together, Network Health and our primary care providers can promote preventive screenings and improve outcomes through early detection and treatment.

Preventive cancer screenings are a key component of primary care, and regular screening mammograms are highly dependent on recommendations and referrals by a patient’s primary care provider. Providers can help educate patients on when a screening mammogram is appropriate for them.

Network Health follows the guidelines of the United States Preventive Services Task Force and Health Resources and Services Administration, recommending that women have a breast cancer screening mammogram as early as age 40 and no later than age 50, and continue through age 74. The decision to start screening mammograms in women prior to age 50 years should be based on an individual’s overall health and history.


Educating Patients on Appropriate Antibiotic Use

Antibiotics can be highly effective against bacterial infections, but they have become victim of their own achievements. Today, antibiotics are used so widely that patients often have a misconception that antibiotics are the only way they will feel better.

Preventive cancer screenings are a key component of primary care, and regular screening mammograms are highly dependent on recommendations and referrals by a patient’s primary care provider. Providers can help educate patients on when a screening mammogram is appropriate for them.

For example, acute respiratory infections are common in the outpatient setting. Although they are predominantly viral, antibiotics are often prescribed for treatment. Prescribing unnecessary antibiotics may contribute to antibiotic resistance. Antibiotic resistance is a serious public health threat in the United States. A direct means of decreasing inappropriate antibiotic use would be to decrease inappropriate antibiotic prescribing. Also, primary care providers play an important role in patient education, and patients have a trusting relationship with their providers.

Working together, we can educate patients on antibiotic resistance and stress appropriate antibiotic use. Please join our efforts to educate patients that antibiotics only fight infections caused by bacteria, and that they are not always necessary and in some cases, may in fact cause harm. Our members value the advice of their primary care providers, and we appreciate your willingness to help educate them on appropriate antibiotic use.

 

Network Health’s Behavioral Health Committee

Network Health facilitates a Behavioral Health Committee that focuses on provider access, quality of care and coordination and advocates for services that promote prevention, treatment, recovery and self-determination for members experiencing behavioral health, opioid or other substance use disorders. This committee reviews and provides input on policies, quality indicators and service evaluations, and serves as an educational resource for providers and Network Health staff.

Consisting of participating providers, community advocates, resources and Network Health clinical and operational leadership and staff, the Behavioral Health Committee’s responsibility is to provide a platform for behavioral health providers and advocates to address recommendations, questions and concerns directly with Network Health. Their duties consist of the following.

  • Identify significant behavioral health integration challenges and recommend timely solutions
  • Identify areas of opportunity and concern regarding care continuity
  • Develop interventions to improve the quality of care patients receive
  • Identify and advise on best practices for behavioral health care
  • Report up to Network Health’s Quality Management Committee

The committee meets quarterly and uses National Committee for Quality Assurance (NCQA) standards and NCQA Healthcare Effectiveness Data and Information Set (HEDIS) measures to help guide this process.

Working together, we can educate patients on antibiotic resistance and stress appropriate antibiotic use. Please join our efforts to educate patients that antibiotics only fight infections caused by bacteria, and that they are not always necessary and in some cases, may in fact cause harm. Our members value the advice of their primary care providers, and we appreciate your willingness to help educate them on appropriate antibiotic use.

If you’re interested in becoming a Behavioral Health Committee member or would like more information about the committee, contact Network Health’s Quality Health Integration department at mzamost@networkhealth.com.


Screening Needs for Patients Prescribed Antipsychotic Medications

Patients with schizophrenia and affective disorders have 1.5 to two times higher rates of diabetes and obesity when compared with the general population. Obesity, ethnic background, family history and certain medications increase these individual's risk of developing type 2 diabetes¹.

Second generation or “atypical” antipsychotics (SGAs) pose varying risks of metabolic effects, requiring the need to monitor weight, glucose and lipids. clozapine and olanzapine carry a high risk; risperidone and quetiapine carry a moderate risk; and aripiprazole and ziprasidone are associated with lower risk, although their side effects are not yet as well documented as older medications.

Monitoring recommendations for individuals taking SGAs².

Weight Glucose Lipids
Baseline X X X
At four weeks X
At eight weeks X
At 12 weeks X X X
At four months X
Quarterly X
Anually X
Every two–five years X


*More frequent assessment may be warranted based on clinical status.

The HEDIS measure Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD) focuses on individuals 18-64 years of age with schizophrenia, schizoaffective disorder or bipolar disorder, who were dispensed an antipsychotic medication and had an annual diabetes screening test (glucose or HbA1c meet requirement).

Please see the HEDIS 101 Guide for further information on this and other HEDIS measures.

¹ Hinds, Coutler, Hudson & Seaton. (2015). Screening for diabetes in patients receiving second-generation atypical antipsychotics. American Journal of Health-System Pharmacy. 2015; 72: S70-3. ² PL Detail-Document, Comparison of Atypical Antipschotics. Pharmacist's Letter/Prescriber's Letter. October 2012.


Challenges in Managing Urinary Incontinence

Urinary incontinence effects more than 13 million Americans, with 85 percent of them being women. To complicate this further, most patients are 65 years of age or older and at least half of them either won’t or don’t discuss their condition with a health care provider.

For most patients, the apprehension to discuss their urinary incontinence issues may be related to embarrassment, denial, inconvenience and/or perceived additional health care costs. These situations support the importance of developing a personal relationship with patients, which empowers them to feel comfortable with these types of discussions.

Urinary incontinence may be a result of numerous diverse factors including medications, foods, age, smoking, being overweight or specific medical illnesses and complications such as urinary tract infection, aging, menopause and/or prostrate problems.

Early intervention and ongoing management are crucial to improving patient outcomes and patient satisfaction. Best practices recommend that providers evaluate and discuss potential urinary incontinence concerns and treatment options with patients at least every six months, for patients who report urinary difficulties. Managing urinary incontinence may include bladder training exercises, medication and/or referrals to a urologist or other specialist, as determined appropriate by the patient’s primary care provider.

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