Provider Resources

June 2019

Table of Contents

Meet the Network Health Medical Directors
Statins: Helping Patients Separate Truth from Myth
Quality Measures for Behavioral Health
Behavioral Health Care Managers Support Patients in Need

Network Health Launches New Clinical Newsletter

This month, Network Health adds a clinical-focus newsletter to our suite of provider communications which currently includes The Pulse (for operations news, such as claims updates) and The Script (for pharmacy news and updates).

The Consult is a monthly communication to strengthen collaboration with clinicians. Together, we can ensure our members, your patients, are satisfied they receive the best quality care in the right place at the right time.

This newsletter will notify you about our member programs designed to close care gaps, inform you about initiatives around specific quality measures, and share highlights and success stories from our health management teams and network providers.

Every month, we will feature a clinician doing innovative work in his or her practice to improve health outcomes and patient satisfaction. For our inaugural issue, we shined the spotlight on our Network Health Medical Director team.

Led by Dr. Gregory Buran, chief medical officer, this team of board certified physicians lends its clinical expertise to business practices in population health—including utilization management, health management, quality and clinical integration.

Meet the Network Health Medical Directors

Dr. Gregory Buran, Chief Medical Officer

Dr. Buran leads the clinical development and direction of Network Health. He has practiced medicine for more than 30 years—primary care internal medicine—and is an award-winning academic hospitalist who spent more than 25 years teaching hospital staff and medical students.

“I like teaching and I have a bias toward efficiency—reducing waste and improving the patient experience—so my role at Network Health is a good transition because I have influence over what type of benefits we offer,” Buran says. “We don’t want to put up barriers to essential services.

“I also feel good about the team we have put together—the medical directors and the great teams in population health have all come together and really gelled.”

This team approach not only benefits members, but also helps providers.

“A key role of a medical director is to serve as a liaison with clinicians,” Buran says. “We are here to understand their concerns on a clinical level. We want to work collaboratively with providers.”
Collaboration includes peer-to-peer reviews for utilization management, but it also encompasses ongoing efforts in provider relations and clinical integration.

“I am proud of the success we have had with the clinical integration process,” Buran says. “Our relationship with providers has improved. There is greater trust on both sides, which allows us to work more effectively together.”

Dr. Rita Hanson, Medical Director of Clinical Integration

Dr. Hanson was a primary care physician for more than 40 years. She now helps lead the Clinical Integration (CI) efforts between six provider systems and Network Health. The providers are compensated based on quality of care and patient satisfaction. The participating systems meet monthly to analyze quality results, share best practices and brainstorm ideas for improvement.
“There is a great deal of similarity between the work I was doing on the hospital and clinic side and the work that I do now,” Hanson says. “My medical knowledge and understanding of how decisions are made in a hospital, and how care is delivered at the bedside, is used every day in my current role as I collaborate with providers.

“It’s common for doctors and hospitals to view insurance companies as ‘the bad guy’ that gets in the way of their ability to take care of patients,” Hanson says. “We have seen that perception shift through clinical integration. CI providers view Network Health as a value-added partner.

“This relationship also helps us identify barriers to access—transportation or help for caregivers, for example—so we can look at benefits to address those concerns. CI is like our think tank—what we learn from the group, we can apply broadly for the benefit of all.”

Dr. Anthony Otters and Dr. Nicole Brady, Medical Directors

In addition to their participation in strategic planning, provider relations and clinical leadership, Dr. Otters and Dr. Brady perform utilization reviews for services, procedures and use of facilities under Network Health’s insurance plans. They evaluate the medical necessity, appropriateness and effectiveness of health care.

Before joining Network Health, Dr. Otters spent more than a decade working as a hospitalist, served as a professor of medicine at the University of Wisconsin Medical School, and worked as the lead Medicaid medical director in Wisconsin for Anthem.

“I came to Network Health to be involved in something transformational in health care,” Otters says. “The insurance side and the clinical side can’t exist separately much longer. I wanted to move to a model where the local control was greater. With big national insurance companies, the decisions are made from the top down—there is no opportunity for out-of-box thinking or creative solutions. Here, we have the autonomy to get innovative and work with our local systems. We can take provider feedback and act.”

Dr. Brady was a part of that feedback loop as a local provider before joining Network Health. She was a family physician at Ascension | Ministry Health Care and Affinity Medical Group. She spent four years as medical director of primary care at Affinity Medical Group prior to serving as regional vice president for Affinity/Ministry Medical Group from 2015 to 2018. During her time with Affinity and Ministry, she served on numerous Network Health committees.

“We have an amazing team working collaboratively with physicians, providers, hospitals and other facilities to truly improve the care of those living in our communities,” Brady says. “I think providers respect that decisions made at Network Health are vetted by colleagues who truly know what it is like to practice medicine and where provider pain points are in the health care environment.”

Dr. Otters agrees, “As a former hospitalist, I am very comfortable with the hospital environment and understand the issues our providers face. This helps me communicate and collaborate more effectively. Then, as an educator, I will dive into specialty cases and prep and research so I can be an educated participant in a peer-to-peer conversation. This way, the specialist doesn’t need to explain all the basics to me and we can focus on the key elements of the case.”

Dr. Thomas Heinrich, Associate Medical Director

Dr. Thomas Heinrich is a professor of psychiatry and family medicine at the Medical College of Wisconsin (MCW) and practices on the psychiatric consultation service at Froedtert Hospital in Milwaukee. He is board certified in family medicine and general adult psychiatry and holds subspecialty certification in consultation-liaison psychiatry and neuropsychiatry.

“As an educator, I have realized that we don’t teach medical students or residents about how insurance companies work and that often contributes to a future of adversarial interactions,” Heinrich says. “It’s important for providers and payers to work together.”

Heinrich, who works on behavioral health quality metrics at Froedtert, says, “The opportunity at Network Health was interesting because I was unfamiliar with the role insurance companies play in driving quality initiatives. It was reassuring to learn how much effort goes into ensuring quality of care for members and patients.”

Heinrich says that as a clinician he has interacted with insurance companies for decades, and now he can represent the insurance company and interact with other clinicians on cases, working peer-to-peer, helping them understand the resources available to their patients.

“I am especially proud of the innovative approach Network Health has taken toward increasing access to behavioral health care,” Heinrich says. “The telehealth options (like MDLIVE®) allow us to help more members find the care they need when they need it.

“Everyone [payers and providers] brings something to the table to influence patient care,” Heinrich says. “Nothing gets done unless it gets done collaboratively.”

Statin Medication: Helping Patients Separate Truth from Myth

It’s estimated that 50 percent of patients stop taking their statin medication within a year of starting, according to research published in Pharmacist’s Letter. Myths spread through the internet that dramatize concerns are likely to contribute to the issue of statin discontinuation or even hesitancy to start a statin.

In most situations, however, the benefits of statin therapy far outweigh the risks, and addressing the myths with patients can play an important role in their willingness to start and remain adherent to a statin medication.

At Network Health, our pharmacists have created an informational member booklet that debunks the seven most common myths that discourage patients from taking statins. This booklet was most recently mailed to members with diabetes to encourage medication adherence. Below is an example of the myths covered in the booklet Statin Medications: Separating Truth from Myth.

Myth #3: Statins will cause muscle pain Less than 5 percent of people on statins will develop muscle pain. If the pain is related to the medication, you may be able to take a different statin medication, reduce your dose or change the frequency (for example, taking three times a week instead of daily).

More than 70 percent of statin users who experience muscle symptoms won’t have the same issue with a different statin or a different dose. If you experience muscle pain while on a statin, talk to your personal doctor about it.

Sharing facts about prescription medication is only one way we promote health and well-being among our members. We also encourage them to build a relationship with you, their personal doctors, so you can help them develop a medication strategy that achieves their goals.

Quality Measures for Behavioral Health

The Network Health quality management team works with providers and members to improve the continuity of care between medical and behavioral healthcare through six quality measures.

Our quality team builds these measures based on factors and standards set by the National Committee for Quality Assurance (NCQA), using HEDIS measures wherever applicable. Quality campaigns include collaboration with providers for data exchange and medical record reviews, as well as member communications encouraging follow-up visits and informational articles in member newsletters, magazines, blogs and social media.

The six measures addressed for behavioral health include the following areas that impact the health and well-being of members.

  • Exchange of Information
  • Follow-Up Care for Children Prescribed ADHD Medication
  • Antidepressant Medication Management
  • Follow-Up After Hospitalization for Mental Illness
  • Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
  • The Need for Depression Screening in Primary Care

Exchange of Information (EOI) assesses the frequency that information is shared between primary care providers and behavioral health specialists regarding their mutual patients. Evidence of EOI is found through documentation in the primary care provider’s EMR. EOI assists providers in developing complete care plans, utilizing complimentary treatments, and avoiding undesired interactions and duplication of services.

Follow-Up Care for Children Prescribed ADHD Medication (ADD) assesses the percentage of members 6-12 years old who had at least three follow-up care visits within a 10-month period of initially starting an ADHD medication, or restarting after a period of 120 days with no ADHD medication being dispensed, mirroring best practice guidelines.

Antidepressant Medication Management (AMM) assesses the percentage of members 18 years and older who were prescribed an antidepressant for a diagnosis of major depression, and who continued taking the medication as prescribed. The goal of this measure is to identify barriers to medication compliance.

Follow-Up After Hospitalization for Mental Illness (FUH) assesses the percentage of members 6 years and older who were hospitalized for treatment of behavioral health diagnoses, and who had a follow-up visit with a mental health practitioner. Behavioral health specialists are uniquely qualified to identify treatment barriers or concerns for this population.

Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD) assesses the percentage of members 18-64 years old who were dispensed an antipsychotic medication, and who had a diabetes screening test during the measurement year. Members in this population have a higher risk of diabetes and obesity, increasing the need for monitoring of metabolic effects.

The Need for Depression Screening in Primary Care assesses the percentage of members who indicated experiencing depression symptoms on the annual Health Risk Assessment (HRA), and who then received screening by their primary care provider. Primary care visits are often the first opportunity to identify depression related concerns.

For more information on how Network Health evaluates the quality of care and services provided to members visit our Quality Health Integration page.

Behavioral Health Care Managers Support Patients in Need

If your patient has recently been discharged from an inpatient behavioral health unit, he or she should have a follow up appointment with a behavioral health provider within 7 days of discharge for optimum stability of symptoms.

Finding the right behavioral health provider for your patient can make all the difference in the counseling experience, and sometimes it can be challenging to find the right fit.

Does your patient need a psychiatrist for medication management, a psychologist for neuropsychological testing or a therapist for talk therapy? Would he or she prefer a male or female therapist? Does the therapist have special interest and training in the issue your patient wants to address?

Referring your patients to a Network Health care manager is like giving them a personal GPS to navigate the health care system, find providers, explore patients’ benefits and offer supportive phone calls between appointments. If patients agree, care managers will collaborate with their primary care doctors and specialists for optimum coordination of their care.

Meet the Care Managers

Laura is a behavioral health social worker care manager and has been assisting Network Health members for 14 years. She believes the first step is to listen to members and support them to reach their personal goals. 

Cheryl is a certified advance practice social worker (CAPSW) and has a master’s degree in social work from UW Oshkosh. She encourages members to use their coping skills and become self-advocates for the care they need.

Both Laura and Cheryl believe it is key for members to connect with the right providers for treatment plans that best serve members’ needs. The care managers stress to members the importance of follow-up appointments with their providers, encourage members to follow through with treatment plans, and help members find additional resources within the community.


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June 2019

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