Provider Resources

July 2019

Table of Contents


Provider Spotlight: Data Drives Quality Patient Care at Froedtert Health
Care Managers Aid Transition of Care
Density Screenings, Falls Prevention Lower Osteoporosis Risk
Promote Preventive Screenings for Colorectal Cancer
How to Meet 2019 HEDIS® Measure for Kidney Evaluation in Patients with Diabetes


Retail Pharmacy Network Transitions to Walgreens

On January 1, 2020, Network Health will transition to Express Scripts (ESI) as the pharmacy benefits manager for all lines of business. ESI has provided pharmacy benefits management for Network Health Medicare members since 2005. Through the transition, the major retail pharmacy network will switch from CVS/caremark™ to Walgreens.

For our members’ convenience, Network Health will provide access to Walgreens pharmacies beginning August 1, 2019. CVS/caremark™ will continue to be in-network until December 31, 2019. This gives you and your patients time to transition pharmacy files from CVS/caremark™ to Walgreens (or any in-network pharmacy).

If members decide not to participate in the early transition, we have advised them to refill CVS/caremark™ prescriptions in December 2019 to cover their medication needs until they can transfer their pharmacy files to an in-network pharmacy on January 1, 2020.

Members and providers can search the entire updated pharmacy network, both retail and mail order, through our Find a Pharmacy tool starting November 1, 2019.



Provider Spotlight

Data Drives High-Quality Patient Care at Froedtert Health

Jonathon D. Truwit, MD, joined Froedtert Health and The Medical College of Wisconsin in 2014 as enterprise chief medical officer (CMO). Dr. Truwit also serves as the associate dean for quality at the Medical College. As enterprise CMO, Truwit is responsible for quality, population health, clinical integration with payers, analytics, physician and advanced practice provider (APP) engagement, and digital health initiatives.

Truwit was formerly a professor of medicine with tenure, chief medical officer and senior associate dean for clinical affairs at the University of Virginia School of Medicine.

Truwit jokes that he came to Wisconsin for the weather, but he stays because of the relationship between Froedtert Health and The Medical College of Wisconsin. “Two superlative institutions...the opportunity for collaboration and the ability to influence and impact the state. I thought that was very attractive,” Truwit says.

“I love UVA,” Truwit adds, “but that was pretty much Charlottesville, and even though it’s the University of Virginia, the influence across the state with patients and other institutions was limited at that time, so this is a broader scope.”

That sense of a broader scope is what first drew Truwit to practice medicine and what keeps him passionate about his work.

“I was exposed to two uncles who were physicians,” Truwit says. “Then I was a biomedical engineer and I got to see the impact of science on patient care. You can make large impacts—broader impacts.

“Medicine is one of the most rewarding careers where you have art and science merged together, and you’re making a difference on an individual level and a population level. Whether you’re saving lives or making life better, you have the opportunity to intervene. And you have the privilege of hearing people in their most vulnerable moments and being there to support them.”

Using data and analytics to provide better patient support is one of the driving forces behind the clinical integration work he does with insurance payers like Network Health.

“We meet to see what we can do to improve care for our patients, our community and the populations we serve,” Truwit says. “We are very good at sharing our data, our learnings, our best practices and challenging each other.”

Truwit says the unique relationship (Froedtert Health is part owner of Network Health) and the ability to innovate together sets Network Health apart as a payer. As a local not-for-profit payer, Network Health can be nimbler when piloting programs.

“Whatever we do with Network Health, we would like to be scalable to other payers,” Truwit says. “I am more concerned about the outcomes for our patients than the dollars and the savings.”

Truwit says he especially appreciates coordination between Froedtert and the Network Health care management team. “We are very clear about who is handling what work,” he says. “Patients don’t want to get duplicate calls, so we have a coordinated hand off.”

Truwit also praises the collaboration with utilization management and the ease of clarifying information to reduce denials and appeals. “Twenty-five percent of health care costs are administrative costs—mostly billing and processing,” he says. “If you can get friction down, you’re actually reducing the costs to patients.”

As patient care continues to evolve, Truwit says he is looking for ways to leverage digital technologies for more standardized care—not just improving the quality of care, but also eliminating waste.

“Ideally you should get your care at home, especially if you have something as simple as a sore throat,” Truwit says. “You should be able to do a virtual visit—it’s cheaper and it’s faster. You don’t have to drive, or park or wait in a waiting room. You can just get it done. We’re partnering with Network Health on this as well. It’s starting to gain some traction. We need to continue to grow that.”

Froedtert Health continues to be ranked among the best and highest performing hospital systems in the nation, according to U.S. News and World Report.

“It is rewarding to see that the quality of care we as an enterprise can deliver, and do deliver, is noticed nationally,” Truwit says. “We’re in the top ten…a group that does data analysis. There’s no fanfare—just the data and being top ten.”

But Truwit says the most rewarding part of his job is the opportunity for servant leadership and the pleasure of working with talented people and watching them grow. “I suppose they technically work for me, but actually, I work for them.”



Care Managers Aid Transition of Care

Navigating health care can be stressful and complex for patients, and in many cases, can result in ineffective transitions of care, often leading to hospital readmissions. At a cost of over $26 billion per year, these readmissions impact health care resources, financial reserves and patients’ long-term health outcomes.

Network Health empowers members to understand their health care options, ask questions and make educated decisions about their own health. But providers and payers can also help improve these outcomes by proactively collaborating during transition of care.

What do we mean by transition of care?

Transition of care refers to the movement of patients between health care practitioners and settings of care during treatment for a chronic or acute illness. Examples might include a patient who sees his/her personal doctor but also is evaluated by a specialist for a condition or illness, or a patient who needs to be hospitalized and is transferred from the hospital to a skilled nursing facility or back home.

Potential barriers to an effective transition of care include the following issues.

  • Poor communication between providers and facilities
  • Incomplete transfer information
  • Lack of education and/or understanding of care by the patient or caregiver
  • Limited or poor essential service during recovery
  • Absence of a single point person to ensure continuity of care 

How can care managers help?

Network Health’s care management department works with individual members to create coordinated plans of care that empower patients and their families to make informed health care decision to maintain their health, independence and quality of life. These plans improve member outcomes, decrease risk of readmission and premature institutionalization, and increase patient satisfaction with quality of care.

A critical step in achieving our goals is collaboration with the hospital care team through discharge planning. The Network Health care manager will do the following.

  • Collaborate with hospital and skilled nursing facility discharge planners to ensure a safe and effective transition.
  • Provide care coordination for access to community resources that will support the patients’ needs.
  • Assist the patient with navigation of the health care system.
  • Ensure effective communication between providers, patients and/or family.
  • Provide support and education for medication management.

Providers many contact Network Health on a member’s behalf to initiate care management by calling 866-709-0019 (TTY 800-947-3529) Monday–Friday from 8 a.m. to 5 p.m. Alternatively, you may fill out a request for help on our website at networkhealth.com/wellness/request-support


Bone Density Screenings and Falls Prevention Lower Osteoporosis Risk

The National Osteoporosis Foundation recommends that providers assess all postmenopausal women aged 50 years or older at risk for osteoporosis with a baseline bone density test (DEXA scan). A follow up DEXA scan is advised every two years for those diagnosed with osteopenia, osteoporosis or those who are at high risk for osteoporosis.

A fractured bone is often the first sign of osteoporosis for many patients. Best practices recommend that any woman 65 years and older who experience a fracture should have a DEXA bone scan performed within six months of the fracture and/or treatment with a bone strengthening medication, unless contraindicated.

Network Health provides bone density screening

Network Health offers free DEXA scans to many of our at-risk members under the supervision of Dr. Nicole Brady, medical director.

The scan results are given to members along with educational material discussing bone health. Members are instructed to discuss results with their personal doctor (Primary Care Practitioner). It is stressed that this is only a screening, and their doctor can help them decide the best next steps for their care. Our screening procedure also includes forwarding a copy of the results to the member’s doctor for review.

Any questions or concerns about DEXA screening may be directed to our quality health integration department at QI@networkhealth.com or call 800-826-0940.

Stepping On Falls Prevention Workshops, other education available

One in four people age 65 or older has a fall each year. Many of these falls result in broken bones. Some common causes of falls include indoor and outdoor hazards as well as problems with balance and gait, muscle weakness or medications with side effects like dizziness or confusion.

Falls are especially dangerous for people who are unaware that they have low bone density. Failure to connect a broken bone to osteoporosis can reduce the chance to make a diagnosis and the opportunity to begin a treatment program. Bone loss continues and other bones may break.

Research shows that planning and making simple lifestyle changes can help prevent falls. The Wisconsin Institute for Healthy Aging (WIHA) offers a Stepping On Falls Prevention Workshop series in communities across Wisconsin.

Network Health promotes attendance at workshops near our headquarters to a sampling of members who live in the Fox Valley area. To search all available workshops throughout Wisconsin, visit wihealthyaging.org/workshops or call the WIHA at 608-243-5690 for more information.


Preventive Screenings Improve Colorectal Cancer Outcomes

Colorectal cancer is the third most common type of cancer affecting both men and women in the U.S, but due to disease progression at the time of diagnosis, it is the second leading cause of cancer-related deaths, according to the Centers for Disease Control and Prevention (CDC). Working together, Network Health and primary care providers can promote preventive screenings and improve outcomes through early detection and treatment.

A colonoscopy continues to be the most highly recommended screening, however, it may not be the best choice depending on patient condition or willingness to undergo the procedure. Providers can help patients choose the method that is right for them by reviewing screening characteristics, benefits, harms, burdens, and costs, as well as considering test availability, patient comorbidities, preference, and likelihood that patients will complete testing.

Regardless of the testing method chosen, the most important thing is to educate patients on the benefits of early detection. We know our members value the advice of their personal doctor, and we appreciate your willingness to discuss colorectal cancer screening with them.

The United States Preventive Services Task Force recommends screening for colorectal cancer starting at age 50 and continuing until age 75. The decision to screen individuals outside of this age range should be based on the individual’s overall health and risk factors. The following screening methods and intervals are recommended for those at average risk. 

  • Colonoscopy every 10 years
  • CT colonography every 5 years
  • Flexible sigmoidoscopy every 5 years
  • gFOBT annually
  • FIT annually
  • FIT-DNA every 3 years

How to Meet the 2019 HEDIS® Measure for
Kidney Evaluation in Patients with Diabetes

At Network Health we partner with providers to ensure members receive high-quality care. One of the ways we evaluate quality is through HEDIS® (Healthcare Effectiveness Data and Information Set). Every year, HEDIS® data is collected through medical record review (MRR) and is used to measure quality improvement processes and preventive care programs.

One preventive care program encourages members with diabetes to monitor their condition through annual tests and screenings. Through bi-annual outreach, we prompt members to see their personal doctors and get the screenings recommended by national care guidelines.

The screening checklist sent to members includes A1c blood testing, blood pressure check, dilated eye exam and kidney screening (Microalbumin test). This coordinates with the 2019 HEDIS® Diabetes Care (Comprehensive) CDC measure, which includes sub-measures for A1c blood testing, dilated eye exam and nephropathy screening test.

Nephropathy screening (kidney evaluation)

To meet the kidney evaluation requirement, a screening must be performed at least once per measurement year. If the member is on ACE/ARBs or has nephropathy, however, evidence of treatment would also meet this requirement.

To view details about qualifying versions for nephropathy screening or monitoring (urine test for protein or albumin), qualifying evidence of treatment for nephropathy and examples of documentation, please read our guide How to Meet the 2019 HEDIS® Measure for Kidney Evaluation in Patients with Diabetes.

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

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July 2019 
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