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CLINICAL CONSIDERATIONS
Supporting You in the New Year
World AIDS Day
To Vaccinate or Not To Vaccinate?
Pride Month
Peer-to-Peer Process
Immunizations
Preventive Immunizations
Proactive Care
Plan Time Wisely
Diabetes
Diabetes Guidelines and Resources
Screenings
Mental Health
Sandra Rivera-Luciano MD, MHSA
Sr. Medical Director, General Pediatrics
View Bio
Supporting You in the New Year - More Improvements To Utilization Management Processes
Reflecting on the past year, we acknowledge the resilience and dedication of medical professionals like you who tirelessly serve our communities. Your commitment to patient care has been truly inspiring to us all.
During 2024, we will continue our efforts to improve our utilization management (UM) processes. On Jan. 1, 2024, the Physician Quality Improvement Committee launched a separate UM committee to examine and review our practices and functions. This sub-committee will receive input from community physicians to give you a voice in how we work together.
As partners in health care, your insights and feedback are invaluable to us. I believe this will be a great opportunity for your suggestions to be heard and for a transparent dialogue to take place.
In the spirit of progress and collaboration, we are excited to enter this year with further enhancements to our provider portal aimed at improving health care delivery and patient outcomes.
Thank you for your continued trust in EmblemHealth and its families of companies. Here's to a year of health, wellness, and shared success.
World AIDS Day
Since 1988, December 1 has been dedicated to worldwide AIDS awareness. The theme for this year’s World AIDS Day is “Let Communities Lead.”
Our companies are truly on the frontline of progress in the HIV response. Both ConnectiCare and EmblemHealth support our members with HIV diagnoses and treatment via enterprise Care Management teams.
We created dedicated care/case management programs to assist our members who may be coping with a complex set of health issues. Our programs and staff can help members reduce their viral loads, manage their medications, find community resources, and navigate the health care system.
We have nurses, social workers, and non-clinical staff who coordinate and help connect members to care. When we find members who have specific difficulties or barriers to care, we have an interdisciplinary care team that collaborates to find solutions.
The EmblemHealth Case/Care Management program has been recognized by the New York State Department of Health for its success, and as a result, was awarded grants for the last three years for its Ending the AIDS the Epidemic initiative for Medicaid members.
The grant currently serves 150 enrolled Medicaid members and provides funding for a community health worker. This health worker can provide one-on-one assistance in helping members navigate the health care system, make home visits, and (where needed) escort members to their appointments.
We recommend that members living with HIV should have a minimum of:
- Two outpatient care visits per year (scheduled six months apart).
- Two viral load tests per year (scheduled six months apart).
- Annual screening for syphilis.
- Monitored HIV medication adherence.
We also support the use of PrEP( Pre-Exposure Prophylaxis) to prevent HIV transmission.
At EmblemHealth and ConnectiCare, we continue to bring awareness and support to our members and families living with HIV. Our greatest challenge is addressing the stigma and misperception around the diagnosis.
We hope you will encourage your patients to reach out for help and not suffer in silence.
Please see the HIV/AIDS resources we have available to you and your patients, which includes instructions on referring appropriate members to our programs.
Our companies also offer classes on nutrition, exercise, and healthy lifestyles at our EmblemHealth Neighborhood Care and ConnectiCare Centers in support of whole communities, including those living with HIV/AIDS.
On World AIDS Day we remember and commit to being part of the solution to addressing inequalities which are still holding back progress in ending AIDS. We remember the loss of those who have succumbed to this disease. As physicians and health care providers we can serve as advocates to those affected, including those that remain silent. Remember that every encounter is an opportunity to provide support, education, and hope.
Thank you to Marcia Allan, Zita Walker, Christine Spooner, and Kimberly Green for their contributions to this post.
To Vaccinate or Not To Vaccinate?
Here we are again. It is Fall 2023 – three-and-a-half years since the pandemic began – and it can still be tricky knowing what to tell your patients about vaccines, especially COVID-19 vaccines. “To vaccinate or not to vaccinate?” – that is the question on everyone’s mind.
We may be in a different place with COVID-19 now than at the beginning of the pandemic. But the challenges remain the same, especially for our patients.
Another complicating challenge is that new vaccines are coming out while new COVID-19 variants continue to emerge. It is a literal moving target, and it appears these new vaccines are the first of what may become an annual COVID-19 booster.
The best thing we can do is help our patients focus on evidence-based recommendations and understand the health impacts that drive these decisions.
The Centers for Disease Control and Prevention (CDC) recommends an updated COVID-19 vaccine for this fall and winter season (as announced in a Sept. 12 press release). Evidence shows that COVID-19 vaccinations remain the best protection against COVID-19-related hospitalizations and deaths.
To help you advise our members, we are sharing a few websites for your review. They cover all recommended vaccinations for both adult and pediatric populations, including influenza and respiratory syncytial virus (RSV).
- CDC site on vaccines for adults (Adult Vaccination | CDC).
- CDC site on vaccine for children (Vaccines for Your Children | CDC).
- Advisory Committee on Immunization Practices (ACIP Vaccine Recommendations and Schedules | CDC).
The CDC also has a user-friendly app for iPhones – CDC Vaccine Schedules on the App Store (apple.com). You may also find this Research White Paper Words Matter: Driving Vaccine Adoption Through Effective Communications February 2021 helpful in choosing how you speak to your patients about vaccines.
Please remember that most individuals can get COVID-19 vaccines through their insurance plans with no out-of-pocket expense since these vaccines are considered preventive care. However, a large segment of our population remains uninsured or underinsured. If you have patients who are not our members, you may refer them to local health departments and pharmacies participating in the CDC Bridge Access Program. Some children may be covered by the Vaccines for Children program.
During the upcoming fall and winter seasons, we all need to keep up to date with the latest recommendations. We will continue to share what we learn to support you as the driver of your patients’ preventive health.
Pride Month
Pride Month 2023 is an integral cultural concept within the LGBTQ+ community, representing solidarity, collectivity, and identity as well as resistance to discrimination and violence.
At EmblemHealth and ConnectiCare, we value diversity and inclusion for all our members including our own staff. Prism is an EmblemHealth and ConnectiCare employee resource group for members and friends of the LGBTQ+ community. We partner with our external communities during Pride Month and celebrate Pride Day as well as National Coming Out Day at our offices.
We strive to provide our members with services that encompass health, wellness, and well-being without discrimination or bias. Our policies follow the standards of care mandates for New York and Connecticut.
To aid and support our LGBTQ+ members, we use evidence-based criteria for preventive care, mental health, and transitioning services, including various forms of plastic, gynecological, and urological surgeries. All requests for transitioning services are reviewed by our team of medical directors who are knowledgeable in this field. We are also able to have complex cases reviewed both internally and externally by matched specialty in order to make the best medical necessity decisions for our LGBTQ+ members and communities we serve.
Peer-to-Peer Process
Although Edward Bulwer-Lytton famously said that the pen is mightier than the sword, we find that a one-on-one conversation with a colleague can be even more effective.
That’s why we created our Peer-to-Peer (P2P) process – to allow for these conversations to address adverse determinations. As physicians, both in the community and within our health plan, we can discuss and collaborate on the right path forward for your patients. See more.
I can personally say that via the P2P process, I have met amazing doctors and mid-level providers in our communities. I have developed professional, working, and even friendly relationships, all with the shared goal of providing the best care to your patients and our members.
A P2P allows us to discuss the reason(s) the adverse determination was issued and allows you to explain in your own voice why the plan should pay for the service. For our commercial and Medicaid members, if your explanation is compelling, we may reverse our decision. Medicare rules restrict us from reversing decisions for our Medicare members through the P2P process. But we welcome the conversation, which may help you more effectively craft your appeal.
We all want to provide the medically necessity services that our patients and members need in a timely manner. We offer P2P discussions Monday to Friday from 9 a.m. to 5 p.m. The adverse determination letter will include the contact information for scheduling a P2P. We are currently looking into online scheduling options through our provider portal.
If your patient requires an urgent determination, a P2P can be expedited at your discretion.
What can you do prior to a P2P appointment?
- Be prepared with any information you believe may help the process.
- Understand that if we agree to disagree, you can still proceed with an appeal that will be reviewed by someone with a similar specialty.
On our end, prior to the meeting, the assigned doctor is alerted and made aware that the P2P has been scheduled. In preparation, they review the clinical information you provided as well as applicable policies and guidelines.
EmblemHealth and ConnectiCare’s team of dedicated professionals are always looking to make this and our other processes member and physician friendly.
We hope you will take advantage of the P2P process and know that we are in it together.
Immunizations
As we look ahead to spring, it is important to keep in mind the connection between wellness and prevention. As a pediatrician, and as Senior Medical Director for EmblemHealth and ConnectiCare, I can’t think of a better way for our members to reach their wellness goals than via vaccinations.
If you go to the Centers for Disease Control and Prevention (CDC) website, you will see that the 2023 immunization schedules are updated and ready to be incorporated into your patient’s yearly visits. Usually, vaccines are considered preventive care. Most private insurances and all health Marketplace plans must cover certain required vaccines regardless of whether deductibles are met, and without charging copayments or coinsurance.
It’s important to inform our patients why we recommend vaccinations and remind them about these 14 diseases we can almost forget about thanks to vaccines:
- Polio.
- Tetanus.
- Flu (Influenza).
- Hepatitis B.
- Hepatitis A.
- Rubella.
- Hib.
- Measles.
- Whooping cough (Pertussis).
- Pneumococcal disease.
- Rotavirus.
- Mumps.
- Chickenpox.
- Diphtheria.
The CDC now recommends that adolescents and young adults, ages 16 through 23 years old, get a serogroup B meningococcal vaccine as well. Your patients with Medicare Part B coverage are eligible to receive the following vaccines:
- Flu vaccine.
- Pneumococcal.
- Hepatitis B.
- Rabies exposure and tetanus.
For all vaccines, check with your patient’s insurance provider for coverage details and whether there is any cost to you.
Preventive Immunizations
Immunizations are an important area of discussion and medical guidance. We recommended vaccinations be considered according to age group and in accordance with the Centers for Disease Control and Prevention’s (CDC) recommendations. The hot topic ones include:
- COVID-19
- Influenza
- MVP (formally Monkeypox)
- Pneumococcal
- Polio
See the Prevention information available to our members. If you need to guide those who are hesitant about getting immunized, words matter. For insights in speaking about COVID-19 and other vaccines, see the White Paper we published in April 2022.
Preventive Care is Proactive Care
We want to shift from fixing what is broken to preventing the damage in the first place or catching it as early as possible. We can do this together by encouraging members to get needed care, including immunizations and screenings.
You may have limited time during an office visit, but as we all know, prevention is the key to good health. Use the opportunity to address:
- Immunizations
- Screenings
- Healthy habits
Tips for our pediatricians:
- Take advantage of the back-to-school season to bring students in for visits.
- Use requests for sports clearances as an opportunity to recommend or check in on healthy habits.
Plan Time Wisely
We want to see you succeed. Plan your practice’s time wisely to meet quality measures and to submit SOAP notes for risk adjustment.
Proactively bring members in for needed care. Don’t get caught at the end of the year with members not seen and holiday schedules preventing them from coming in for a needed visit.
Diabetes
Even after a diagnosis is made, preventive care can help keep a bad situation from getting worse. One area where preventive care can have a great impact is with diabetes since its management requires support, motivation, and medication adherence.
We understand the complexity of living with, and treating, diabetes. We usually recommend an interdisciplinary approach informed by current, evidence-based guidance. If you have patients that may need additional support, we at EmblemHealth and ConnectiCare are available.
Diabetes Guidelines and Resources
Medical societies update their guidelines frequently (see below for the current guidance) and we keep an eye out for their changes to stay informed.
We have many resources to support you and your patients.
- If a diabetic member has a Care Plan, you will be able to find it on our provider portal to support coordination of care among all treating providers.
- EmblemHealth’s Pharmacy Programs can help with comprehensive medication reviews and we offer a Medicare-specific Medication Therapy Management Program to support adherence. We strive to integrate the latest pharmacological updates to prevent diabetes complications.
- Online virtual and in-person classes are available at our EmblemHealth Neighborhood Care and ConnectiCare Centers. These classes are available to everyone in the community – including you, our health care professionals as well as your patients!
- Diabetes Resources for Our Providers
- Medicaid National Diabetes Prevention Program
- 2022 Quality Measure Resource Guide including diabetes quality measures
- Diabetes Resources for Our Members
- GHI City of New York Members’ Diabetes Program
- EmblemHealth’s Diabetes Health
- ConnectiCare’s Let’s Talk About Diabetes
Screenings
Screenings are critical tools for health care professionals. They help guide our medical decisions and help us put our patients on the right path.
Encourage your patients to get their mammograms. October, is National Breast Cancer Awareness Month. Suggest they take part in one of the many fundraising walks as a way to get them moving. Maybe start your own team and invite them to participate. The exercise is good for their bodies and helping others can help with depression. Getting out is good for you, too!
Preventive care is not limited to physical health. Be sure to screen for mental health issues and refer EmblemHealth patients and ConnectiCare patients to their respective behavioral health programs should you uncover an issue.
Mental Health
We hope you take advantage of the resources we have available to you and your patients:
- Behavioral Health Clinical Practice Guidelines
- EmblemHealth’s Clinical Corner – Behavioral Health
- EmblemHealth’s Live Well Member Page for Mental Health
- ConnectiCare’s Live Well Member Page for Mental Health
You may want to take advantage of these October observances (and the resource materials offered on each of these sites) as ways to raise the need for, and importance of, screenings.
