Popular DrugsGo Generic

HoosierHealthwise BidSubmitted

NPI Update

On the Inside

August 2006

For the past 13 years, the St. FrancisHealth Network has worked with physi-cians, their medical office staff members,hospital departments and health plans toprovide top-notch managed care expertise.“The Network’s greatest asset has alwaysbeen the support of St. Francis Hospitaland the physicians who participate in theNetwork” said Jennifer Westfall, RegionalExecutive Director, St. Francis HealthNetwork. “Their cooperation has beenessential to our success.”

The network brings a knowledgeable man-aged care team (the staff of 17 has 200combined years of managed care experience)to serve providers. The following informa-tion describes SFHN’s responsibilities andvalue added services:

Serves as a liaison to Network physicians,St. Francis Hospital and health plans.

Contracts with and administers commer-cial and Medicaid HMO risk programs.As a result, the health care needs of35,000+ lives are directed exclusively toSFHN’s providers.

Performs health services medical man-agement programs according to NCQAguidelines.

Administers disease management pro-grams, focusing on arthritis, asthma,chronic low back pain, congestive heartfailure, coronary artery disease anddiabetes.

Negotiates contracts for St. FrancisHospital and St. Francis Medical Groupwith fee-for-service managed care payers.

Offers streamlined authorization andclaims processing services for the HMOproviders and members through CMCS,a third party administrator partly ownedby St. Francis.

Creates and manages direct contractinginitiatives such as Premier Healthway,the cardiac case rate program.

Offers direct contract employer groupsfee-based access to competitively discountedservices from the Network’s providers.

Streamlines the provider credentialingprocess by performing the service fornumerous health plans.

The Network staff is always seeking newways to serve providers. One of the latestefforts is the creation of a health plan formedical provider offices. This plan is in thedevelopment stages but should be operationalby the end of 2006. It will provide physicianswith reasonably priced health coverage forthemselves and their office staff.

For more information on the Network andits work on behalf of providers, callJennifer Westfall, Regional ExecutiveDirector, (317) 782-6671.

SFHN: Membershiphas its benefits

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Current EnrollmentCurrent Enrollment

Cluster group meetings with theprimary care physicians began inMay and have focused on fourimportant areas.

High tech radiology procedures.The auth procedure was effectiveFeb. 1 and so far has been successful.

In some cases, physicians were surprised to learnthe actual cost of the procedures.

Pill splitting. We’ve written much about the M-Plan pill splitting campaign. We’ve visited officesand provided each one with information about pillsplitting and individual reports listing potentialpatients who are candidates for pill splitting. Thisamounts to a major savings for all of us in the net-work and for the members. Refer to the SFHN pillsplitting campaign statistics on page 4.

Pediatric referral guidelines. These guides provideuseful information on the in-network pediatricspecialists who are available and the services thatcan be performed at St. Francis. We’ve noted adecrease in out-of-network pediatric referrals sincethese guidelines were distributed. This informationwill be updated periodically.

Quality. Carla Rowe, Director of QualityImprovement and Disease Management, has beenattending cluster group meetings. She shared infor-mation related to quality initiatives in progress forboth SFHN commercial and MDwise members.She emphasized the importance of accurate claimscoding for services rendered to patients with diabetesand asthma in particular. She also mentioned theCHIRP immunization registry and the CAQHapplication requirements. We continue to seek waysto improve our quality performance for HMOmembers. The feedback physicians have given usin the cluster meetings assists in the developmentof realistic performance measures and complemen-tary programs. Network staff does have a voice increating the components of quality initiatives andstrives to keep administrative policies and proce-dures reasonable for both physicians and staff.

Cluster meetings will be ongoing through the end ofthis month. We will take a break and begin meetingwith offices again in October. If you have questions,please don’t hesitate to contact me at (317) 782-6551.

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Dr. Need’s NotesDr. Need’s Notes

Specialty Care PhysiciansGerald Godfrey, M.D. Emergency

MedicineCharles Salazar, M.D. OB/GYNAbdulkarim Sharba, M.D. Neurology

Welcome NewProvidersWelcome NewProviders

Current HMO enrollment throughJune 30, 2006:

Advantage . . . . . . . . . . . . . . . . . . . . .6,325Franciscan . . . . . . . . . . . . . . . . . . . . .4,116M-Plan . . . . . . . . . . . . . . . . . . . . . . .12,521MDwise St. Francis . . . . . . . . . . . . . .13,205Total . . . . . . . . . . . . . . . . . . . . . . . . .36,167

MedicalManagement MattersMedicalManagement Matters

These statistics compare utilization forSFHN YTD June 30, 2006.

2006 Goal 2005

Bed Days / 1000 218.57 256.87 270.71

Admits / 1000 45.58 51.79 54.70

ALOS 4.80 4.96 4.95

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Congratulations Dr. Beardsley

Richard Beardsley, M.D.was recently selected as theIndiana Family Medicinephysician of the year. Thisaward was presented to himby the Indiana Academy ofFamily Physicians at theirannual meeting in July.He is now entered intocompetition for the nationalfamily physician award.

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In an effort to further educate M-Plan members about thecost-savings related to pill splitting, SFHN case managementstaff began calling members who were taking prescriptionsfor eligible pill splitting drugs.

Judy Rodgers, R.N., SFHN case manager, noted that patientswere very receptive to the information. “Many rememberedvaguely hearing about the program. We were able to answerquestions about how much the members could save.”

Phone calling to the top 50 pill-splitting eligible prescription

holders began in early June andtook about a week. Interestedpatients were advised to call M-Plan and their doctor. SFHNcase management staff also con-tacted the physician’s office.

As a result of the phone calling, 26 percent of patients calledswitched to the pill splitting program. Case managers calledthe next 50 eligible prescription holders in July. Results ofthis campaign are pending at press time.

Responding to the Indiana Family & Social ServicesAdministration’s (FSSA) request for proposals, MDwise sub-mitted a bid this summer to expand its Hoosier HealthwiseMedicaid managed care organization (MCO) activities farbeyond its current service area (Central and NorthwestIndiana) to include statewide coverage, effective 2007-2010.

In 1994, St. Francis Hospital was a charter “DeliverySystem” with CIMCO, which became MDwise in 2001 andhas administered the state contract since its inception.Highlights of this year’s bid emphasize that MDwise will:

Continue to utilize the HMO license of IU Health Plan.Support the integrated service delivery system model todrive more dollars to the caregivers and members, thusspending the State’s money wisely.Expand its solid Pay for Performance experience,focusing on measurable HEDIS and other quality ofcare improvements.

Utilize CompCare to ensure integration of behavioralhealth with physical health.Create a new delivery system, MDwise Hoosier Alliance, forproviders who are not directly affiliated with existing hos-pital systems and/or are adverse to taking on full risk. Toadminister this new entity, MDwise selected Ameri-HealthMercy, a nationally recognizedMCOwith more than 23 yearsof experience exclusively with Medicaid and other publicprograms. Ameri-HealthMercy currently serves about 2millionMedicaid members across multiple states, including Kentucky.

The FSSA announced the bidder’s selection results on Aug. 4.MDwise, Anthem/Wellpointe and Coordinated CareCorporation, Indiana, Inc. (doing business as ManagedHealth Services (MHS) were selected to serve statewide. Thebid selection means that three current MCOs will no longerserve Hoosier Healthwise members in 2007. These areHarmony, Molina and CareSource. The Network certainlyappreciates the efforts our MDwise SFHN providers putforth to make this provider-sponsored MCO successful.

SFHN Case Managers Contact Pill Splitting Candidates

MDwise Submits Statewide Bid for Hoosier Healthwise

Readership surveys for the FYI newsletterwere mailed in the spring. There were127 surveys returned. Of those, 57percent of respondents said they readevery issue of FYI and 23 percentindicated they read some of the issues.

Sixty one percent of respondentsnoted that the content of FYI was useful or very useful.

The most popular content areas were descriptions of new services,lists of new providers and the letter from the medical director.

There were suggestions for change. These included thefollowing:

Sending the newsletter electronically.Incorporating a SFHN staff contact directory into the publication.Updating readers on changes in health insurance.Explaining how the actions of the corporate communitywill impact the Network.Providing more information on Mooresville and changesat other campuses.

These and all suggestions will be carefully considered by theFYI editorial board for future enhancements.

Winners of the two gift certificates to O’Charleys were JamesCole, M.D., Center for Orthopaedic Surgery & SportsMedicine and Gregory Smith, M.D., Southpointe Pediatrics.Thanks to all who participated.

Readership Survey Results In

Questions you ask about SFHN are answeredin each issue of FYI in the Question andAnswer Box.

Q: Although SFHN prior authorizationrequirements have been significantly reduced,we still have questions when it comes topatients with two commercial insurance pro-grams. Are we required to follow the priorauthorization guidelines for both?

A: SFHN cannot speak for any other commer-cial plan but we can give you guidelines forSFHN HMO members who have Advantage,Advantage Franciscan or M-Plan coverage.

If the SFHN HMO plan is the primary payer,you must follow the SFHN prior authorizationguidelines. If the SFHN HMO plan is thesecondary payer, the Indiana AdministrativeCode dictates that the secondary payer acceptsthe authorization rules for the primary payer.Therefore, if the primary payer allows theservices, SFHN will process without priorauthorization. SFHN authorization rules donot apply when SFHN is secondary to anothercommercial payer.

Q: Occasionally one of our physicians will havea problem with a specific drug they want toprescribe for a MDwise SFHN patient. What doyou suggest?

A: MDwise contracted with Perform Rx tomanage their comprehensive pharmacy benefitprogram July 1, 2005. Please contact PerformRx to help in the resolution of your problemand/or to appeal their decision. The PerformRx phone number is (800) 558-1655.

Please remember there is a wealth ofinformation available on the MDwise website:www.mdwise.org. To find a copy of the currentPreferred Drug Listing (PDL) or a list of thedrugs requiring prior authorization, click on“Providers.” Scroll down to “MDwisePharmacy” and click on the searchableMDwise PDL.

The Question& Answer BoxThe Question& Answer BoxPharmacy ForumPharmacy Forum

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Concerta®

Lamisil®

Zofran®

Methylpheni-date (longacting)

Terbinafine

Ondansetron

AttentionDeficitHyperactivityDisorder(ADHD)

Fungalinfections

Nausea &vomiting

2006, fourthquarter

2006, fourthquarter

2006, fourthquarter

Brand Ingredient Common AnticipatedName Name Use Generic

Release Date

Pharmaceuticals Set to Go GenericRecently the popular brand names drugs Pravachol,Proscar, Zocor and Zoloft were released as generic drugs.Other commonly prescribed drugs are expected to becomeavailable as generics throughout this year. The anticipatedgeneric release date is when the pharmaceutical industryexpects to see generics hit the market for those that havehad patent expirations. However, if the branded manufac-turer (the one with the original patent) contests the expira-tion in court (e.g., patent infringement) then the anticipatedgeneric release date for that product is extended.

Remember generic drugs are available to members at alower co-pay level than are brand name drugs. TheAmerican Association of Retired Persons (AARP), recentlynoted that prices charged by drug makers for brand-namepharmaceuticals jumped 3.9 percent, four times the generalinflation rate, during the first three months of 2006. This isthe largest quarterly price increase in six years.

Please review the table below for more information.

Pill Splitting UpdateThe number of M-Plan SFHN members who participate inthe pill splitting program is shown in the table below:

February 2006 48March 2006 62April 2006 70May 2006 81June 2006 108

Date Number of M-Plan SFHNPill Splitting Participants

Pharmacy StatisticsPharmacy StatisticsSt. Francis Health Network: Top 10 Drugs Prescribed for M-Plan Members, YTD June 30, 2006.

By Cost †Label Name Avg. RX Cost (Excluding Rebates)ZOFRAN $410ABILIFY $351ZOFRAN ODT $339LAMISIL $327PROVIGIL $301ZYPREXA $281GEODON $280DESOXYN $217SEROQUEL $216ALDARA $214

By FrequencyLabel Name Number of ScriptsAMOXICILLIN 9,073HYDROCODONE/APAP 7,911ALBUTEROL 6,429CEPHALEXIN 2,341OMNICEF 2,337ALPRAZOLAM 2,228IBUPROFEN 2,200CLONAZEPAM 2,110ZOLOFT 2,074AMOX-POTASSIUM CLAV 2,017

Total 38,720

St. Francis Health Network: Top 10 Drugs Prescribed for MDwise Members, YTD June 30, 2006.

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By Cost †Label Name Avg. RX Cost (Excluding Rebates) Program StatusABILIFY $402 Second Tier Brand SelectLAMICTAL $362 Second Tier Brand SelectACIPHEX $224 Third Tier Brand NON-Select *TOPAMAX $220 Second Tier Brand SelectRISPERDAL $212 Second Tier Brand SelectIMITREX $212 Second Tier Brand SelectHUMALOG $205 Second Tier Brand SelectACTOS $203 Third Tier Brand NON-Select *SEROQUEL $194 Second Tier Brand SelectPULMICORT $194 Third Tier Brand NON-Select *

† For drugs with an RX count greater than 50 during the measurement period.

By FrequencyLabel Name Number of Scripts Program StatusHYDROCO/APAP 2,218 First Tier GenericLISINOPRIL 1,334 First Tier GenericAMOXICILLIN 1,203 First Tier GenericFLUOXETINE 1,109 First Tier GenericPREVACID 1,082 Second Tier Brand SelectMETFORMIN 1,000 First Tier GenericTOPROL XL 981 Second Tier Brand SelectLEVOTHYROXIN 816 First Tier GenericZOCOR (Pill splitting drug; please prescribe generic) 811 Third Tier Brand NON-Select *ALPRAZOLAM 758 First Tier GenericTotal 11,312

* Third Tier Brand Non-Select means that another drug in the same class is available at a lower co-pay.

Number of Generic Prescriptions, SFHN YTD June 30, 2006:All M-Plan Networks SFHN SFHN Goal56.2% 56.3% 60%

† For drugs with an RX count greater than 50 during themeasurement period.

(Excludes specialty pharmacy)

Nonprofit OrganizationU.S. Postage

PAIDPermit No. 5807Indianapolis, IN

St. Francis Health Network’s FYIis published quarterly by the St.Francis Hospital and HealthCenters’ Community RelationsDepartment, in cooperation withthe St. Francis Health Network.Pam Jursik, RN / Director ofOperations&BusinessDevelopment,Editor, with Annette Fulton, APR,Provider Relations Manager,Marketing. Please call 782-7990with comments or suggestions.

The St. Francis Health Network,composed of physicians, the hospi-tal and community leaders, existsto promote the consistent deliveryof quality medical care in the mostcost effective setting. We willdevelop managed care strategies inwhich the continuum of care pro-vided through the Network willenhance and promote the improve-ment of the overall health of thecommunity we serve.

The St. Francis Health Network islicensed to engage in the businessof insurance in the state of Indianain the capacity of utilizationreview, subject to applicable lawsand rules. License number 31316.

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1600 Albany St.Beech Grove, IN 46107

The 1996 Health Insurance Portability andAccountability Act (HIPAA) mandated theadoption of unique identifiers for health careproviders and health plans. The purpose is toimprove the efficiency and effectiveness ofelectronic transmissions of health informa-tion. The Center for Medicare &MedicaidServices (CMS) has developed the NationalPlan and Provider Enumeration System(NPPES) to assign these unique identifiers.

May 23, 2007, is the date when providersmust begin using the new National ProviderIdentifier (NPI) in standard electronic healthcare transactions, such as claims. The NPIeliminates the need for multiple identificationnumbers for multiple health plans. NPIs mayalso be used to identify illegible names of healthcare providers on prescriptions; in coordina-tion of benefits between health plans and inmedical record systems.

Physicians are assigned only one NPIregardless of the number of places wherethey practice. There are three ways to applyfor a NPI (use only one):

Apply through a web-based applic-ation process. The web address ishttps://nppes.cms.hhs.gov.

Prepare a paper application and mail it tothe NPI Enumerator. The NPI Enumeratoris responsible for dealing with health plansand providers on issues relating to uniqueidentification. The application, includingthe Enumerator’s mailing address, isavailable at https://nppes.cms.hhs.gov.Providers may also call the Enumerator fora copy of the application at (800) 465-3203.

An organization, such as a professionalassociation, may submit a provider’sapplication in an electronic file (with theprovider’s permission). Editor’s note:SFHN has already received manyrequests for this information from con-tracted health plans.

Additional information and educationalresources are available on the CMS NPIwebsite, available at http://www.cms.hhs.gov/NationalProvIdentStand/.

NPI Deadline Only Nine Months Away