What a Health Plan Should Be

Provider Newsletter

We are all well aware of the financial crisis of the last several months, and its effects on our already strained healthcare system. Health Plan Select has seen many of its member groups struggle to continue providing health insurance for their employees. We have seen businesses layoff employees and some go out of business altogether. Employers are purchasing leaner plans and moving the costs to their employees.

HPS has responded by offering leaner benefit programs to the employers who request them. We feel that private insurers are better able to design plans to meet their customers’ needs than the government could do. Over the next few weeks we will see what plans come out of Washington and whether they really will be a step in the right direction.

Pharmacy
After a couple of years of relative stability, we have seen pharmacy costs begin to rise. The injectable drugs continue to be expensive. Overall, our two most expensive drugs by cost are Enbrel and Humira. Only a few years ago, the top two were Prozac and Prilosec; two drugs which are now inexpensive generics.

We continue to encourage members to use the $4 programs at Kroger, Walmart, and Target. These drugs save money for the members, their employers, and HPS.

Due to an interaction between Plavix and omeprazole, we now cover pantoprazole, the generic form of Protonix, as first line treatment for patients who take Plavix.

Clinical Use of Bone Densitometry
Cummings, Bates and Black in JAMA 2002;288:1889-1897 published a useful outline for when to obtain testing for bone mineral density (BMD). The decision to test for BMD should be based on an individual’s risk profile and testing is never indicated unless the results are likely to influence a treatment decision. BMD testing is recommended for (1) women 65 or older, regardless of additional risk factors, (2) for postmenopausal women younger than 65 years and with one or more additional risk factors for osteoporosis, and (3) postmenopausal women who have had a fracture of any type as an adult after age 45. Risk factors include parental history of hip fracture, current cigarette smoking, a body weight less than 57.2 kg, use of (or plans to use) oral corticosteroids longer than 3 months, or serious long-term conditions thought to increase fracture risk such as hyperthyroidism or malabsorption.

HPS pays for bone density testing in women age 50 and over, once every 23 months. Other bone density testing requires prior approval.

Utilization of Office Codes
We have begun a project to review office coding, particularly codes 99212-99215. In the next few weeks, you will receive a report of your office coding with a comparison of your coding to national standards. At this point, the goal of this project is to give physicians feedback about where they stand in comparison to their peers.