Connect Archives

January 2008

Tuesday, January 1, 2008

Health First Network: 2007 Reflections

As we embark on 2008, it is worth taking some time to reflect on the events and accomplishments of the past year. Perhaps the most notable change for Health First Network was the absence of our relationship with Blue Cross Blue Shield of Florida. Although our contract ended in 2006, 2007 marked the first year in our history operating without any revenue from this provider. Initially, some were concerned this void would affect our viability; however, thanks to the foresight of the board, Health First Network held its own.

Here are some of our successes from 2007:
•We increased our WellCare rolls with the addition of two new dual eligible Medicare/Medicaid products and project increased revenues for both the network and our primary care physicians as we enter 2008.
•We capitalized more on predictive modeling, increasing the number of WellCare and Health Ease members in case management. We’ve already reduced WellCare hospital admissions by more than 10 percent, and we anticipate similar results for HealthEase.
•Dr. William Whibbs joined Health First Network full time in August.
•In November, we finalized the formation of a new, joint venture company with Physician Care Network, an IPA located in the Florida Big Bend area.
•We are in the midst of finalizing plans to introduce a new pre-paid primary care product in Escambia and Santa Rosa Counties. This product is designed to service the needs of uninsured and underinsured working families.
•We have added a substantial number of new Medicare members to our rolls thanks in part to a joint marketing effort with WellCare, the addition of new primary care physicians from West Florida and Sacred Heart Hospitals, and new agreements from physicians.
•We held two anchor community events: In March, we co-sponsored a series of anti-tobacco rallies for Escambia and Santa Rosa County high school students and Pensacola Naval Air Station student sailors. In April, we collaborated with local author John Appleyard, the Escambia School System, and Escambia Health Departments to produce a text/coloring book about good health, which we then gave to all fourth grade students.
•We co-sponsored “Managing Pain” – an educational seminar that drew more than 60 physicians and health care professionals.
•We began distributing Connect via e-mail to nearly 600 recipients, as well as upgraded our web site.
•We provided two new opportunities for cost savings to physician practices by signing contracts with Gulf Coast Office Products and Clearwave (a kiosk based patient registration and eligibility verification tool).

In summary, 2007 was a strong year for Health First Network. We made great strides and positioned the organization and its physicians for a great year to come. We wish every one the very best in the New Year.

Physician Quality Reporting Initiative (PQRI)

The new Physician Quality Reporting Initiative (PQRI), which is being administered through the Center for Medicare and Medicaid Services (CMS), might seem overwhelming at first. The reality is, however, this new program is an opportunity for physician offices to make more money and to contribute to a more effective, efficient health care delivery system.

The program provides a way for CMS to track the quality of services provided to the beneficiaries of both Medicare and Medicaid (at this time, only Medicare is affected) by providers, as well as to pay physicians based on the success of their reporting. It is critical to note that incentive dollars are based strictly on reporting, not in meeting guidelines – at least initially. What we are seeing here are baby steps toward pay for performance.

The bonus for reporting is 1.5 percent of all appropriate Medicare charges submitted during the recording period, to be paid out in the middle of the following year. The criteria for earning this bonus, which again applies to all Medicare billing, are successful reporting on three of CMS/PQRI measures. Successful reporting equates to documenting standards/measures at least 80 percent of the time, when appropriate (there are exceptions).

There are nearly 120 measures to choose from in 2008. While only three are required to qualify for the bonus, practices are encouraged to pick more to increase their likelihood of success. The measures chosen by CMS/PQRI are well established, evidence based measures that multiple physician professional organizations have approved and accepted, and really do reflect standards of care to which Health First Network physicians do aspire.

Physicians are allowed to pick the measures they report on, which makes good sense because many of the measures are very specific and will only apply to some practices (i.e. timing of prophylactic antibiotics in surgical cases where prophylaxis is appropriate).

Again, because of the potential difficulty in achieving the 80 percent goal, CMS encouraged physicians to report in as many categories as possible to increase their chances of achieving the minimums in at least three, as well as to avoid a cap on the amount of bonus available if only three categories are reported (this cap is a complicated formula, and is in place to discourage physicians from choosing only the minimum number of categories that seem easiest to achieve). Reporting in more categories also enriches the data pool that CMS has to work with in doing quality analysis.

It is probably, in time, bonus pay will also be based on performance. But, we reiterate, for now it is based strictly on reporting. Electronic medical records (EMR) will vastly simplify the task of counting and reporting; however, the use of EMR remains likely less than 15 percent of our network’s practices overall, and significantly less in small practices where resources allocation is most critical. Movement toward EMR and pay for performance will likely occur somewhat in tandem.

Of significance in the 2008 PQRI measures, CMS has included one measure that counts use of EMR and another for the use of e-prescribing. So, any practice currently using these types of systems has already achieved compliance with two of the three required measures. Recent legislation mandates the deployment of EMR and e-prescribing as a requisite for participating in full Medicare reimbursement by 2011, although this date will likely be pushed back because of cost and logistics.

Bottom line, PQRI is designed to measure and improve the quality of the health care product that physicians are largely responsible for, and it is built around evidence based medicine principles that physicians accept.

For more information about PQRI, visit the official CMS website at

Finally, MedLearn Matters Articles, the CMS educational resource for physicians and other healthcare providers on pertinent Medicare issues, has two excellent articles on PQRI. Find them at and

Future PQRI information will also be posted on the Health First Network website, Physicians are also welcome to contact me (Dr. Whibbs) directly at 850.434.8147.

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New Column: Featuring Practices and Providers

Beginning with this issue, Health First Network will spotlight a network practice or contracted provider in each issue of Connect. The organization’s leadership hopes to promote the great work being done and the high quality of care being delivered by our members and affiliates.

To be considered for this column or to share your story, please contact Jenny Caillouet at or 850.438.0818.

Helping Patients Understand Medicare Open Enrollment

Medicare Open Enrollment is quickly approaching, and Health First Network encourages its physicians to support their patients through this process. In the last issue of Connect, we shared information about Medicare with you. The one-page handout which highlighted key dates of the enrollment process was so popular that we added it to our online resources on our website

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Thrifty Drugs: Making a Difference in Care

In sharing in conversation with Darryl Miller, it’s obvious why his pharmacy Thrifty Drugs, a contracted provider of Health First Network, has become a top ally of the organization. Darryl and his team go above and beyond delivering medicine; they deliver top-notch care and customer service.

“Our focus here, first and foremost, is to take care of the patient,” said Darryl. “Whether it’s a matter of getting people the right meds and correct dosage, educating them how to use their prescriptions, making sure their insurance goes through, or offering delivery services, we are here to help.”

This coming from a man who is quick to point out that the thing he loves most about his job is “being behind the counter, filling prescriptions, and talking with customers.” He stresses the importance of knowing customers, emphasizing the more information he and his team have, the better they can do their job.

“We treat everyone like they are a member of our family,” said Darryl. This includes patients, family members, and physicians. “We have a great rapport with doctors,” he added. “You wouldn’t believe how many come in and just talk with us or ask questions.”

Darryl credits Thrifty Drug’s strong rapport with physicians mainly to the fact the pharmacy is local. “We are trusted members of the community; we have a vested stake in Northwest Florida.” He goes on to say this is another strength that Thrifty Drugs and Health First Network share.

“Health First Network operates in the same way I run my pharmacy,” said Darryl. “We’re local and independent, which means we don’t have to climb up the corporate ladder to make decisions. We decide things quickly and in the best interest of patients.”

Just one more example of how Thrifty Drugs upholds the best interest of patients is through education. Pharmacists at the two locations (mid-town and Cordova areas) pride themselves on working closely with patients to promote proper use and compliance.

A common lesson centers on diabetes. “A patient who has a new blood glucose machine can be easily overwhelmed,” said Darryl. “There are all these manuals and devices, and people think, ‘What in the World?’”

“We take time to take the equipment out of the box, go through it, show them how it works, and do a trial run,” he added. Darryl also explains to people what to do if they get an error, drop the machine, or have other issues. He also points out that the same machine is not right for everyone. “Sometimes a person is visually impaired and we need a voice machine, or they shake to much and we need to address this.”

Bottom line, Thrifty Drugs strives to empower people to comply so that they can get better and/or manage their disease. Health First Network is fortunate to be connected with Thrifty Drugs – a company that certainly exemplifies its mission of improving the health care experience and quality of life of people in Northwest Florida.

Point of Service Plan

Patients enrolled in WellCare Choice and WellCare Value Medicare Advantage Plans can now go out of network for care, based on the new point of service plan. They must however, follow two criteria: 1. Patients must obtain authorization from their primary care physician to go out of network; and 2. Patients must pay 30 percent of the bill when they go out of network. It is important for office staff to communicate these criteria to patients, especially emphasizing the shift in cost.

Part D Vaccine Admin Fee

The Center for Medicare and Medicaid Services released updated information on how vaccines will be covered in 2008 for Medicare-eligible beneficiaries. Medicare Part D changed some billing rules on vaccines. Updated information is needed for office billing staff. For WellCare/Medicare Members, effective January 1, 2008, physicians can no longer bill Medicare Part B for the administration of Medicare Part D-covered vaccines, using the special G code (G0377). That “G” Code (G0377) was created for the administration of Part D vaccines for 2007 only, as mandated by the Tax Relief and Health Care Act of 2006. Instead, offices will need to bill the patient for the vaccine and its administration, and the patient will need to submit the claim to their Part D plan for reimbursement.

Please refer to the following two web addresses for important guidance and information regarding Vaccine Administrations in 2008, and reimbursement for vaccines under Medicare Part D:

A letter was sent out from Dr. Whibbs in December to all WellCare PCP’s with information on the changes. If you wish additional information or a copy of the letter, please contact the Health First Network Provider Relations Department.

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Medicare Open Enrollment Has Begun

Please remind patients that Open Enrollment Period (OEP) runs from January 1 through March 31, 2008. During this time, individuals may change from like plan to like plan. If you are in a Medicare Advantage Plan you may change to another Medicare Advantage Plan. If you have Part D coverage, you may change to another plan that has Part D coverage, including Medicare Advantage. If the individual is in traditional Medicare with no Part D, they can change to a Medicare Advantage Plan with no Part D.

Wellcare Benefit Overview Online

Health First Network has posted the WellCare Benefit Overview Online as a resource to physician practices.

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