Dear Providers:
I am pleased to introduce the first edition of the FirstCarolinaCare provider
newsletter—Provider Points. I expect Provider Points to be a valuable communication tool between physicians and FirstCarolinaCare. Our objective will be to provide useful, actionable information that will benefit you, your patients and FirstCarolinaCare members.
This has been a year of “Firsts” for FirstCarolinaCare as described in the 2006 Annual Report. I am also the first locally based medical director for FirstCarolinaCare and, for those of you whom I haven’t had a chance to meet, there is a brief article in Provider Points that outlines my background and role in ensuring medical input in the decision-making processes of FirstCarolinaCare.
Athenahealth recognized FirstCarolinaCare as the best payer in the South. This is one
of several firsts that benefit physicians, patients and FirstCarolinaCare members. I hope you will take the time to read the 2006 Annual Report and learn about other areas where we have become leaders in improving access to health care while reducing the rate of growth in the working uninsured population. I appreciate your support in making FirstPlan a success, something that you can also read about in this newsletter.
Our continued success depends on building an active working partnership among physicians, employers, members, the MCPO, hospitals and FirstCarolinaCare. I look forward to working with you to help improve the health status of our community. If I can help you, or if you have comments, you can reach me at (910) 295-7250 or via e-mail at lnewton@mcpo.net.
Sincerely,
Leonard J. Newton, M.D.
Medical Director
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Profile: Leonard J. Newton, M.D., Medical Director  |
Leonard J. Newton, M.D., joined FirstCarolinaCare as medical director a little more than a year ago. Over the past year, Dr. Newton has served as a key member of the FirstCarolinaCare team to ensure high-quality, cost-effective care for health plan members. Dr. Newton serves as a liaison between FirstCarolinaCare and network providers, and is primarily responsible for quality-improvement programs and utilization management.
“I provide education on the precertification process and the use of InterQual criteria, and help providers and staff to understand how it works,” he says.
In addition, Dr. Newton’s input regarding precertification criteria has led to changes to ease the precertification process for |
certain procedures. “I work
in conjunction with physicians to bring medical input to the plan to assure that our decisions not only make financial sense, but make medical sense as well,” he says.
As chair of the FirstQIC committee, FirstCarolinaCare’s quality improvement committee, Dr. Newton has completed a comprehensive quality improvement program that enlists the help of FirstQIC committee members and the FirstCarolinaCare staff to improve HEDIS results.
“As medical director, Dr. Newton plays a lead role in developing programs and initiatives aimed at improving the overall health of our members,” says Barbara Adcock, provider relations manager. |
“He serves as a valuable
resource to our providers as well as to the FirstCarolinaCare staff.”
Dr. Newton also serves as medical director for Mid-Carolina Physician Organization and the Sandhills Community Care Network. Prior to coming to the Sandhills area, he was physician director of surgical services at Cayuga Medical Center in Ithaca, N.Y. He also worked as president of Finger Lakes Management Associates (FLMA), a 125-member physicians’ organization, and as medical director for Cayuga Area Plan, a PHO of which FLMA was a partner. From 1993 to 2005, Dr. Newton was in private practice at Otolaryngology and Otolaryngic Allergy in Ithaca, N.Y.
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| Physician Input Valuable to FirstCarolinaCare |
| New Pharmacy Programs |
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In September 2006, FCC implemented a new tablet-splitting program, “Split the Pill, Split Your Bill,” that can save participating members 50 percent on their monthly copayment. |
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The program is currently limited to simvastatin, pravastatin, Crestor and Lipitor. |
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FCC will pay for two tablet splitters
per year for members participating in the program to safely split their tablets. |
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Members will need a new prescription for:
• A higher strength tablet
• A quantity of 15 tablets
• Directions take ½ tablet daily |
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FCC plans to expand the tablet
splitting program in 2007.
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| Updates on FCC Formulary |
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On March 19, FCC added a step
therapy requirement to the proton pump inhibitor (PPI) class medications. This means adult FCC members new to PPI therapy will need to try Prilosec OTC or omeprazole 40mg/day as firstline therapy before they can “step” to Protonix. If the desired results are not achieved with Protonix, members can then “step” to Prevacid, Nexium, Aciphex or Zegerid. This change will affect only adult members who are new to PPI therapy and not current members on a PPI. |
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Omeprazole is now on the $10 generic
copayment level. This allows members to receive either PrilosecOTC or omeprazole for a $10 copayment per month. |
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Prilosec 40mg capsules will no longer
be covered. If members need a higher dose of Prilosec, please prescribe (two) omeprazole 20mg capsules or (two) Prilosec OTC 20mg tablets. Current members on Prilosec 40mg will not be affected by this change. |
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Amerge and Frova are now on the
non-preferred tier with a $40-$50 member copayment.
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FirstCarolinaCare recently conducted a
satisfaction survey in which providers were
asked if they felt they had the ability to
affect change at FirstCarolinaCare. From
the responses to this survey, it became
apparent that providers are not aware of heir
ability to impact policies and procedures at
FirstCarolinaCare.
“Physicians are our partners in providing
quality care to our members,” says Barbara
Adcock, provider relations manager. “We
rely on their expertise to assist in developing
policies and procedures regarding pharmacy benefits, credentialing, utilization and quality improvement.”
Recent changes made to FirstCarolinaCare’s pharmacy benefits are an example of a collaborative effort among the health plan, physicians and local pharmacists to develop an over-the-counter and pill splitting strategy to better serve members.
Physicians comprise almost 50 percent of the FirstCarolinaCare Board, and all committees include physician members. These members bring the physician perspective to decision-making to ensure that FirstCarolinaCare policies help maintain a strong physician-patient relationship.
“FirstCarolinaCare welcomes physician involvement and provides a channel for providers to communicate,” says James Lewis, M.D., an emergency department physician and a member of FirstCarolinaCare’s quality improvement and finance committees. “FirstCarolinaCare is the only health plan that I work with that seeks and considers provider input when it comes to decisions
affecting physicians and members.” |
Christoph Diasio, M.D., a pediatrician with Sandhills Pediatrics and a FirstCarolinaCare board member, echoes Dr. Lewis’s comments regarding the health plan’s communication efforts with providers. Dr. Diasio also appreciates the responsiveness of staff when issues or concerns arise. “One of the current challenges in pediatrics is that many new vaccines have been introduced, but often insurance companies don’t tell clinicians what, or if, they reimburse them,” Dr. Diasio says. “I had one of the largest insurance companies in North Carolina take eight months to tell me if they reimbursed for a new vaccine. When I called FirstCarolinaCare, I had an answer in two days.”
The staff at FirstCarolinaCare is available to answer any questions or discuss provider concerns. Feel free to contact Barbara Adcock, provider relations manager, at (910) 715-8115 or bjadcock@firsthealth.org.
In addition, providers can contact Leonard Newton, M.D. Dr. Newton’s primary function as FirstCarolinaCare’s medical director is as a liaison between the health plan and network providers to ensure that members receive high-quality, cost effective health care. A profile of Dr. Newton and an overview of his role as medical director are included in this newsletter. He can be reached at (910) 295-7250 or lnewton@
mcpo.net.
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| New Generics for 2006 and 2007 |
Brand Name
Biaxin XL
Ditropan XL
Effexor
Flonase
Inderal LA
Mobic
Natelle
Norvasc
Pravachol
Toprol XL
Univasc
Uniretic
Zantac syrup
Zocor
Zoloft sertraline
Zofran ondansetron |
Generic Name
clarithromycin (extended release)
oxybutynin extended release
venlafaxine tablets
fluticasone Nasal Spray
propranolol SA
meloxicam
vinate AZ
amlodipine
pravastatin (not 80mg dose)
metoprolol extended release
Moexipril
moexipril/hydrochlorothiazide
ranitidine syrup
simvastatin
sertraline
ondansetron
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| FirstPlan |
FirstPlan – A choice for small business
When everyone is covered, everyone wins |
FirstPlan is a special health care coverage product offered
through FirstCarolinaCare that was created to provide unique,
affordable coverage for small businesses and the working uninsured.
FirstPlan was created in 2002 to ensure quality coverage at an affordable price. “With the uninsured rate reaching close to 50 percent among small business workers in this area, we knew we had to do something about it,” says Rebecca Ballard, sales manager for FirstCarolinaCare.
The uninsured often go without preventive health care and may require more costly medical services when they become ill. FirstHealth, along with local providers (including the MCPO), also wanted to be part of the solution to the working uninsured issue. FirstCarolinaCare, as a wholly owned subsidiary of FirstHealth and as a local health insurer, created FirstPlan. This program is based on a shared contribution model among hospitals, providers, the insurer and small businesses. Three tools are offered to make coverage more affordable for both the employers and employees of small businesses.
- CareCredits: FirstCarolinaCare’s contribution through premium rating adjustments and incentives to employers currently without coverage.
- Subsidy: Through grants and other external recourses, lower paid employees of small businesses can access subsidies to help with their portion of the premium payment.
- Reduced Reimbursement: FirstCarolinaCare’s participating providers have agreed to accept a reduced reimbursement for the subsidized employees and their dependents.
“The providers are now getting paid, because that patient now has coverage, whereas before, the patient couldn’t afford to pay the medical bill or just simply didn’t go to the doctor,” says Barbara Adcock, provider relations manager for FirstCarolinaCare. FirstCarolinaCare requires 100 percent participation from all employees of a business for which a subsidy is provided. “We don’t care where you get your insurance, just as long as you are covered,” says Ballard. “ If we allowed employees to opt out of insurance with this program, we wouldn’t be able to make an impact. They’d still be uninsured.”
As with all FirstCarolinaCare clients, FirstPlan enrollees have access to comprehensive benefit plan designs, education, on-site health screenings, case and disease management programs, and wellness programs.
As of March 2007, FirstCarolinaCare provided coverage to more than 2,700 small business employees and their dependents. Almost 20 percent of them were previously uninsured.
If you would like more information about FirstPlan, or if you would like to know how FirstCarolinaCare can help your practice manage employee health care costs, please contact us at (910) 715-8100.
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| Chronic Care Management Program |
FirstCarolinaCare (FCC) is committed to helping its members
attain the highest possible level of wellness. To work toward this
goal, FCC offers a Chronic Care Management Program that is provided at no cost to members.
The Chronic Care Management Program begins with screening tools that identify members who could benefit from its services and provides these members with the tools to improve their health and well-being. The program uses tools such as Medical Health Questionnaires and health screenings (consisting of checking triglycerides, cholesterol, glucose levels and blood pressure) to identify members who may need assistance. Bone density screening is also provided for age-appropriate female members. The health screenings are provided at the work site shortly after enrollment and periodically thereafter. The work site location provides convenient member access and maximizes member participation. Another benefit along with identifying potential candidates for the program, the screenings help make participants aware of their health risks and create a consumer health focus. In addition to using the screening tools, we hope to get referrals from providers for their FCC patients who could benefit from the chronic care program.
The objective of the Chronic Care Management Program is to provide participants with a comprehensive set of tools to improve their health status. Options available to members include access to educational materials, telephone support, one-on-one interaction and support from FCC’s chronic care nurses. FCC’s goal is to work with identified members to achieve and maintain the best possible health outcomes in a caring, appropriate and cost-effective manner. The program is not meant to replace the physician role with the patient, but to be a support for the physician.
If you have any questions regarding the Chronic Care Management Program, please call (910) 715-8138.
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| Our name has changed to FirstCarolinaCare Insurance Company |
FirstCarolinaCare Inc. (FCC) has applied for and received approval from the North Carolina Department of Insurance to be licensed as a health and accident insurer with a health maintenance organization line of business.
Under its new name and structure, FirstCarolinaCare Insurance Company is licensed to offer preferred provider organization (PPO) plans, in addition to its point-of-service (POS) and HMO plans.
Ownership, management and operations will remain the same for FirstCarolinaCare Insurance Company as they were for FCC. In addition, FCC’s contracts with its clients and participating providers will be unaffected beyond the name change.
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| FirstCarolinaCare Insurance Company, Inc. is a
wholly-owned subsidiary of FirstHealth of the Carolinas. |
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