The Point Issue 2 2022

Posted 8/18/2022
Lower back pain

For more of The Point Provider Newsletter


  • Use of Imaging in Low Back Pain (LBP)
  • Improved Patient Experience: Our Shared Goal & the CAHPS
  • Medicare HOS Survey
  • Plan Benefits Support Osteoporosis Risk Management
  • COPD Transitions of Care Program
  • Just for Kids: Child and Adolescent Health
  • JUST FOR KIDS. HEDIS® Measures for Pediatric Weight Assessment and Counseling:
  • Just for Kids: Child and Adolescent Immunizations
  • Advancing Health Equity
  • Use of Imaging in Low Back Pain (LBP) Note: Change to Claims Processing for Imaging

    Guidelines for imaging of patients with LBP have been adopted and published by the American College of Radiology, the National Institute for Health and Clinical Excellence, and the American College of Family Practice, among many others. 1,2,3,4 All stress the following principle:

    Routine imaging of patients with LBP should not be undertaken within the first six weeks of presentation, unless there are signs and symptoms of severe or progressive neurological deficit, cancer, cauda equina syndrome, infection, or fracture.

    a. Early advanced imaging studies are indicated for all the above except fracture.
    b. Early plain film studies are indicated for fracture suspected after trauma or in the setting of osteoporosis, cancer, or chronic steroid use.

    We encourage clinicians to take the time to discuss the risks and benefits of imaging with their patients. A short conversation about the risks of radiation, expected time frames for recovery, and recommended treatments can go a long way in helping inform shared treatment decisions.

    Highlights from the American College of Physicians clinical practice guideline of noninvasive treatments for acute, subacute, and chronic low back pain state that:

    • Acute back pain is defined as lasting fewer than four weeks. Subacute back pain lasts four to 12 weeks.
    • Most patients with acute back pain have self-limited episodes that resolve on their own. 
    • Symptoms usually improve within the first month regardless of treatment.
    • Clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence).
    • If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation)

    Claim Processing Change: Martin’s Point has recently put in place a measure to assess claims for imaging for low back pain. The claim is manually reviewed according to the TRICARE® Policy Manual Chapter 5, Section 1.1, to determine if this is the first instance of back pain and if there are any clinical warning signs from the patient history and/or physical exam, e.g., fracture, possible tumor, cancer, or infection. If there is no patient history of low back pain and no clinical warning signs, then the claim likely will be denied.  Please contact our Provider Inquiry department for more details or if you have any questions or concerns.

    Sources: American College of Radiology, Committee on Appropriateness Criteria, “Low Back Pain,” Originally published 1996, updated 2015.


    Improved Patient Experience: Our Shared Goal & the CAHPS

    The one constant in health care is that it is always changing and how health care quality is measured is no exception. One important example is the dramatically increasing emphasis on member/patient experience in industry-standard quality assessments.

    The Consumer Assessment of Healthcare Providers and Systems Survey (CAHPS) is the gold standard used by the Center for Medicare and Medicaid Services (CMS) and the National Committee for Quality Assurance (NCQA) for determining member experience with their health plan and health care providers. Although CAHPS measures relating to member experience have always contributed to the NCQA Health Plan Ratings and Medicare Star Ratings, the weighting of these responses has jumped from making up 24% of a plan’s CMS Star Rating to 46% in a two-year period.

    This significant shift of focus to member experience with their providers creates challenges for health plans and providers alike—it’s a much more difficult aspect to quantify given patients’ differing conceptions of their ideal health care experience. And health plans have few, if any, means to independently influence this measure.

    The only way to accomplish the shared goal of creating the best possible member/patient experience is for health plans and providers to lean into each other. If we, as the health plan have a better understanding of barriers to achieving a positive patient experience or themes provider offices are identifying in their own surveys or day-to-day practice, we have the potential use that information to support our members through enriched benefits, resources, and education.

    We are currently working on ways to enable sharing of survey-reported patient experience themes with provider offices. To promote a closer partnership, we wanted to start by sharing the provider-related composites that make up the CMS Star and/or the NCQA Health Plan Rating measures: 

    • Getting Needed Care
      • Getting care, tests or treatments necessary
      • Ease of getting appointment with a specialist
    • Getting Care Quickly
      • Obtaining needed care right away
      • Obtaining care when needed, when not needed right away
      • Saw person came to see within 15 minutes of appointment time 
    • Care Coordination
      • Personal doctor’s office followed up to give test results
      • Got test result as soon as needed
      • Doctors had medical records or other information about your care
      • Doctors talked about prescription medicines
      • Got help managing care
      • Doctors informed and up to date about specialty care
    • Rating of Healthcare 
    • Rating of Provider
    • Rating of Specialist

    We hope this information is helpful and look forward to developing closer partnerships as we work together to improve the experience of those we mutually serve. If you have any suggestions or comments on how we can collaborate on this shared goal, please reach out to [email protected].

    Medicare HOS Survey

    Focus on Fall Risks, Exercise, and Urinary Incontinence Care

    Every year a sample of our Medicare population is administered the Health Outcome Survey (HOS). The Center for Medicare and Medicaid Services (CMS) in collaboration with NCQA created this survey as a way for CMS to assess the ability of Medicare Advantage Organizations to maintain and improve the physical and mental health of their beneficiaries over time. Beneficiaries are surveyed initially with a follow-up survey two years later.

    Currently, the Star Measures that are derived from the HOS results are the following:

    • Fall Risks: The percent of beneficiaries with a problem falling, walking, or balancing who discussed it with their doctor and received a recommendation for how to prevent falls during the year
    • Exercise: The percent of beneficiaries over 65 who discussed exercise with their doctor and were advised to start, increase, or maintain their physical activity during the year
    • Urinary Incontinence: The percent of beneficiaries with a urine leakage problem in past 6 months who discussed treatment options with a provider 

    To be successful with these measures and drive better health outcomes, we rely heavily on our network providers to have these discussions with their patients, and we remind our beneficiaries to have these discussions with their doctors.

    Supplemental Generations Advantage plan benefits support these health concerns:

    • Our flexible Wellness Wallet benefit reimburses up to an annual amount for a wide range of eligible gear, fees, and services to help keep members moving indoors and out. This includes such items as golf fees, bicycles, gym memberships and much more. 
    • Members with a documented history of falls or hip fracture are eligible for the following reimbursements:
      • Some bathroom safety equipment up to a maximum of $200
      • $50 per plan year to attend a non-plan sponsored Fall Prevention class supported by the National Council on Aging (NCOA).
    • Members also receive a quarterly dollar amount to purchase CVS over-the-counter products including incontinence supplies.

    Plan Benefits Support Osteoporosis Risk Management

    Did you know?

    • One in two women will experience a fracture during their life related to osteoporosis.
    • Nearly 80% of older adults who have experienced a bone fracture are not tested or treated for osteoporosis.

    With our Generations Advantage plans, in-network bone density scans have no cost share for qualified individuals (at risk of losing bone mass or at risk of osteoporosis) every 24 months. Additionally, Generations Advantage has bisphosphonates, a type of osteoporosis medication, on the formulary as low as tier 1.

    If you have a female patient between the ages of 67-85 who has not been tested for osteoporosis and experiences a fracture, please consider a bone density test. Osteoporosis is a silent disease—often not detected until a fracture occurs. Through testing and treatment, we can prevent some subsequent fractures and maintain the health and independence of our patients.  

    COPD Transitions of Care Program

    Your qualifying patients may receive outreach from us regarding pharmacotherapy management after an inpatient discharge.

    Martin’s Point Health Care has found that beneficiaries with COPD are at risk for adverse outcomes when transitioning from the inpatient setting to home. Our COPD Transitions of Care program is designed to help mitigate this risk through targeted interventions, including using HEDIS recommendations for pharmacotherapy management of COPD exacerbation after discharge.

    Please note that you may be contacted by a Martin’s Point Care Manager, or Health Plan Pharmacist regarding your patient’s treatment plan. Participating patients may also reach out to you with questions. We appreciate your involvement as we both provide services and resources to keep our members/your patients as healthy as possible.

    Which patients qualify?
    We use the following claims data to identify those who meet the HEDIS eligible-population criteria: Age 40 and older with COPD who had an acute inpatient discharge or an Emergency Department (ED) encounter with a principal diagnosis of COPD.

    What are we checking for?
    Once identified, we review the member’s medical records to determine if they have received the HEDIS-recommended care, including the following.

    • Had spirometry testing completed to diagnose COPD or within 180 days post discharge
    • Been prescribed both of the following:
      • a systemic corticosteroid and have filled the prescription within 14 days of discharge
      • a bronchodilator and have filled the prescription within 30 days of discharge
        • Per the 2022 GOLD Global Strategy for Prevention, Diagnosis and Management of COPD: maintenance therapy with a long-acting bronchodilator should be initiated as soon as possible before hospital discharge for management of exacerbations.

    What do we do?
    We reach out to beneficiaries by phone in an attempt to reduce COPD complications which could lead to readmission. The outreach provides the following:

    • Education—to ensure understanding of the dosage, timing, importance of adherence
    • Medication adherence assessment—offering formulary alternatives and referring to prescription-access programs to address inhaler costs
    • Medication reconciliation
    • Complete medication review—to ensure the member has a rescue inhaler on hand and to address high-risk medications, drug interactions, and any other potential gaps in therapy
    • Care coordination
    • Promotion of lifestyle changes

    Results so far:
    Since initiation of this program, we’ve seen improvements in prescribing practices and medication adherence for program participants in the case of both bronchodilators and, more significantly, for systemic corticosteroids. Due to the pandemic, spirometry testing has been a challenge with the drop of in-person visits. We hope to see performance on this measure rebound as members return to pre-pandemic visit levels.

    If you have any questions regarding this program, please contact Health Plan Quality at 1-866-484-2788.

    US Family Health Plan

    Just for Kids: Child and Adolescent Health

    We use NCQA standards to measure quality of care.

    Ensuring the children insured by our health plan are receiving great care is very important to us. The quality program at Martin’s Point uses standards/guidelines developed by the National Committee on Quality Assurance (NCQA) to measure the quality of care our network providers are delivering to the children in our health plan. 

    We measure the following visits and actions taken at visits and urge our network providers to meet these NCQA quality standards:

    • Well-Child Visits in the First 30 Months of Life (W30) - A count of the number of well-child visits that occur on or before the child turns:
      • 15 months – looking for 6 or more well-child visits
      • 30 months of age – looking for 2 or more well-child visits
    • Child and Adolescent Well-Care Visits (WCV) - A count of children/adolescents from 3 through 21 years of age who have at least one comprehensive well-care visit during the past year.
    • Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC) – this measure has not changed:
      • A count of children from 3 through 17 years of age who have had an outpatient visit in the past year and the following are assessed.
        • BMI—Documentation of a height, weight, and distinct BMI percentile (BMI ranges and thresholds are not acceptable)
        • Nutrition—Documentation of nutrition being addressed (e.g., discussion of behaviors, referrals for nutrition education, providing educational materials, anticipatory guidance, or counseling for weight or obesity)
        • Physical Activity—Documentation of physical activity being addressed (e.g., discussion of behaviors, referrals for physical activity, providing educational materials, anticipatory guidance, or counseling for weight or obesity)

    US Family Health Plan

    Just for Kids: Child and Adolescent Immunizations

    Immunizations for Adolescents (IMA)
    Each year, approximately 17,600 women and 9,300 men are affected by cancers caused by HPV. Recommending HPV vaccination for all 11–12-year-olds can protect them long before they are ever exposed. CDC recommends two doses of HPV vaccine for all adolescents at age 11 or 12 years. CDC recommends that HPV is recommended like any other vaccination - “Now that your son is 11, he is due for vaccinations today to help protect him from meningitis, HPV cancers, and whooping cough. Do you have any questions?” Parents will need to be reminded to make another appointment before they leave the office.

    Childhood Immunization Status (CIS)
    Childhood vaccines protect children from a number of serious and potentially life-threatening diseases such as diphtheria, measles, meningitis, polio, tetanus and whooping cough, at a time in their lives when they are most vulnerable to disease. Approximately 300 children in the United States die each year from vaccine-preventable diseases.
    Immunizations are a critical aspect of preventive care for children. Vaccination coverage must be maintained in order to prevent a resurgence of vaccine-preventable diseases in children.

    Vaccine Catch-Up Guidance
    CDC has developed catch-up guidance job aids to assist health care providers with interpreting the child and adolescent immunization schedule. The CDC recommends identifying children who have missed well-child visits and/or recommended vaccinations and contacting them to schedule in person appointments.

    Annual Kidney Health Evaluation for Diabetics HEDIS

    Ensuring our diabetic health plan members receive great care is very important to us. Our Martin’s Point quality program uses standards developed by the National Committee on Quality Assurance (NCQA) to measure the quality of care our network providers deliver to our diabetic members. One of the services we measure is testing of overall kidney health.

    Did you know?

    • An estimated 37 million Americans have chronic kidney disease (CKD). According to the American Diabetes Association, nearly 90% are unaware they have CKD because of low awareness about the importance of CKD testing and diagnosis.
    • In the US, diabetes and high blood pressure are the leading causes of kidney failure, accounting for 3 out of 4 new cases.
    • Two key markers to test for CKD are “urine albumin-to-creatinine ratio (uACR)” and  “estimated glomerular filtration rate (eGFR).”
    • An annual kidney evaluation should be performed to monitor members with type 2 diabetes and members who have had type 1 diabetes for five or more years.

    As you schedule Annual Wellness Exams, remember to include kidney health evaluations, if indicated.

    Sources: and, and 

    Advancing Health Equity

    CDC Resources for Providers

    As health care providers, we all witness firsthand the health impacts that social, environmental, behavioral, and other factors have on the health of our patients. Disparities in all these areas often result in increased incidence and severity of chronic and acute conditions for vulnerable populations.

    To help providers think about and work to improve health equity for those we serve, the CDC has developed A Practitioner’s Guide for Advancing Health Equity: Community Strategies for Preventing Chronic Disease (Health Equity Guide PDF.) We invite you to check it out and visit the CDC’s Health Equity section for resources and tips for promoting health equity into your everyday practice.