The Point | Issue 2 | 2024

Important Update:

Referral Requirements & ProAuth System Implementation for US Family Health Plan

Encourage Annual Retinal Eye Exams for Your Diabetic Patients

Help stop vision loss due to diabetes-related retinopathy.

Did you know that the rate of eye complications in patients with diabetes increased by 54% from 2009-2018? With roughly a quarter of the population aged 65 and older having diabetes, that’s a statistic that shouldn’t be ignored.¹

Vision loss can take a significant toll on a patient’s physical and mental health, including adding challenges to managing other health conditions. Because retinopathy is generally asymptomatic until later stages, early identification and treatment is critical in slowing or stopping the progression of diabetic retinopathy.

We encourage our network PCPs and endocrinologists to educate and support our members in getting recommended annual retinal eye exams. To support this goal, Martin’s Point Health Plan sent out a communication in July to eye care providers who have previously seen any of our members to encourage them to get our members in for their retinal eye exam if they are due.

Please consider discussing this important preventive care with your diabetic patients.

¹ The Centers for Disease Control and Prevention (2024). CDC Eye Complications Research.

Use of Imaging in Low Back Pain

Follow best-practice guidelines to avoid unnecessary interventions.

One of the ways Martin’s Point monitors the quality of care our health plan beneficiaries receive is by tracking claims received for imaging within six weeks of an initial diagnosis of acute back pain.

Low back pain (LBP) is extremely common and, for 85% of people with LBP, it usually resolves in a few weeks.¹ Approximately 25% of patients 18 to 50 years of age with acute LBP who underwent imaging exams had no identifiable indication for imaging.²

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.^3,4,5 All stress the following principle:

• Routine imaging of patients with acute LBP should not be undertaken within the first 6 weeks of presentation, unless there are signs and symptoms of severe or progressive neurological deficit, cancer, cauda equina syndrome, infection, or fracture.
• Early advanced imaging studies are indicated for all of the above except fracture.
• Early plain film studies are indicated for fracture suspected after trauma or in the setting of osteoporosis, cancer, or chronic steroid use.

Clinicians are encouraged to take the time to reassure their patients that pain usually improves over time (90-95% of the time) regardless of treatment and discuss the risks and benefits of imaging. 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. Clinicians can also educate their patients to access shared-decision-making tools available on our website through Healthwise; explore the comprehensive Healthwise decision-making guide.

Martin’s Point recently performed a study of the records for a statistically significant number of health plan beneficiaries who received imaging within the first six weeks of an initial diagnosis of low back pain. The findings revealed that:

• Providers with ready access to imaging services provide an x-ray on the same day regardless of other conditions.
• Females were more likely to get imaging than males.

We recommend providers assess their practices to ensure adherence to the best-practice imaging guidance noted above.

Talking about Incontinence, Fall Risks, and Physical Activity

Prompting Conversations when Your Patients Won’t

Each year the Centers for Medicare and Medicaid Services (CMS) canvasses a sample of our Generation’s Advantage members on important health topics using the Medicare Health Outcomes Survey (HOS). There are five Medicare Star measures based on the HOS results broken into two categories: Functional Health, which asks about improving/maintaining physical and mental health; and Effectiveness of Care, which asks about provider communications around important health topics. Specifically, the Effectiveness of Care category covers urinary incontinence, fall risks, and physical activity. This section inquires if providers are asking about these topics and providing suggestions if members indicate problems with incontinence and/or are determined to be at risk for a fall. The physical activity question asks if their provider advised them to start, increase, or maintain their physical activity 

HOS results in the Effectiveness of Care category continue to indicate a challenge for our health plan members. Unfortunately, not addressing these three important areas of health on a regular basis can lead to poorer, preventable outcomes down the road. Many patients don’t understand that, although some of the conditions may be more common with aging, there are options to improve bladder control and decrease risks of falls, and maintaining appropriate levels of physical activity can help preserve and/or improve overall health and quality of life.

Tips for breaking the ice around these topics:

These subjects can be uncomfortable for patients to bring up with providers face to face. Here are some suggestions to help with open communication:

• Provide a checklist at check-in that covers these topics. Patients can complete it in the waiting room and then bring it into the exam room for discussion during the visit.
• Display posters in exam rooms that cover these topics with the aim of desensitizing these topics to help drive open discussions with providers.

We hope you’ll take the opportunity at your patient visits to start these important conversations.

Has Your Patient Had an ED Visit?

Aim for Follow-Up within Seven Days

The CDC reported that, in 2018, 27% of the U.S. population were living with at least two chronic conditions. Given the increased vulnerability of people living with multiple chronic conditions, it is imperative that these patients have timely follow-up—ideally within a week—after an Emergency Department (ED) visit. ED follow-ups don’t always have to be in person to be effective—your patient’s medical history and ED diagnoses can help you determine if a telehealth visit or phone call should suffice. The goal of the ED follow-up visit is to:

• Ensure the patient clearly understands their diagnosis and discharge instructions
• Ensure the discharge instructions do not conflict with other elements of the patient’s care plan
• Ensure the member has all necessary equipment, prescribed medications, and care coordinated with specialist referrals, testing, etc.

These follow-up visits also offer an excellent opportunity to gain an understanding of why the patient utilized the ED. This could help identify challenges with access or opportunities to educate the patient on what level of health care need is ED-appropriate (versus seeking urgent care or primary care) and what steps to take in the future.

Source: CDC - Chronic Conditions Report

Fall Prevention Saves Lives

Generation Advantage Benefits Designed to Help

The CDC reports that falls are the leading cause of injuries (including fatal) for those aged 65+ and that, on average, close to one in three older adults in Maine and New Hampshire have reported experiencing a fall.

We encourage you to continue to evaluate fall risk and provide suggestions to our shared population (including a reminder of the fall-prevention benefits available through their Generations Advantage plan). 

All Generations Advantage members receive:

• A quarterly amount to purchase CVS brand, over-the-counter products, including DME and bathroom safety equipment.     
• An annual routine vision exam with a $0 in-network copay and eyewear allowance.
• Hearing aid benefit through Amplifon^®.
• Wellness Wallet allowance for eligible fitness/recreational gear, fees, and services that can support mobility and strength training.     

Does your patient have a history of a hip fracture or a fall?
If so, they qualify for an additional $200 towards bathroom safety devices, safety inspection, or device installation. If we have not received a claim with a fall or hip fracture diagnosis.

Download Provider Attestation for Supplemental Benefits Form (PDF)

You can also find the form on our Forms and Documents page.

Making Post-Fracture Follow-Up Care a Priority

Promote Bone Density Scans & Osteoporosis Medications When Appropriate

Did you know that only 20% of patients who experience a hip fracture are prescribed medications proven to significantly reduce the risk of a second fracture, while 95% of patients who experience a heart attack are prescribed medications to prevent another heart attack? ¹ This statistic is particularly troubling, as unidentified or untreated osteoporosis can result in additional fractures which can be painful, costly, decrease patients’ quality of life, or even result in death.

In fact, the challenges with post-fracture care are so prevalent that the problem was addressed as part of Medicare’s Proposed 2025 Physician Fee Schedule (PFS) rule. The rule indicates a two-fold issue affecting appropriate post-fracture care:

• There is a disconnect as to which provider has ownership of osteoporosis diagnosis and treatment following fracture.
• There is more focus on acute fracture recovery than osteoporosis diagnosis and treatment.

CMS is now proposing new billing codes for managing fractures under a treatment plan to incentivize providers to provide this care.

In addition, the NCQA HEDIS^® measure—Osteoporosis Management in Women Who Have Had a Fracture—promotes appropriate post-fracture care, monitoring the frequency that women 67-85 years of age who experience a fracture have a bone density scan or are prescribed a drug to treat osteoporosis within six months of the fracture event. (Women are excluded if they have had a bone density test within two years of the fracture event.)

At Martin’s Point, we continue to support our members in this effort by notifying provider offices of members with recent fractures and inquiring about the appropriateness of a bone density screening. We also encourage these members to discuss bone density scans with their providers. We hope you can support our goal of ordering bone density scans or osteoporosis medications, as appropriate, to help prevent future fractures and promote the best health of our members/your patients.

Source: Bone Health & Osteoporosis Foundation, 2024

Deprescribing: Focus on Proton Pump Inhibitors

Optimizing a medication regimen through deprescribing can benefit patients in many ways, including decreasing medication burden and risk of side effects, improving quality of life, and saving money on drugs. Proton pump inhibitors (PPIs) are a medication class where deprescribing should be considered with long-term use.

The American Gastroenterological Association (AGA) Best Practices on Deprescribing PPIs:

• All patients on a PPI should have a regular review and documentation of the ongoing indications for use done by their primary care provider.
• All patients without a definitive indication for long-term PPI use should be considered for a deprescribing trial.
• Most patients with an indication for chronic PPI use who take twice-daily dosing should be considered for step down to once-daily dosing.
• Patients who stop long-term PPI therapy should be advised that they may develop rebound acid reflux.

Additionally, AGA best practice statements identify the following patients as not candidates for PPI deprescribing: patients with complicated GERD, such as those with a history of severe erosive esophagitis, esophageal ulcer, or peptic stricture, patients with known Barrett’s esophagus, eosinophilic esophagitis, or idiopathic pulmonary fibrosis, patients at high risk for upper gastrointestinal bleeding.

PPIs available OTC (Prevacid 24HR, Nexium 24HR, Prilosec OTC, Zegerid OTC) may be viewed as safe for your patients, but we recommend verifying all OTC items at each appointment and assessing how long they have been taking them and how often.

Recommended Resources for Providers:

• Deprescribing.org
• NSW Therapeutic Advisory Group
• AGA Clinical Practice Update on Deprescribing PPIs
• ASCP Deprescribing Toolkit
• Master Clinician Training Toolkit

Source: Bone Health & Osteoporosis Foundation, 2024

Medicare PrEP Coverage Switch from Part D to Part B Expected Soon 

We encourage providers to prepare for the CMS proposed shift in Medicare coverage for Preexposure Prophylaxis (PrEP), the FDA-approved treatment using antiretroviral drugs to prevent HIV, from Part D to Part B

On July 12, 2023, CMS released a proposal to transition PrEPcoverage to Medicare Part B. Coverage under Part B will begin once the final National Coverage Determination (NCD) is released, which is expected in late September 2024. 

For details, please refer to the CMS fact sheet and proposed NCD decision memorandum via their online tracking sheet. 

Disruptions in Local Medicare Advantage Landscape

Your Patients Can Rely on Generations Advantage—Now and in the Future

As other Medicare Advantage plans have pulled out of the market, scaled back on benefits, or stopped contracting with providers in Maine and New Hampshire, many patients on Medicare are questioning their coverage for 2025.

As Maine and New Hampshire’s only local, not-for-profit offering these plans, we remain committed to investing in the health of our members/your patients and in the well-being of our greater community. We’ve been providing the highest-quality coverage to our neighbors with the extras—like dental, hearing, vision, and wellness benefits—necessary to support their best overall health. And we intend to continue serving them with this trusted coverage for years to come.

Want Timely Claim Payments and More New Patients?

To stay compliant, we make it easy to submit timely provider changes to ensure our provider directory is current.

CMS requires us to regularly contact network providers to confirm the accuracy of our directory information. Up-to-date information helps our members find new providers when they need care and helps claims get processed in a more timely and accurate way. To comply with regulatory requirements and maintain appropriate continuity of care for our members, we require that you provide 30 days advance notice of any changes to your provider/practice information, including when providers leave your organization.

Two Ways to Update:

Use these convenient online tools to keep your NPI-related practice/provider information accurate.

• Provider DataPoint: Use our web-based provider data management tool to submit real-time changes:
  • Change practice information, including name, phone, fax, address, billing information, NPI, and the like
  • Add/delete a location for your already-contracted practice/group
  • Change provider information, including name, specialty, and panel status; add a language, and more
  • Add a provider who needs credentialing to your practice
  • Terminate a provider from your practice/group
  • Check the status of a previously submitted data change-request
  Visit: Provider DataPoint Tool. If you have questions, see the instructions on our website or speak to a Provider Representative.
• National Plan and Provider Enumeration System (NPPES): CMS now allows providers to use NPPES to certify NPI data. Find information and FAQs about NPPES as a reliable source for provider directory data at NPPES Information. Questions about NPPES? Contact [email protected].

Tips for Practice Administrators:

• Set a monthly tickler reminder to check provider/practice information in Provider DataPoint.
• We no longer accept NPI-related updates/changes and credentialing applications via email or fax. They must be submitted online via Provider DataPoint.
• Radiologists, anesthesiologists, and midlevel providers such as nurse practitioners and physician assistants who do not practice as PCPs do not require credentialing.
• For more information on Provider Demographic Updates, please review this section in our Provider Manual: Provider Demographic Updates.

Shared-Decision-Making Aids

Meeting your patients where they are.

Shared-decision-making (SDM) aids are valuable tools that help facilitate collaborative discussions between health care providers and patients. In partnership with Healthwise, you can access over 90 SDMs available through our website. These evidence-based resources present treatment options, benefits, and risks in a clear, unbiased manner, empowering patients to make informed choices about their care.

Health Equity Training

Tools to serve all patients with compassion and fairness.

Earlier this year, the CDC’s Office of Health Equity (OHE) launched the Foundations of Health Equity training plan. This self-guided, online training plan is designed to facilitate foundational knowledge and skill development on topics related to health equity, health disparities, and structural and social determinants of health. Enhance your impact by joining the training plan, where you’ll gain valuable tools to better serve all patients with compassion and fairness.

Martin’s Point in the Community

Martin’s Point is proud to support the Maine Cancer Foundation - Tri for a Cure— the largest triathlon in Maine, raising funds for cancer research, prevention, and treatment.

We are also promoting the UNE - Health Careers Exploration Camp, collaborating to inspire future health care professionals and investing in the advancement of medical education and professional development in our greater community. 

Where to Get Help

Get Mental Health Support 24 Hours a Day, 7 Days a Week

If you or someone you know is in emotional distress—help is available no matter what time of day or night. The Suicide and Crisis Lifeline is there to assist with a range of support—from those in crisis and/or considering suicide or self-harm to those who need help with the mental health challenges that come with substance abuse, economic worries, relationships, sexual identity, getting over abuse, mental or physical illness, loneliness, and more.

For more information and additional resources for mental health care, visit the Mental Health section of the Martin’s Point website.

To get help right away:

• Call the Suicide and Crisis Lifeline at 988.
• Veteran’s Crisis Line: call 988 then press 1.
• Call 1-800-273-TALK (1-800-273-8255).
• Text HOME to 741741 to access the Crisis Text Line.