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Select News: July 2016

HEDIS® Spotlight: Imaging avoidance for low back pain

As one of the most common reasons for seeking health care services, low back pain affects 75 percent of adults at some point in their lives. Evidence shows many patients diagnosed with low back pain receive excessive imaging, resulting in unnecessary worry and unneeded surgery. The Imaging Studies for Low Back Pain Healthcare Effectiveness Data and Information Set (HEDIS) measure presents an important opportunity for quality improvement by identifying excessive imaging studies and providing recommendations for treatment.

The HEDIS measure definition is the percentage of adults ages 18 to 50 with a primary diagnosis of low back pain who did not have an imaging study (X-ray, MRI, or CT scan) within 28 days of the diagnosis. A higher score indicates better performance.

What providers need to know:

  • Five clinical specialty societies, including the American Academy of Family Pediatricians, American College of Physicians, American College of Occupational and Environmental Medicine, American Association of Neurological Surgeons and Congress of Neurological Surgeons, and North American Spine Society, recommend against the use of imaging for non-specific low back pain when no "red flag" symptoms (including neurologic deficit, history of cancer, recent trauma, fracture, or intravenous drug use) are present.
  • Imaging may be warranted if the patient experiences no improvement with conservative treatment or when red flag symptoms are present.
  • Clinical guidelines state that low back pain can be adequately managed without imaging. They recommend thorough physical examination, medical history, initial pain management (as needed), and physical therapy as the best first courses of action.
  • Avoid imaging when there is no clinical necessity to prevent unnecessary harm to patients and reduce health care costs.
  • Most patients with low back pain experience improved function and reduced pain within four weeks.
  • Early imaging does not improve outcomes in patients with low back pain.

What if the patient goes to an emergency room or urgent care center?

If you are the primary care provider, your patient is counted in your HEDIS rate if he or she is seen by and receives images from an emergency room, urgent care center, or other provider.

How to improve your HEDIS scores

  • Avoid diagnostic studies within the first four weeks of diagnosis of new-onset back pain in the absence of red flags.
  • Provide patient education on pain relief, stretching exercises, safe back habits, and activity level.
  • Consider non-imaging interventions — pharmacological and non-pharmacological — including pain medication, oral corticosteroid therapy, physical therapy, and other physical modalities such as ultrasound therapy.
  • Use correct exclusion codes when appropriate.
    • Code for cancer, neurologic impairment, or other secondary diagnosis if these are the red flag symptoms that warrant the imaging study.
    • Most HEDIS measures use claim (or administrative) data to evaluate performance. If a service is not billed or coded correctly, it may not be captured accurately. *

*Billing and medical record documentation should always support the level of service provided at that visit.

Look for more HEDIS spotlights and contact your Provider Network Account Executive to be considered as a "physician champion," a newsletter spotlight on a provider who excels in the care of our members.

First in Quality, First in Care: Our 2016 Annual Message

Jeffrey Travis, M.D.

We'd like to share with you our 2016 Message to the Community. Select Health has provided access to high-quality health care for South Carolinians for more than 20 years through our First Choice health plan. We were the first Medicaid health plan in the state, and today we have the privilege of serving the most South Carolina Medicaid members.

Please take a moment to learn about our mission of helping people get care, stay well, and build healthy communities. You will also find our quality data and stories of the positive results of managing our members' health.

Important pharmacy change — combination inhaled corticosteroids

Effective July 1, all formulations of budesonide/formoterol (Symbicort®) will become non-preferred. Please transition First Choice members currently receiving Symbicort to Dulera® (mometasone/formoterol) or Breo® Ellipta® (vilanterol/fluticasone). After July 1, Symbicort will require prior authorization. If you have questions, call PerformRx℠ Pharmacy Services at 1-866-610-2773.

Play ball with Marcus! No cost for the first 25 who register

Marcus Lattimore

Select Health is again sponsoring First Choice Fit® Football Camps with Marcus Lattimore for our members ages 5 to 17. Each camp is available at no cost to the first 25 First Choice plan members who register. There is a $40 fee for all others. Members can register by calling Tricia at 1-843-569-4643.

Camp dates and locations:

  • July 30 — Columbia, Dreher High School.
  • August 13 — Myrtle Beach, Carolina Forest High School.

Camps run from 8 a.m. to 2 p.m. and include community health fairs with health screenings and education at no cost.

New and current subscribers: Win $50

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We hold random monthly drawings for a $50 e-certificate for online subscribers. Subscribe for a chance to win. Current subscribers are automatically included. We'll notify July's winner in August, so sign up now!

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