Provider Update

Volume 19, Issue 3 

June/July 2002

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Pharmacy Prior Authorization and Preferred Drug List

The Department of Health and Hospitals (DHH) announces the implementation of a pharmacy prior authorization (PA) process with a preferred drug list (PDL) for certain drugs covered under the Medicaid Pharmacy Benefit Program. This program was effective June 10, 2002. On May 22, 2002, the Legislature's Joint Committee on Health and Welfare granted approval for implementation of the Medicaid program process. 

With the implementation of the PA process, drugs will be considered "preferred" or "non-preferred." Non-preferred drugs will require PA as a condition for payment by the program. The PDL is established by selected therapeutic classes for those drugs that do not require PA. Prior to the effective date for inclusion on the PDL, providers will be notified regarding those drugs selected for placement on the list by selected therapeutic classes. Drugs in those therapeutic classes that are not included on the PDL shall require PA and prescribing practitioners must obtain PA by contacting the Prior Authorization Unit at the University of Louisiana at Monroe (ULM), College of Pharmacy. 

Implementation of the PA process is being initiated as a phase-in approach starting with the Proton Pump Inhibitors and the COX2 Inhibitors therapeutic classes effective June 10, 2002. In June, the following materials were sent to you as an attachment to a provider notice to facilitate the new process: 

1. A listing of drugs in the first group of therapeutic classes to be included in the PA process with effective 
implementation dates. 
2. A process and procedures document, "Louisiana Medicaid Pharmacy Benefits Management Prior Authorization Program." 
3. "Request For Prescription Prior Authorization" Form.

Information on the prior authorization process, including the PDL, is also available on the Louisiana Medicaid website (www.lamedicaid.com). This website will be updated when changes (additions or deletions) are made to the PDL. PDL changes will also be in a message on the provider's remittance advice.

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DHH Medicaid Pharmacy Benefits Management (PBM) System Launches New 
Peer-Based Prescribing and Dispensing Profile Program

In July 2002, the DHH Medicaid Pharmacy Benefits Management (PBM) System launched its new Peer-Based Prescribing and Dispensing Profile Program. This is a new enhancement to the already successful State and Unisys operated PBM which is saving the program over $187.5 million annually, including approximately $24 million from its Point of Sale prescription electronic billing system with Prospective Drug Utilization Review (prepayment edits) and $123 million from a state of the art manufacturer rebate system.

The program is being implemented as a result of Act 395 of the 2001 Regular Session of the Louisiana Legislature which mandates DHH, ��in consultation with and upon the recommendation of the Louisiana Medicaid Pharmacy Advisory Committee and the Department�s Interdisciplinary Medicine and Pharmacy Committee, shall develop peer-based prescribing and dispensing practice patterns for health care providers who participate in the Louisiana Medicaid Program and shall develop a process to promote such practice patterns through the Drug Utilization Review Board.� 

In State Fiscal Year 2000-2001, the Louisiana Medicaid Program paid $417 million (net of rebates) for over 12.5 million prescriptions issued by approximately 13,000 prescribers. These expenditures represented 11.4% of the Medicaid budget. This new PBM feature will result in cost avoidance through the reduction of excess drug expenditures and the growth of total pharmacy expenditures through increased provider-specific focused education interventions which will encourage rational prescribing and dispensing practices. As drug therapy improves, additional savings would be expected in programs other than the prescription drug program, i.e., reductions in the number of Emergency Room visits, inpatient admissions, and physician visits. There is the potential for the new program to save $2.6 million in its first full operational year.

The overall objectives of this enhancement are to:
� Identify, evaluate, and monitor existing levels of delivery of pharmaceutical care by prescribing providers;
� Improve the quality of recipient�s pharmaceutical care;
� Identify and help correct aberrant prescribing patterns of pharmaceutical care services delivery by prescribing providers.

This is the first phase of the Peer-Based Prescribing and Dispensing Profile Program. The program will focus on 
educational outreach to the providers whose prescribing and/or dispensing practices are aberrant to his/her peers. By intervening with prescribers and pharmacists having questionable practices, the PBM�s educational components will motivate change.

During the initial phase of the program, some prescribers will receive their Peer-Based Prescriber Profiles containing prescribing indicator data charts that will enable them to compare their prescribing patterns to those of their same 
specialty-prescribing peers. The Department, through its fiscal intermediary, Unisys, will utilize a Data Warehouse 
database, statistical software program, (i.e. SAS), and graphic interface software programs to develop physician/
prescriber, pharmacy, inpatient and outpatient hospital demographic and claims information.

Unisys will develop and maintain a database extract program to:
� Identify peer-based appropriate/acceptable standards of prescribing and dispensing patterns by parish or region;
� Rank providers within these patterns;
� Develop provider specific educational interventions to address aberrant practicing patterns; and
� Develop a reporting system with audit trails, intervention tracking reports, and special projects reports.

Your support and input are critical to the success of this program.

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HIPAA Implementation Dates

In a joint effort, Louisiana Medicaid and Unisys are developing plans for meeting the projected Health Insurance Portability and Accountability Act (HIPAA) implementation date. We are currently in the process of defining the requirements necessary to satisfy the HIPAA mandate for local code sets and electronic transactions. As we move forward with HIPAA implementation plans, Medicaid will continue to maintain an "open line of communication" with the provider community and trading partners to disseminate detailed information regarding HIPAA mandates, deadlines, and seminar schedules.

The HIPAA mandate initially required all covered entities to be compliant with the local code sets and electronic health care transactions by October 16, 2002. On December 27, President Bush signed a bill allowing covered entities to delay compliance with the code sets and electronic transactions rules for one year. Medicaid has filed for this extension to meet the delayed compliance deadline of October 16, 2003.

The April 14, 2003 Privacy Rule effective date continues to remain in effect.

In order to introduce the best solution to comply with HIPAA mandates, while meeting the required HIPAA implementation date, LA Medicaid proposes to phase-in implementation by Medicaid Program Type. The tentative dates that have been established for the Local Code Sets and the Electronic Transactions for each Medicaid Program Type group are as follows:

Proposed Local Code Implementation Schedule by Medicaid Program Type

The dates indicated on the Electronic Transactions Implementation Schedule are the proposed dates that Unisys will be ready to accept the new HIPAA Electronic Transaction formats. Unisys will continue to accept and process the current electronic formats along with the new HIPAA Electronic Transactions until Louisiana Medicaid has designated a cutoff date. 

Proposed Electronic Transactions Implementation Schedule by 
Medicaid Program and Transaction Type

We are also in the process of developing testing plans to ensure HIPAA compliance and will advise you of the dates as soon as possible.

As we move forward on the HIPAA project, continued communication on the above proposed implementation schedule and dates will be distributed to you as quickly as possible through bulletins, remittance advice messages, provider articles, and by other means. Updated information will also be made available at provider training workshops. Remember these are tentative dates and subject to change. 

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Medicare Crossover Claims

If your Medicare/Medicaid claims are not crossing over electronically, please call Unisys Provider Relations for assistance at (800) 473-2783 or (225) 924-5040. Be very specific with your inquiry. You should indicate whether all of your claims are not crossing over or only claims for certain recipients. Were the claims crossing over previously and suddenly stopped, or is this an ongoing problem? The more information you can give, the better. The Unisys representative will check certain pieces of information against the provider and/or recipient files to determine if an identifiable file error exists. If a file update is required, the Unisys representative will route this information to the Provider Enrollment or Third Party Liability Unit to correct the Medicaid file. If a problem cannot be identified, you may be referred to the Third Party Liability Unit for further assistance.

If you are not certain that you have supplied your Medicare provider number(s) to Unisys Provider Enrollment, please mail a copy of your Medicare Certification letter to this unit to have your number(s) loaded correctly on your Medicaid provider file. You must include a valid Medicaid provider number in your request for it to be processed correctly. Many Medicare providers have a primary provider number and one or more secondary provider numbers linked to this primary number. Claims will cross over electronically ONLY if the Medicare provider number(s) is cross-referenced to the Medicaid provider number. If any or all of your Medicare provider numbers have not been reported to Unisys Provider Enrollment, please do so immediately. 

Medicare adjusted claims do not automatically cross over. The provider must submit Medicaid adjustments with the Medicare adjustment EOB attached for corrected payment.

Providers are responsible for verifying on the Medicaid Remittance Advice that all Medicare payments have successfully crossed over. If Medicare makes a payment that is not adjudicated by Medicaid within 30 days of the Medicare EOB date, you should submit your crossover claim hard copy with the Medicare EOB attached. All timely filing requirements must be met even if a claim fails to cross over.

Also, if you are submitting a claim that Medicare has denied, the EOMB attached must include a complete description of the denial code.

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EMC Contract Change
RA Message - 5/7/02, 5/14/02, and 5/21/02

The contract form for �Provider�s Election to Employ Electronic Media Submission of Claims for Processing in the Louisiana Medical Assistance Program� was revised in August 2001. Effective June 3, 2002, Provider Enrollment will no longer accept any version of this contract with a revision date prior to August 2001. All requests submitted on outdated contracts will be returned to you with the correct forms for resubmission. If you need to obtain an updated copy, please call the EMC Department at 
(225) 237-3200, ext. 2.

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Reminder to CommunityCARE PCPs
RA Message - FIMS # 6575
5/21/02, 5/28/02, 6/4/02, and 6/11/02

This is to remind all CommunityCARE PCP's that payment of CommunityCARE management fees is made after the signature sheet from the monthly CP-0-92 is submitted to Unisys for payment at the end of the month. The timely filing requirements for claims are applicable to the management fees, in that they must be filed within one year from the date of service, which is the first day of the month. Providers should submit signature sheets and confirm receipt of payment for each month in a timely manner, to avoid denials for failure to file timely. 

Providers should keep a copy of each signature page without the signature. If payment is not received for any month, an original signature can be placed on the copy of the signature sheet, and it can be resubmitted to Unisys for payment. 

Questions regarding this matter may be directed to Unisys Provider Relations at 1-800-473-2783.

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BCSS Children's Choice Waiver Provider Orientation Training Workshops

Prospective Children's Choice Waiver providers (Agencies interested in being an approved provider for this waiver) must attend a mandatory Provider Enrollment Orientation (PEO) workshop conducted by The Bureau of Community Supports and Services (BCSS). 

*In addition, currently enrolled Children's Choice providers must attend a mandatory Provider Re-Enrollment Orientation Workshop prior to expiration of their current enrollment year. 

BCSS will routinely conduct these half day Children's Choice Waiver Provider Enrollment and Re-Enrollment workshops during the third (3rd) week of January and June of each year. Workshop training dates for June 2002 and January 2003 have been scheduled as follows: 

Prospective Children's Choice Waiver Provider Enrollment Orientation

Date: Wednesday, June 19, 2002 & Wednesday, January 15, 2003
Time: 9:00 a.m. - 3:00 p.m.
Location: BCSS State Office - 446 N. 12th Street, Baton Rouge, LA

Requirement: In order to qualify for enrollment as a provider of Children's Choice Waiver Services, you must first be licensed and enrolled in each DHH Administrative Region in which your agency will provide services by the Department of Social Services (DSS) as a Personal Care Attendant (PCA) Provider. The PCA licensing process is separate and apart from the Children's Choice Provider Enrollment process. PCA licensing information may be obtained by contacting DSS at:

Department of Social Services
Bureau of Licensing
P.O. Box 3078
Baton Rouge, LA 70821-3078
(225) 922-0015 

Note: You must call the BCSS Toll Free HELP LINE at 1-800-660-0488 and request to be added to the Prospective/Interested Children's Choice Waiver Provider List. A PEO Workshop Registration Notice with instructions on how to register for this training will be mailed to you. 

Children's Choice Waiver Provider Re-enrollment Orientation

Date: Tuesday, January 14, 2003
Time: 9:00 a.m. - 12:00 noon
Location: BCSS State Office - 446 N. 12th Street, Baton Rouge, LA

Note: A Provider Re-Enrollment Workshop Registration Notice informing you of upcoming workshops, and instructions on how to register for this training will be mailed to you.

You may contact Delphine M. Jackson, BCSS Field Staff Monitoring Oversight, at (225) 219-0208 if you have any questions regarding this notice.

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Increase in Annual Cap in Children�s Choice Waiver Services

Effective April 21, 2002, the Bureau of Community Supports and Services adopted an emergency rule to increase the annual cap for Children's Choice Waiver services from $7,500 to $15,000 per individual per plan of care year. Implementation of the emergency rule is pending approval from the Center for Medicare and Medicaid Services (CMS).

Additionally, BCSS adopted a rule to establish a non-crisis provision to allow a Children's Choice Waiver participant's name to be restored to the Request for Services Registry (formerly the Waiver Waiting List) when all four of the following conditions are met: 

1.     He or she would benefit from the services that are available in the MR/DD Waiver, but are not 
actually available to him or her through their current waiver or through Medicaid State Plan 
services; AND

2.     He or she would qualify for those services under the standards used for approving and denying the
services to the MR/DD Waiver's participants; AND 

3.     There has been a change in circumstances since the child's enrollment in the Children's Choice 
Waiver that causes these other services to be appropriate. The change does not have to be a 
change in the recipient's medical condition, but can include loss of in-home assistance through a 
caretaker's decision to take on or increase employment, or to obtain education or training for 
employment. (Note: The temporary absence of a caretaker due to a vacation is not considered 
"good cause".); AND

4.     The person's original request date for the MR/DD Waiver has been passed on the Request for
Services Registry. 

If the Children's Choice Waiver participant meets all four of the above criteria, they may be restored to the Request for Services Registry after their original request date has passed. This will allow him or her to be placed in the next available waiver slot, provided the person is still eligible when a slot becomes available. 

If you have any questions, please contact Claudette Hill, MR/DD Waivers Program Manager at 225-219-0211 or Judith Baker, Director of Case Management at 225-219-0200.

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KIDMED Objective Hearing and Vision Screenings

Effective immediately, the KIDMED objective hearing and vision screenings (codes 92551 and X9007) may be performed by trained office staff under the supervision of a licensed Medicaid 
physician, physician assistant, registered nurse, or an optometrist for vision screening and licensed audiologist or speech pathologist for hearing screenings. The interpretive conference to discuss any findings from the screenings must still be performed by a licensed physician, physician assistant, or registered nurse as is currently the policy reflected in the KIDMED manual.

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Clarification for Newborn Hearing Screening

LA R.S. 46:2261 requires newborn hearing screening to be performed in all birthing hospitals in Louisiana. Administrative rules accompanying that statute (Louisiana Administrative Code-LAC 48:V. Chapter 22) specify that only certain types of personnel are allowed to perform hearing screening as cited below:

2209. Hearing Screening Procedures
            A. Personnel. Hearing screening will only be performed by:
                1. Board eligible or board certified physicians with special training in auditory brainstem response     testing and/or otoacoustic emissions testing and in infant hearing testing.
                2. Audiologists licensed by the Louisiana Board of Examiners for Speech Pathology and Audiology   with special training in auditory brainstem response testing and/or otoacoustic emissions testing                         and in infant hearing testing.
                3. Persons trained and supervised by personnel meeting requirements for 2209.A.1. or 2. above.

While the above individuals are allowed to perform the screening, Medicaid reimbursement for newborn hearing screening is available only under the following circumstances:

Medicaid enrolled physicians or audiologists are entitled to bill for newborn hearing screening if they own, rent or lease the equipment used to conduct the test and they perform the professional component of the service. If the screening device used to perform the screening does not require the interpretation services of a doctor or audiologist, no claim for the professional component (modifier -26) should be submitted. Additionally, no claim for the professional component should be submitted if a trained and salaried employee of the hospital performs the screening. 

If a technician or nurse employed by the hospital performs the testing and the hospital owns, rents or leases the equipment, the hospital may only bill the Medicaid per diem rate established for that hospital. If the hospital finds that the costs of the screening exceed the Medicaid reimbursement, at the end of each year they may either request an increase in the per diem rate or an additional cost settlement for salaries of those personnel.

Technicians under the supervision of an audiologist cannot bill Medicaid for newborn hearing 
screening.

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Physician and Hospital, Inpatient and Outpatient, and Anesthesia Providers
RA Message - 5/7/02, 5/14/02, and 5/21/02

Unisys Provider Relations has received questions concerning the denial code 478 (Send written sonogram results with operative report, pathology report and history.) When a claim for D&C for an incomplete or missed abortion is denied with a code 478, the provider must submit documentation to substantiate that the fetus was not living at the time of the D&C. Specifically, the documentation must indicate that this was not an abortion for pregnancy termination. This documentation may be (1) a sonogram report showing no fetal heart tones; (2) a history showing passage of fetus at home, in an ambulance, or in the emergency room; (3) a pathology report showing degenerating products of conception; or (4) an operative report showing products of conception in the vagina. All reports are not needed. These are examples of the information needed to provide enough documentation to properly review the claim and substantiate payment.

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Changes to the Pre-Admission Screening for Persons with Mental Illness 

The Department is revising its internal procedures governing the pre-admission screening process (PASARR) for individuals with mental illness seeking placement in a nursing facility. The Health Standards Section will no longer make the final determination regarding appropriateness of placement. The Office of Mental Health (OMH) will make the determination. The Level II assessment will be completed by a Health Standards consultant psychologist or psychiatrist who will forward the information to the OMH Prior Authorization Unit where the final determination regarding placement will be made. OMH will also review the need for specialized services. Specialized services will be either evaluation and follow-up by a local mental health clinics or services covered under the Medicaid Mental Health Rehabilitation Program. 

In addition, the Level 1 Pre-admission/Readmission Screening (PAS/RAS) form has been revised. This form must be submitted to Health Standards along with Form 90L for all nursing home admissions. Providers can download the revised form from the following two web sites:

Internet: http://www.dhh.state.la.us/hss/ltc_publications.htm

MDS Intranet: login to CMS MDS Submission web site, click on Resources link, click on Forms link, click on Item 2 PAS/RAS link. 

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Provider Enrollment for the Personal Care Attendant Waiver

The Bureau of Community Support and Services announces that it is currently enrolling providers for the Personal Care Attendant Waiver Program. This waiver requires that the agency provider services beyond the basic personal care as specified in the Personal Care Attendant Waiver Program Provider Manual.

For additional information regarding this waiver you may view a fact sheet on the DHH website, http://DHH.state.la.us, under the heading Community Supports and Services by clicking on services. A provider enrollment packet can be obtained by contacting Unisys Provider Relations at 1-800-473-2783. 

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Louisiana Drug Utilization Review (LADUR) Education

Treating Hypertension in the Patient with Diabetes: Revised Goals and Medication Management

Justin J. Sherman, Pharm.D.
Assistant Professor of Clinical Pharmacy Practice University of Louisiana at Monroe College of Pharmacy

Issues:

� Uncontrolled hypertension causes high mortality rates, accounting for 86% of all deaths in patients with diabetes.

� Several non-drug therapies have been proven to be effective in blood pressure reduction.

� Clinical trials demonstrated that stroke and other outcomes could be prevented in patients with diabetes by tightening blood pressure control.

Estimates of the number of patients with diabetes who concurrently have hypertension approach 60%, leading to a significant impact on risk for cardiovascular events, such as myocardial infarction and stroke.¹ Uncontrolled hypertension causes high mortality rates as well, accounting for 86% of all deaths in patients with diabetes.² Recent studies have focused on this select population to determine the effect of intensive blood pressure control on decreasing both cardiovascular events and microvascular complications, such as nephropathy and retinopathy. This review will emphasize changes in the American Diabetes Association (ADA) practice recommendations based on the latest studies and will also describe the rationale behind using different classes of antihypertensives in patients with diabetes.

Recommendations from the Joint National Committee (JNC) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure submitted in 1997 state that a lower target blood pressure measurement should be instituted for patients with diabetes (130/85 mmHg) when compared to the general population.³ Table 1 categorizes the 3 stages of hypertension and goals for each. However, the ADA has recently advocated to aim for a target of <130/80 mmHg whenever it can be safely achieved due to the epidemiological evidence of increased cardiovascular event rates that are associated with having blood pressures greater than 120/70 mmHg.⁴ Also, these risks have been shown to decrease even into the normal range of blood pressures, leading to the conclusion that no threshold value exists.¹ While it is cautioned that aggressively lowering blood pressure levels may be a formidable task in clinical practice and may increase drug-induced side effects and cost of care in the short term, poor cardiovascular outcomes can be avoided in the long term with proper diet and exercise, counseling, and efficient medication management.

Non-drug Management of Hypertension
Several non-drug therapies have been proven to be effective in blood pressure reduction, including weight reduction, sodium restriction, increased physical activity, smoking cessation, and moderation of alcohol intake. Specifically, mean arterial blood pressure can be decreased by approximately 1 mmHg for each kilogram in body weight lost, and this reduction is independent of sodium intake.⁴ Likewise, systolic and diastolic blood pressures have been reduced by 5 mmHg and 2-3 mmHg, respectively, by restricting sodium intake of 4,600 mg per day by fifty percent. Certain populations, such as the elderly and African-Americans, are also more sensitive to the effects of sodium restriction in their diet. Another benefit of sodium restriction is the synergistic response when used concomitantly with antihypertensive medications due to the volume overload associated with hypertension.

The macrovascular complications for patients with type 2 diabetes and hypertension may be compounded by smoking, inducing an increased risk of morbidity and premature death.⁵ Therefore, this population should be targeted for smoking cessation and appropriate interventions implemented. Recommendations include 1) assessing smoking status and history, 2) repeated advice to non-smokers not to initiate smoking and counseling for smokers as a routine component of diabetes care, and 3) effective systems for inducing smoking cessation, including an offer to provide pharmacological supplements (i.e., nicotine replacement therapy) along with behavioral interventions.

The clinician should remember two caveats when applying non-drug therapies to decrease blood pressure in patients with diabetes. First, weight reduction through the use of appetite suppressants can often increase blood pressure levels and should be avoided. Second, the use of non-drug therapies has not been specifically studied in the diabetic population. However, non-drug management of hypertension has been applauded as the cornerstone of therapy by the JNC VI, and the results of these studies could be extrapolated to the diabetic population with hypertension.

Goals for Blood Pressure Reduction
Two large, multicenter, clinical trials, the United Kingdom Prospective Diabetes Study (UKPDS) and the Hypertension Optimal Treatment (HOT) trial, demonstrated that stroke and other outcomes could be prevented in patients with diabetes by tightening blood pressure control.^6,7 Tight control was achieved with blood pressure measurements less than 144/82 mmHg and diastolic blood pressure less than 81 mmHg with the UKPDS and the HOT studies, respectively. Although previous guidelines have submitted that the goal blood pressure for patients with hypertension and diabetes should be less than 130/85 mmHg3, increased mortality and cardiovascular event rates have been discovered through epidemiological analyses to occur in this patient population when blood pressures exceed 120/80 mmHg. Also, these risks continue to decrease when blood pressures are lowered well into the normal range. Therefore, recent guidelines support the reduction of blood pressures below 130/80 mmHg whenever this can be safely achieved.⁴ During every routine visit for diabetes, blood pressure via mercury sphygmomanometer also should be measured. If the systolic or diastolic blood pressures are greater than or equal to 130 or 80 mmHg, respectively, another confirmatory measurement should be conducted on a subsequent day prior to initiating treatment. Table 1 describes the recommended treatment algorithm for the treatment of hypertension in patients with diabetes.

Reduction of morbidity and mortality can be achieved in this patient population through antihypertensive treatment to reduce blood pressures below the recommended goals. Both microvascular (i.e., nephropathy, retinopathy, neuropathy) and macrovascular complications (i.e., stroke, coronary artery disease, congestive heart failure) have been attenuated in studies using angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), b-blockers, and diuretics.⁴ All of these medications will decrease blood pressure measurements in a similar fashion at clinical doses, approximately 10 to 15 mmHg for systolic and 5 to 10 mmHg for diastolic. Finally, reduction of blood pressure to goal is often a very difficult undertaking clinically and may require the use of three or more antihypertensives.¹ Several of the most common antihypertensive agents used in the diabetic patient population are described, with the remaining antihypertensives included in Table 2. 

Angiotensin Converting Enzyme Inhibitors
Decreasing the onset and progression of diabetic nephropathy remains one of the most challenging goals of attenuating microvascular complications, since as much as 30% of patients with diabetes will develop either microalbuminuria (>30 mg albumin/24 hour urine) or overt nephropathy (>300 mg albumin/24 hour urine). Likewise, almost half of all cases of end stage renal disease (ESRD) occur as a result of diabetic nephropathy.¹ ACE inhibitors have been historically useful tools to meet this challenge. In fact, hypertensive patients with diabetes are commonly started on an ACE inhibitor due to the vast number of studies that demonstrate that this action will decrease onset or progression of nephropathy, cardiovascular events, and mortality. The American Diabetes Association (ADA) suggests the use of ACE inhibitors as the initial choice for hypertensive patients with type 1 diabetes or non-hypertensive patients with some degree of kidney dysfunction (i.e., microalbuminuria or overt nephropathy).8 Although patients with type 2 diabetes are more likely to develop and suffer macrovascular complications than to progress from overt nephropathy to ESRD, it is clearly prudent to initiate ACE inhibitors to prevent the progression of nephropathy in this patient population.

Publication of the recent Heart Outcomes Prevention Evaluation (HOPE) study both demonstrated that cardiovascular endpoints could be decreased with the use of ACE inhibitors and raised the question of whether this group of medications could benefit patients with diabetes independent of the antihypertensive effects.⁹ Ramipril 10 mg per day or placebo was randomly assigned to 3577 patients with diabetes for 4.5 years. The subsequent risk reduction of primary cardiovascular events included a 25% decrease of the combined primary outcome, 22% decrease of myocardial infarction, 33% decrease in stroke, and a 37% decrease in cardiovascular death. These results were seen despite only modest and non-significant reductions in blood pressure. This is in contrast to the significantly reduced blood pressures achieved in the Systolic Hypertension in the Elderly (SHEP)10 and UK Prospective Diabetes Study (UKPDS),6 which also resulted in similar risk reductions of cardiovascular events. Therefore, for patients with diabetes over 55 years old with hypertension or at least one other cardiovascular risk factor, ACE inhibitors are indicated.

Angiotensin Receptor Blockers
The delayed onset of ESRD with ARBs has been demonstrated in several recent trials of patients with type 2 diabetes. Losartan 50 to 100 mg per day was compared versus placebo in the Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan (RENAAL) trial.¹¹ This randomized, double-blind study involved 1513 patients who had already presented with nephropathy, and they were followed for a mean period of 3.4 years. Risk reductions of 25% and 28% were achieved for doubling of serum creatinine concentrations and ESRD, respectively. 

These endpoints were also analyzed in a randomized, placebo-controlled study of 1715 patients with type 2 diabetes, hypertension, and nephropathy.¹² Irbesartan 300 mg, amlodipine 10 mg, or placebo was given daily for a mean period of 2.6 years. The relative risk of doubling serum creatinine for patients on irbesartan was 33% lower than those receiving placebo and 37% lower than those on amlodipine. However, the risk reduction for irbesartan with respect to ESRD or death was not significant. In both the RENAAL trial and the study by Lewis, et al., blood pressure measurements for the study medications were not significantly decreased from placebo, indicating that reduction in serum creatinine and ESRD (RENAAL trial only) were independent of the effects on hypertension. 

Head-to-head trials comparing ARBs with ACE inhibitors are limited. One small study compared the use of either candasartan 16 mg per day, lisinopril 20 mg per day, or both in a double blind, prospective, randomized study in 199 type 2 diabetics with hypertension and microalbuminuria.¹³ The authors concluded that at 12 and 24 weeks duration, both classes of medications were equally effective at reducing microalbuminuria and blood pressure. Therefore, in the absence of large clinical trials directly comparing ARBs and ACE inhibitors � and in light of the fact that studies of cardiovascular outcomes with ARBs are limited � current recommendations for first-line use of ARBs in patients with hypertension and type 2 diabetes is solely when the only other cardiovascular risk factor (i.e., dyslipidemia, family history, smoking) is the presence of microalbuminuria.⁸

b-Blockers
Clinicians historically have not robustly embraced b�blockers to treat hypertension in patients with diabetes due to their perceived blunting effect of counter-regulatory responses to hypoglycemia and delay in recovery from hypoglycemia.¹⁴ However, it has been increasingly recognized that this class of medications may reduce cardiovascular events (i.e., myocardial infarction) to an equal or greater degree in patients with diabetes than in non-diabetics. Furthermore, b-blockers have been shown to reduce morbidity and mortality in patients with other disease states (i.e., congestive heart failure), and it would be prudent to control blood pressure with this class of antihypertensives in such patients.

Although ACE inhibitors and ARBs may attenuate microvascular endpoints in patients with diabetes without concomitantly reducing blood pressure, b-blockers and ACE inhibitors have been proven to be equally effective in decreasing microvascular and macrovascular complications when blood pressure is significantly reduced. A comparative trial of captopril 50 to 100 mg per day versus atenolol 50 to 100 mg per day was designed to determine if the choice of agent in tightly controlling blood pressure had an impact on complications.¹⁵ Both classes of medications were equally effective in decreasing blood pressure (144/83mmHg with captopril and 143/81mmHg with atenolol) versus the control group (154/87mmHg). All endpoints were significantly reduced, including diabetes-related deaths, myocardial infarction, microalbuminuria, and proteinureia, without either medication exhibiting superiority. Atenolol was only associated with modest weight gain and a slightly lower compliance rate when compared to captopril, but it did not show an increased incidence of hypoglycemic events. Therefore, the tight control of blood pressure seemed to have made a more significant impact for the hypertensive patient with diabetes than did the choice of the antihypertensive agent. This finding was complemented by the fact that both tightly controlled blood glucose and blood pressure produced an additive effect in reducing microvascular and macrovascular complications.¹⁶

Conclusions
Tight control of blood pressure has been shown to decrease microvascular and macrovascular complications in patients with concomitant diabetes. Therefore, clinicians should be encouraged to routinely monitor blood pressure in this group of patients at every visit. Goals of blood pressure control in this selected patient population should be to achieve measurements of less than 130/80 mmHg and should include a behavioral approach of increased physical activity, smoking cessation, and restrictions of sodium, calories, and alcohol intake. If blood pressure goals cannot be achieved through a behavioral approach alone, the clinician should add medication therapy. Initial choices include ACE inhibitors, ARBs, b-blockers, and low-dose thiazide diuretics. Starting an ACE inhibitor has become an established practice for diabetic patients with hypertension or those without hypertension but with multiple cardiovascular risk factors. If the ACE inhibitor cannot be tolerated or if the diabetic patient only has microalbuminuria as the sole risk factor, ARBs can be used. However, the clinician should keep in mind that long-term cardiovascular data with ARBs is lacking. Finally, b-blockers present another first-line choice, especially when this class is indicated to reduce morbidity and mortality of other concomitant disease states. 

References

1 Arauz-Pacheco C, Parrott M, Raskin P. The treatment of hypertension in adult patients with diabetes (technical review). Diabetes Care 25(1):134-47, 2002.

2 Wingard D, Barrett-Conner E. Heart disease and diabetes. In Diabetes in America. Washington, DC, US Govt Printing Office 429-48, 1995.

3 Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure: The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI). Arch Int Med 157:2413-2446, 1997.

4 American Diabetes Association. Treatment of hypertension in adults with diabetes (position statement). Diabetes Care 25(1):S71-3, 2002.

5 American Diabetes Association. Smoking and diabetes (position statement). Diabetes Care 25(1):S80-1, 2002.

6 UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ 317:703-12, 1998.

7 Hansson L, Zanchetti A, et al. Effects of intensive blood-pressure lowering and low dose aspirin on patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomized trial. Lancet 351:1755-62, 1998.

8 American Diabetes Association. Diabetic Nephropathy (position statement). Diabetes Care 25(1):S85-9, 2002.

9 Heart Outcomes Prevention Evaluation Study Investigators. Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and MICRO-HOPE substudy. Lancet 355:253-9, 2000.

10 Curb JD, Pressel SL, et al. Effect of diuretic-based antihypertensive treatment on cardiovascular disease risk in older diabetic patients with isolated systolic hypertension: Systolic Hypertension in the Elderly Program Cooperative Research Group. JAMA 276:1886-92, 1996.

11 Brenner BM, Cooper ME, et al. Effects of Losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. NEJM 345:861-9, 2001.

12 Lewis EJ, Hunsicker LG, et al. Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. NEJM 345:851-60, 2001.

13 Morgensen CE, Neldam S, et al. Randomized controlled trial of dual blockade of renin-angiotensin system in patients with hypertension, microalbuminuria, and non-insulin dependent diabetes: the candasartan and lisinopril microalbuminuria (CALM) study. BMJ 321:1440-4, 2000.

14 Goldberg DE. Diabetes Mellitus. Pharmacotherapy Self-Assessment Program, 3rd Edition. 129-73, 2000.

15 UK Prospective Diabetes Study Group. Efficacy of atenolol and captopril in reducing risk of macrovascular and microvascular complications in type 2 diabetes (UKPDS 39). BMJ 317:713-20, 1998.

16 American Diabetes Association. Implications of the United Kingdom prospective diabetes study (position statement). Diabetes Care 25(1):S28-32, 2002.

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Insert - Provider Training Information and Schedules

2002 Unisys Provider Workshops

Following is the schedule for the 2002 Unisys Provider Workshops. The annual Unisys Provider Workshops focus on presenting vital policy and billing information to our Medicaid provider community. With that in mind, our intent is to create a neutral atmosphere for delivery of the educational materials to the providers in attendance. The Department of Health and Hospitals has asked Unisys Provider Relations to address questions relating to recent policy and procedure changes. HIPAA updates will be provided at each workshop.

Our training format separates basic information from specific program information. The Basic Medicaid information workshops will cover general Medicaid policy such as standards for participation, recipient eligibility/ID cards, third party liability, how to obtain assistance from Unisys, etc. This information will be presented ONLY in the Basic sessions and will not be repeated in specific program workshops. All Basic workshop sessions will be identical in content.

THIS YEAR, BECAUSE OF THE STATEWIDE CommunityCARE EXPANSION, CommunityCARE WILL BE COVERED IN A SEPARATE CommunityCARE WORKSHOP. CommunityCARE will not be discussed in detail in any other workshops. These workshops will also be identical in content and will cover all aspects of the CommunityCARE Program. We encourage you to attend one of these workshops.

In each specific program workshop, Unisys staff will discuss recent policy or procedure changes for that specific program. Basic information such as eligibility, third party liability, CommunityCARE, etc. WILL NOT be presented in the specific program workshops.

Providers may choose to attend any of the basic sessions and any of the CommunityCARE sessions, in addition to their specific program session, or they may choose to attend only the specific program session for their provider type.

An Eligibility workshop geared toward the LaCHIP eligibility category, Medicare Buy-In, and EPSDT services availability and access is being offered again this year. Anyone who services EPSDT recipients is encouraged to attend.

Hospital training and Precertification training are being held as separate sessions. Personnel from the Utilization Review Department of each hospital and those involved in precertification for inpatient admissions, including hospital case managers who do precertification, should attend the Precertification workshop, which will contain information specifically for precertification. The Hospital workshop will focus on hospital policy in general and on billing policies and procedures.

Hemodialysis policy and billing information for free-standing hemodialysis centers will be presented in the hospital training session.

Pharmacy workshops will focus on Pharmacy Prior Authorization and Peer Based Profiling. Pharmacy providers who also provide services through the DME program may wish to attend the DME workshop, also.

Case Management, Waiver, and Mental Health Rehabilitation program workshops WILL NOT be held this year. Providers of these services will be notified of other arrangements for training as that information becomes available.

ONLY ICF-MR and Adult Day providers should attend the Long Term Care workshop.  Training for nursing homes will be held independently at a later date.  Nursing home providers will be notified of other arrangements for training as that information becomes available.

Due to space limitations in all workshops, please limit attendees to two (2) persons per provider. Attendees should arrive 15 - 20 minutes early to register. Remember, 

� each person MUST have his or her provider name and Medicaid provider ID number in order to register and attend, and 

� providers are required to have a valid Medicaid provider ID number for each specific program workshop attended.

Medicaid programs for discussion at the workshops include:

1. Basic Medicaid Information: All providers may attend. Basic Medicaid information will be presented, including standards for participation, recipient eligibility and ID cards, third party liability, remittance advice review, how to obtain assistance from Unisys, Provider Relations information, common generic denial reasons and methods of correction, etc. This information will not be repeated in any of the specific program workshops listed below.

2. Eligibility: Includes LaChip, Medicare Buy-In, and EPSDT services. All providers may attend.

3. Professional: Physicians, Labs, Optometrists, Chiropractors, Ambulatory Surgery Centers, Optical Suppliers, Nurse Practitioners, Audiologists, Nurse Midwives, CRNAs, Hemodialysis (supervision ONLY), and Mental Health Clinics.

4. Hospital/Hemodialysis: Acute, Rehabilitation, Long Term, Free-standing Psych, Distinct Part Psych hospitals, AND Free-Standing Hemodialysis Centers. Hospital policy and billing issues and Hemodialysis policy and billing issues will be presented. 

5. Precertification (Precert): Hospital Utilization Review or other personnel involved in obtaining precertification. Precertification workshops will include policy and procedures specific to precertification (not billing). THIS SESSION IS FOR HOSPITAL CASE MANAGERS/UTILIZATION REVIEW STAFF.

6. Long Term Care: ONLY ICF-MR Facilities and Adult Day Providers. (Hospice if offered in a separate workshop.)  The program will be held in all locations except Houma and Covington. (Nursing homes will be notified of other arrangements for training as that information becomes available.)

7. Hospice: Hospice providers. This program will be held in all locations EXCEPT Houma and Covington.

8. Home Health Agencies: Home Health providers who are also DME providers should attend both the Home Health and DME sessions.

9. Durable Medical Equipment (DME) Suppliers. Pharmacists who also provide services through the DME program providers may wish to attend this workshop.

10. Free-Standing Rehabilitation Centers: This session is for free-standing centers ONLY � it does not include hospital rehabilitation providers. (Hospital providers should attend the hospital workshop.) This program will be held in all locations EXCEPT Houma and Covington.

11. Dental: EPSDT and Adult and Oral Surgery. Presentation of specific HIPAA information is planned. Dental training will be offered at all locations except Houma and Covington.

12. Ambulance Transportation: Ambulance providers only�does not include non-emergency non-ambulance transportation. This session will be held in New Orleans, Shreveport/Bossier City, and Lafayette.

13. Non-emergency Medical Transportation: Non-emergency non-ambulance providers only�does not include ambulance transportation. This session will be held in New Orleans, Shreveport/Bossier City, and Lafayette.

14. EPSDT/PCS Services: EPSDT Health Services (school boards and Early Intervention Centers ONLY). This program will be held in all locations EXCEPT Houma and Covington.

14. Federally Qualified Health Centers and Rural Health Clinics: This program will be held in all locations EXCEPT Houma and Covington.

15. KIDMED: This program will be held in all locations EXCEPT Houma and Covington.

16. Pharmacy: This program will be held in all locations EXCEPT Houma and Covington.

Please refer to the following list for dates (Day 1, Day 2, and Day 3) and times at each workshop location. Note that there may be more than one session held at the same time. There is no pre-registration required. Please direct any questions concerning the workshops to Unisys Provider Relations at 800/473-2783 or 504/924-5040. Meeting sites should be contacted for directions or sleeping accommodations ONLY! DO NOT contact the meeting sites with questions related to the workshops!

CITY	DAY, DATE, TIME, AND SESSION
Baton Rouge	Tuesday, October 1		Wednesday, October 2			Thursday, October 3
Room Name	Auditorium	Classroom 3	Main Auditorium		Classroom 3	Classroom 3
LA State Police Training Academy 7901 Independence Blvd Baton Rouge, LA	Basic � 8:00 � 9:30 CommunityCare � 9:45 - 12:00 Eligibility � 1:00 � 2:00 Professional � 2:15 - 4:15 KIDMED � 4:30 - 5:45	Hospital � 1:30 - 3:15 Precert � 3:30 � 5:00 Pharmacy PA � 5:15 - 6:30	EPSDT/PCS � 8:30 � 9:30 RHC/FQHC � 9:45 � 11:15 Eligibility � 11:30 - 12:30 Basic � 1:30 � 3:00 CommunityCare � 3:15 � 5:15		DME � 8:30 � 10:00 Home Health � 10:15 � 11:45 Rehab � 12:00 � 1:00	LTC � 8:30 � 9:45 Hospice � 10:00 - 11:30 Dental � 11:45 � 1:45
Covington	Friday, October 4
Room Name	Ballroom 1	Ballroom 3
Holiday Inn 501 N Hwy 190 Covington, LA	Basic - 8:00 - 9:30 CommunityCARE - 9:45 - 12:00 Eligibility - 1:30 � 2:30 Professional - 2:45 � 4:45	Hospital - 1:30 - 3:15 Precert - 3:30 - 5:00
Bossier City	Monday, October 7		Tuesday, October 8				Wednesday, October 9
Bossier Civic Center 620 Benton Rd Bossier City, LA	Basic � 8:00 � 9:30 CommunityCare � 9:45 - 12:00 Eligibility � 1:00 � 2:00 Professional � 2:15 - 4:15 KIDMED � 4:30 - 5:45	Hospital � 1:30 - 3:15 Precert � 3:30 � 5:00 Pharmacy PA � 5:15 - 6:30	EPSDT/PCS � 8:30 � 9:30 RHC/FQHC � 9:45 � 11:15 Eligibility � 11:30 - 12:30 Basic � 1:30 � 3:00 CommunityCare � 3:15 � 5:15		DME � 8:30 � 10:00 Home Health � 10:15 � 11:45 Rehab �12:00 � 1:00     NEMT � 5:30 - 6:30		LTC � 8:00 � 9:15 Hospice � 9:30 - 11:00 Ambulance � 11:15 - 12:15 Dental � 12:30 � 2:30
Lafayette	Monday, October 14		Tuesday, October 15				Wednesday, October 16
Room Name	Pink Perfection	Purple Dawn	Pink Perfection		Purple Dawn		Purple Dawn
Holiday Inn Holidome 2032 N Evangeline Thru Lafayette, LA	Basic � 8:00 � 9:30 CommunityCare � 9:45-12:00 Eligibility � 1:00 � 2:00 Professional � 2:15- 4:15 KIDMED � 4:30 - 5:45	Hospital � 1:30-3:15 Precert � 3:30 � 5:00 Pharmacy PA � 5:15-6:30	EPSDT/PCS � 8:30 � 9:30 RHC/FQHC � 9:45 � 11:15 Eligibility � 11:30 - 12:30 Basic � 1:30 � 3:00 CommunityCare � 3:15 � 5:15		DME � 8:30 � 10:00 Home Health� 10:15 � 11:45 Rehab � 12:00 � 1:00     NEMT � 5:30 � 6:30		LTC � 8:00 � 9:15 Hospice � 9:30 -  11:00 Ambulance � 11:15 - 12:15 Dental � 12:30 - 2:30
New Orleans	Monday, October 21		Tuesday, October 22				Wednesday, October 23
Room Name	Hall A	Meeting Rooms 1&2	Hall A	Meeting Rooms 1&2			Meeting Rooms 1&2
John A. Alario Center 2000 Segnette Blvd Westwego, LA	Basic � 8:00 � 9:30 CommunityCare � 9:45 - 12:00 Eligibility � 1:00 � 2:00 Professional � 2:15- 4:15 KIDMED � 4:30 - 5:45	Hospital � 1:30 - 3:15 Precert � 3:30 � 5:00 Pharmacy PA � 5:15-6:30	EPSDT/PCS � 8:30 � 9:30 RHC/FQHC � 9:45 � 11:15 Eligibility � 11:30 - 12:30 Basic � 1:30 � 3:00 CommunityCare � 3:15 � 5:15	DME � 8:30 � 10:00 Home Health � 10:15 �11:45 Rehab � 12:00 � 1:00     NEMT � 5:30 - 6:30			LTC � 8:00 � 9:15 Hospice � 9:30 - 11:00 Ambulance � 11:15 - 12:15 Dental � 12:30 - 2:30
Houma	Thursday, October 24
Houma-Terrebonne Civic Center 346 Civic Center Blvd Houma, LA	Basic - 8:00 - 9:30 CommunityCARE - 9:45 - 12:00 Eligibility - 1:30 � 2:30 Professional - 2:45 - 4:45	Hospital - 1:30 - 3:15 Precert - 3:30 - 5:00
Alexandria	Monday, November 4		Tuesday, November 5					Wednesday, November 6
Room Name	Magnolia/Camellia	Wisteria/Gardenia	Magnolia/Camellia	Wisteria/Gardenia				Wisteria/Gardenia
Best Western Inn- Suites & Conference Ctr 2720 West MacArthur Dr Alexandria, LA	Basic � 8:00 � 9:30 CommunityCare � 9:45 - 12:00 Eligibility � 1:00 � 2:00 Professional � 2:15 - 4:15 KIDMED � 4:30 - 5:45	Hospital � 1:30 - 3:15 Precert � 3:30 � 5:00 Pharmacy PA � 5:15-6:30	EPSDT/PCS � 8:30 � 9:30 RHC/FQHC � 9:45 � 11:15 Eligibility � 11:30 - 12:30 Basic � 1:30 � 3:00 CommunityCare � 3:15 � 5:15	DME � 8:30 � 10:00 Home Health � 10:15 � 11:45 Rehab � 12:00 � 1:00				LTC � 8:00 � 9:15 Hospice � 9:30 - 11:00 Dental � 11:15 - 1:15
Lake Charles	Thursday, November 7		Friday, November 8
Lake Charles Civic Center 900 Lakeshore Dr Lake Charles, LA	Basic � 8:00 � 9:30 CommunityCare � 9:45 - 12:00 Eligibility � 1:00 � 2:00 Professional � 2:15 - 4:15 KIDMED � 4:30 - 5:45	Hospital � 1:30 - 3:15 Precert � 3:30 � 5:00 Pharmacy PA � 5:15 - 6:30	EPSDT/PCS � 8:00 � 9:00 RHC/FQHC � 9:15 � 10:45 Eligibility � 11:00 - 12:00 Rehab � 12:15 - 1:15 Basic � 1:30 � 3:00 CommunityCare � 3:15 � 5:15	DME � 8:00 � 9:30 Home Health � 9:45 � 11:15 LTC � 11:30 � 12:45 Hospice � 1:00 - 2:30 Dental � 2:45 - 4:45
Monroe	Tuesday, November 12		Wednesday, November 13					Thursday, November 14
Room Name	Jackson/Lafitte	Bonaparte	Jackson/Lafitte	Bonaparte				Bonaparte
Holiday Inn Holidome 1051 Hwy 165 Bypass Monroe, LA	Basic � 8:00 � 9:30 CommunityCare � 9:45-12:00 Eligibility � 1:00 � 2:00 Professional � 2:15 - 4:15 KIDMED � 4:30 - 5:45	Hospital � 1:30 - 3:15 Precert � 3:30 � 5:00 Pharmacy PA � 5:15 - 6:30	EPSDT/PCS � 8:30 � 9:30 RHC/FQHC � 9:45 � 11:15 Eligibility � 11:30 - 12:30 Basic � 1:30 � 3:00 CommunityCare � 3:15 � 5:15	DME � 8:30 � 10:00 Home Health � 10:15 � 11:45 Rehab � 12:00 � 1:00				LTC � 8:00 � 9:15 Hospice � 9:30 - 11:00 Dental � 11:15 - 1:15