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Utilization Update: Pediasure, Orthotics & Glucose Strips |
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"Why is SFHP denying my request?"
Unlike for-profit health plans, it is SFHP’s providers, not shareholders, that benefit from utilization management. We aim to strike the right balance of being good stewards of appropriate use through reliance on objective medical necessity criteria, with the aim of not inappropriately interfering with the doctor-patient relationship. If you haven’t yet been compelled by the data from the Dartmouth Atlas, showing how regional variation in medical interventions impacts health and mortality, this article is an excellent review.
Since we have had many requests for the following items, we wanted to give a little more background on each of them here.
Pediasure
Pediasure and other nutritional supplements are frequently prescribed by providers in our network. Medi-Cal only approves Pediasure when medically necessary, which is defined as the inability to swallow blended foods. If a patient can drink smoothies or other blended foods, SFHP will deny pediasure, as it is a food supplement, not a medication.
We came across this interesting blog on pediasure, which asks the question:
“Since pediasure is essentially chocolate milk, but with more calories, more fat, and a worse Omega 6:Omega 3 ratio, why is it being promoted as a healthy supplement for children who don’t want to eat broccoli? “
Orthotics
Any provider who sees children knows how attached parents can be to the correction of many common childhood conditions: flat feet, in-toeing, or normal variant bow-legs or knock-knees. The conversation about “why your child does not need orthotics” can be as challenging as “why your child doesn’t need antibiotics.” We do urge providers to have these conversations, as there is no evidence supporting the use of orthotics or other durable medical equipment in these conditions, unless there is associated disability or functional impairment. When children are referred to specialists for normal variant conditions, and the specialist prescribes orthotics or other durable medical equipment, these prescriptions are usually denied by the medical group or by San Francisco Health Plan, leading to parental frustration and confusion, and more visits to the primary care provider.
Please see our website for more details about SFHP’s criteria for approval of orthotics. In this document, it states that we will only approve referral to a pediatric orthopedist and medical equipment in the following scenarios:
For more information please click on the following links:
Glucose testing strips
SFHP recently adopted the Medicare policy restricting glucose strips to one a day for type II diabetics. Why? The literature has not been able to show improved A1c outcomes with home testing, but it HAS shown an increase in patient anxiety and depression. The decision to test should remain between a provider and patient, but SFHP encourages providers to apply the same decision-making process here as in all areas of medicine: will testing improve this patient’s outcome? How will this information help my patient better manage their disease? Many patients test “because they are supposed to” and do not know how to interpret the difference between a fasting and a post-prandial test, nor do they use the tests to change their behavior. For many patients, A1cs can be a simpler, more effective teaching tool.
For more information please click on the following links:
References: EBM Guidelines from Essential Evidence Plus 2005-05-01; Up to Date, reviewed July 2009; Aetna Guidelines, reviewed July 2009
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