Clinical Connections: May 2025 - www.westernhealth.com

CMO Reflections and Gratitude

AI, with its seemingly supernatural ability to review, aggregate, and synthesize data to create incredibly nuanced solutions to incredibly complex issues, still relies on reviewing what has been done in the past to understand how to create solutions for the future. Part of what makes fixing healthcare today so challenging is that so much of what has worked well in the past does not help us get to the answers we need to make healthcare better going forward. Cost. Consistent quality. Burnout. Access. Affordability.

Go to any health system or physician office in America and these are the common themes that we are all trying to solve for, and despite some of our brightest minds trying, we are struggling to find traction in the efforts. We live in a time where we are experiencing incredible breakthroughs in treatments and interventions for diseases that have confounded us for so long. Yet, despite these leaps in clinical approaches, health care feels more broken than ever. But I do not despair. I still believe that we can make health care better, by learning from our past, but not being bound by it. The solutions that will move the needle will have to change the paradigm, and that almost always requires courage, ingenuity, and the willingness to make bets.

Great healthcare can be one of the most empathetic, loving, transformational things in a person's life. The difference it can make is so substantial, that it warrants (I daresay demands) that we figure this out. Great outcomes. Better value. Experience that is compassionate and efficient. Recreating joy in medicine. It will not be easy, and will require a ton of hard work, working with physicians and caregivers in true partnership, and the willingness to really think differently- the proverbial ‘Out of the Box, Out there” thinking. If AI can't figure it out for us, we are going to have to do it. I am grateful for each of you that is working alongside your peers, your health plans, your organizations, and public health agencies and with yourself to do exactly that.

NEWS & FEATURED

Expanding Doula Services to Address Maternal and Infant Health Disparities Confronting the Maternal Health Crisis

The United States faces a significant maternal health crisis, with Black, American Indian, Pacific Islander and Hispanic women and birthing persons experiencing maternal mortality rates nearly 3.5 times higher than their white counterparts. Structural racism, implicit bias in healthcare, and socioeconomic inequities contribute to these alarming disparities. For example, Tori Bowie – The three-time Olympic medalist and world champion died in 2023 from complications related to childbirth, including eclampsia and high blood pressure. Despite her elite athletic status, she experienced a maternal health crisis that disproportionately affects Black women. This and other countless stories serve as painful reminders of the urgent need for culturally competent, continuous maternal support—which doulas can provide

Doulas— who are trained professionals who provide continuous emotional, physical, and informational support—play a crucial role in improving birth experiences and health outcomes. Studies show that doula-assisted births result in fewer cesarean deliveries, lower rates of preterm birth, improved maternal-infant bonding, and enhanced postpartum recovery.

At Western Health Advantage (WHA), we are committed to improving maternal health outcomes and reducing these disparities by expanding coverage for doula services. WHA’s vendors offering in person and virtual doula services are Raya Health or FindRaya.com. and Maven Maternity is also available for virtual doula services only.
By integrating doula care into our maternity benefits, WHA aims to provide holistic, equitable support to all birthing individuals, particularly those at higher risk for complications.

WHA’s Doula Benefit: Comprehensive Support for Maternal Health

To combat these disparities and enhance maternity care, WHA offers a doula services benefit that includes:

Initial Visit – An introductory session to establish rapport and plan care.
Up to 8 Prenatal or Postpartum Visits – Tailored support for prenatal education, birth planning, postpartum recovery, and newborn care.
Labor and Delivery Support – Continuous presence to provide comfort, advocacy, and assistance during childbirth, including situations ending in stillbirth, miscarriage, or abortion.
Up to 2 Extended Three-Hour Postpartum Visits – Focused support on recovery, breastfeeding, and emotional well-being.

Exclusions:

The following services are not covered under WHA’s doula benefit:

Belly binding (traditional/ceremonial)
Birthing ceremonies (e.g., sealing, closing the bones)
Group classes on babywearing
Maternal or infant massage
Photography
Placenta encapsulation

How can you ensure that birthing individuals receive comprehensive, culturally competent care:

Refer Patients to In-Network Doulas – Inform eligible patients about the availability of covered doula services.
Integrate Doulas into Care Teams – Work collaboratively with doulas to create cohesive birth plans and postpartum care strategies.
Advocate for Equity in Maternal Care – Participate in training to recognize and mitigate implicit bias, ensuring all patients receive respectful, equitable treatment.

Through this initiative, we aim to:

Reduce preventable maternal complications
Improve birth experiences for underserved communities
Ensure that every birthing individual, regardless of race or background, has access to continuous, compassionate support

By working together, providers and WHA can make a lasting impact on maternal health equity. For more information on WHA’s Doula Services Benefit through Raya Health and Maven Maternity Program, please visit our Pregnancy and Postpartum Support page or contact our Member Services team at 888.563.2250.

COMPLIANCE

Bill Summary

As of Jan 1, 2025, California Assembly Bill 3059 ensures that all health plans cover medically necessary pasteurized donor human milk obtained from a tissue bank licensed by the State Department of Public Health as a basic health care. It also makes it easier for hospitals to provide donor human milk. Please check with your pediatrician or neonatologist to understand if this is available to you.

As of Jan 1, 2025, California Assembly Bill 2105 mandates health insurance plans to cover the diagnosis and treatment of Pediatric Autoimmune Neuropsychiatric Disorders (PANDAS) and Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) when prescribed or ordered by the treating physician and surgeon and is medically necessary. This includes therapies like antibiotics, medication and behavioral therapies to manage neuropsychiatric symptoms, immunomodulating medicines, plasma exchange, and intravenous immunoglobulin therapy.

The law prohibits cost sharing for these services at a rate higher than other services and ensures timely authorization based on clinical need. It also prevents denial of care based on prior diagnoses and requires alignment with established clinical guidelines, aiming to improve access to care for affected children.

Introducing Senate Bill (SB) 607 for Controlled Substances

Please be advised of SB 607, which outlines specific requirements before directly dispensing or issuing a patient of any age their first prescription for a controlled substance containing an opioid. Before dispensing, you must discuss the following:

Risk of Addiction and Overdose: Explain the potential for addiction and the dangers of overdose associated with opioid use.
Increased Risk for Individuals with Mental and Substance Use Disorders: Inform patients that those suffering from both mental health and substance use disorders are at a heightened risk of developing an addiction to opioids.
Dangers of Concomitant Use: Advise patients of the risks associated with taking an opioid alongside a benzodiazepine, alcohol, or another central nervous system depressant.

These requirements do not apply when the patient’s treatment includes emergency services and care (as defined in Section 1317.1 of the Health and Safety Code), is associated with emergency surgery, or if, in the prescriber’s professional judgment, discussing these risks would be detrimental to the patient’s health or safety, or violate the patient’s legal rights regarding confidentiality.

Adhering to SB 607 is essential for ensuring patient safety and responsible opioid prescribing. We appreciate your commitment to these guidelines and to the highest standards of care.

PHARMACY UPDATE

Opioid Provider Education

As of January 1st, 2025, WHA has adopted Optum’s Opioid Risk Management Program through our P&T committee via our PBM. This program was designed to increase safe use and dispensing of opioid medications. In alignment with Food and Drug Administration (FDA) and Centers for Disease Control and Prevention (CDC) guidelines, the following utilization management has been implemented:

Prior authorization (PA) is required for opioids that exceed recommended treatment naïve or treatment experienced quantity limits (QLs)
- QLs differ between drugs and between treatment naïve and treatment experienced. Please refer to the Formulary Lookup Tool for specific QLs information.
- Short acting opioids (SAOs) have a new to therapy 7-day supply limit
- Long-acting opioids (LAOs) QLs are based on FDA max daily dose
PA is required when cumulative opioids (SAOs/LAOs) exceed 180 Morphine Milligram Equivalents (MME) per day
PA is required on LAOs with step therapy through SAOs
All SAOs have a maximum 2 fills in a 60-day time period
Age related UM edits:
- PA is required on opioid-containing cough medications (cold/cough meds) for those less than or equal to 19 years old
- All SAOs have a new to therapy 3-day supply limit for those less than or equal to 19 years old

Whenever possible, please include an active treatment plan (including other pharmacological and non-pharmacological agents tried), documentation of a risk assessment (such as the Opioid Risk Tool), and documentation of a signed pain contract on file when submitting a request for opioid medications. For specific PA requirements, please refer to the WHA Pharmacy PA Criteria website and search for the “Opioid Risk Management” guideline. Additional guidelines used for opioid reviews include “Opioid Quality Limit Overrides,” (used for opioids without an FDA maximum dose) “Commercial MEDLIMIT CDUR Criteria” (used for those exceeding MME), and “Quantity Limit General” (used for opioids with an FDA maximum dose). Updated formulary and P&T approved PA criteria is found on our webpage, P&T meets quarterly and formulary booklets are updated on a monthly basis. For additional information please contact the Pharmacy department: pharmacy@westernhealth.com.

HEDIS & RATINGS

HEDIS Articles to Note

DOC TALK

Jiva Health endocrinologist Aaron-Ross Jimenez, M.D., MPH, on how advanced technology helps patients living with diabetes

Continuous glucose monitoring (CGM) is a milestone for clinicians and patients in managing diabetes—not only because of the real-time data it provides, but also thanks to insulin pump advancements that are moving us closer to what is essentially an autonomous pancreas. Compared to more traditional methods of monitoring blood sugar levels, CGM can be used to effectively measure responses to insulin, evaluate time in range over an extended period, and reveal other metrics that can better inform regimen adjustments. CGM also helps us empower patients to do more for themselves and make lifestyle changes without having to wait for their next doctor’s visit.

CGM aids clinical decision-making and allows us to incorporate detailed changes, fine-tuning medications and being more proactive about treatment. For example, say I have a new consult for a patient with diabetes who is on four daily doses of insulin. The patient tells me that they measure their blood sugar three or four times a day, once before each meal and at bedtime. If the patient is taking short-acting insulin with meals, CGM can tell me what is happening with their blood sugar levels after they eat so I can adjust the mealtime insulin if it is indicated. Or a patient may experience low blood sugar overnight when they are not checking their glucose levels. CGM will show me that data so I can adjust the patient’s long-acting insulin. I can track the trends after those changes and make different adjustments as needed.

Or I might have a patient with rebound hyperglycemia. Patients may have a lot of low blood sugar levels overnight without knowing because they are asleep, but every time they have a low, their body makes their blood sugars go up. In the morning, their blood sugars actually look good, or sometimes even high. And without a continuous glucose monitor, patients might unknowingly increase the long-acting insulin that they take at night in response to these high blood sugar readings. CGM can be especially useful in such cases.

Physicians can also use CGM for hypoglycemia syndromes that are not related to diabetes, although it might be tougher to get insurance approvals in such cases. If you have access to a sample glucose monitor and are concerned about a patient with low blood sugar, use CGM to see if the patient actually has low blood sugars when they are experiencing symptoms or just have low blood sugars in general—or perhaps they are dealing with something else entirely. Additionally, CGM can be used to inform care for patients who don’t need medication interventions but could benefit from food or lifestyle modifications even if they aren’t managing diabetes.

The only real limitation to the technology is patient use. Is the patient wearing the sensor for the directed duration? Is the data being transmitted correctly to the patient’s smartphone, or is it getting disconnected because the patient doesn’t always keep the phone nearby? Although guidelines from the American Diabetes Association (ADA) now recommend continuous glucose monitoring for patients living with type 1 and type 2 diabetes, older populations may be intimidated by the technology and not want to try it. Other barriers might include access and cost—although with the ADA recommendation, more insurance companies are approving coverage. At this point, CGM companies typically have a good idea of what the requirements are for insurance approvals. Dexcom, for example, has a coverage calculator where you put in the patient’s name, date of birth and your NPI number, and it tells you if you should send this prescription to the pharmacy or a Durable Medical Equipment vendor.

Most medical device companies will work with a clinician's office to streamline access to data and in-depth reports. Partner with your local reps to establish a system that integrates with your clinic, whatever your goals may be. Put in the work in the beginning, and then it's easy going forward.

BEHAVIORAL HEALTH

Closing the Gap on Behavioral Health Follow-up and SUD Measures – How Primary Care roles expanded with recent HEDIS changes.

As of 2025, medical providers play an even more critical role in ensuring their patients receive the appropriate follow-up care after discharge for behavioral health hospitalizations and emergency department visits. HEDIS expanded the criteria allowing for medical providers, PCPs, and additional care settings to qualify for the 7-day and 30-day follow-up visits. By using qualified billing and diagnostic codes, these follow-up visits within 7 and 30 days of discharge will count towards the measures and are allowed to close gaps. Both visits are needed to meet the measures, and virtual visits are now allowed. For more information see Optum BH’s "Closing the Gap on Follow-up Care After Discharge". Billing and diagnosis codes can be found on Optum BH’s tip sheets: Follow-up After Hospitalization Procedure Codes and Follow-up After ED Visits Procedure Codes.

Proper documentation of a substance use disorder remission is also necessary to avoid triggering new events, with or without a hospitalization or ED visit. Every patient visit that includes an SUD diagnosis code with mild, moderate, or severe severity levels indicates a new diagnosis and requires the initiation and engagement of SUD treatment (IET). By using a “1” at the end of an SUD diagnosis code, and eliminating contradicting active SUD diagnosis codes, this will document the condition is in remission and thus avoid creating a potential gap for the IET HEDIS measure. For guidance on which codes to use for SUD abuse and dependence in remission, please review Optum BH’s "Documenting Substance Use Disorder (SUD) Remission". Play especially close attention to the cannabis codes as these are frequently missed.

UTILIZATION MANAGEMENT

ADVANTAGE REFERAL PROGRAM AT WHA - Important things for you to know

Western Health Advantage (WHA) developed the Advantage Referral Program to offer members greater flexibility when accessing specialist care. Once the Primary Care Physician (PCP) determines that it is medically necessary for the member to see a specialist, the member may request to be referred to any appropriate participating specialist within WHA’s network, rather than being limited to specialists within their PCP’s medical group or Independent Practice Association (IPA).

For example, if a PCP from Mercy Medical Group determines that a referral is needed, the member may request to see any WHA-contracted specialist, regardless of group affiliation, through the Advantage Referral Program.

WHA has updated the Advantage Referral Program Handbook, which now includes the revised Policy and Procedure, additional information regarding the program, and an expanded FAQ section to provide clearer guidance. Additionally, information about the Advantage Referral Program is also available in the Provider Manual. We encourage all contracted providers and medical groups to review both documents for the most up-to-date information.

Last review date: April 25, 2025