issue 1, 2015 care-outlook - alicare medical management · alicare medical management t he...

Care-OutlookN E W S L E T T E R

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P R E S I D E N T ’ S M E S S A G E

The Impact of the Affordable Care Act on Clinical Trials Julie O’Brien, BSN, RN, MS, President, AliCare Medical Management

The Affordable Care Act (ACA) implemented dramatic changes to our health care system, expanding coverage

to more Americans and creating a host of new mandates for health plans. In the wake of all the health insurance exchange publicity, limited public attention has been paid to a new key requirement for insurers and group health plans to cover costs related to clinical trials.

Clinical trials are performed to determine if new treatments and procedures, new drugs and combinations of drugs or new devices are clinically

safe and effective and should be used as a standard of care for future patients. They can also help determine whether a new treatment works as well as or better than an existing treatment. That being said, participation in clinical trials is often

See President’s Message, page 5

I N T H I S I S S U E . . .

President’s Message .................................. 1

AMM Celebrates Its 25th Anniversary .. 1

Employee Spotlight ............................... 2

Follow us on LinkedIn! .......................... 2

Clinical Update: Measles on the Rise .... 3

In the News ............................................. 6

AliCare Medical Management Celebrates Its 25th YearCorporate Milestone Caps a Period of Steady Growth and Recognition

AliCare Medical Management (AMM), a member of the Amalgamated Family of Companies, is marking 2015 as its

25th anniversary year. The company, which is recognized for promoting optimum health outcomes while containing health care costs and effectively advocating for its patients, has been on a path of steady growth and recognition since its inception in 1990. Over the past two and a half decades, AMM has grown to provide a comprehensive suite of care management solutions concurrent with receiving significant accreditations and honors.

According to David J. Walsh, President and CEO, Amalgamated Family of Companies, “AMM is a member company of which our entire organization is extremely proud. Not only has the firm lived up to its mission of providing excellent care management programs and services, but it has also done so while adhering to the highest standards of service. We are anticipating nothing short of another successful 25 years from AMM.”

See 25th Year, page 5

Julie O’Brien


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www.alicaremed.com • page 2

AliCare Medical Management (AMM) has announced the appointment of Julie O’Brien as President. O’Brien formerly

served as AMM’s Senior Vice President and Chief Operating Officer. In her new role, she will continue with past responsibilities, which include leadership for all aspects of AMM’s call center operations, including clinical services, customer service, strategic marketing and product development. Additionally, her new role entails driving the continued growth and expansion of AMM’s services and client base, strategic alliances, joint ventures, quality controls and overall fiscal performance.

David J. Walsh, President and CEO, Amalgamated Family of Companies, has stated that, “Since joining our organization in November 2002, Julie has been a tremendous asset to AMM. She has proven an extraordinary team player—one who is clearly a team leader and knows how to motivate and inspire her staff to perform at the highest level. As COO, she has been vital to AMM’s impeccable reputation both within the care management field and the broader markets it serves: from diverse businesses and unions to health care providers and managed care organizations. I expect nothing less than a continuation of her strong leadership as AMM’s new president.”

O’Brien’s first position with AMM was as an Assistant Vice President. She subsequently was named Vice President, then Senior Vice President and COO, a role through which she maintained complete oversight of all operations at AMM’s New Hampshire and Pennsylvania locations. Over the past 13 years, O’Brien has been instrumental in AMM’s securing of important

URAC accreditations for its various programs, including Utilization Management, Case Management, 24/7 Nurse HelpLine and Independent Review Services, as well as driving operational efficiency.

Prior to joining AMM, she served as Director of Clinical Services for Health Dialog, where she was responsible for clinical operations. She also held the position of Administrator

for Neurology at Massachusetts General Hospital.O’Brien is a Registered Nurse and holds a

Bachelor’s degree in Nursing and a Master’s in Business with a specialty in Health Care Administration. Her professional affiliations include memberships in the American Nursing Association, American Academy of Ambulatory Care Nursing and the Women Business Leaders. Currently, she also sits on the URAC Accreditation Committee, serves as Vice Chair for the RadSite Committee and is active with the National Association of Independent Review Organizations (NAIRO). She resides in Topsfield, MA. •

Since joining our organization in

November 2002, Julie has been

a tremendous asset to AMM. She

has proven an extraordinary team

player—one who is clearly a team

leader and knows how to motivate

and inspire her staff to perform

at the highest level.

Follow us on LinkedIn to find out the latest news from AliCare Medical Management, participate in discussions and hear about product updates!

Julie O’Brien Named President of AliCare Medical Management


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Over the last few weeks, you have probably seen news stories about the recent outbreaks of the measles in the United States. From January

1 to March 20, 2015, 178 people from 17 states and Washington DC were reported to have contracted the measles from a large, multi-state outbreak linked to an amusement park in California. This follows the news that the U.S. experienced a record number of measles cases during 2014: 644 incidents in 27 states, according to the Center for Disease Control’s (CDC) National Center for Immunization and Respiratory Diseases. This is the greatest number of a cases since measles elimination was documented in the U.S. in 2000.

At AliCare Medical Management, we care about your health. This Special Alert shares information about the measles and how you can protect yourself and your family from this disease. Knowledge and preparation are your best tools in the fight against the measles; these resources will help you make smart decisions to keep you healthy and out of the hospital.

Why the Concern? Knowing the history of the measles in the U.S. helps explain our current, serious situation. According to the CDC, in 1912, the measles, also known as rubeola, was first considered a “notifiable disease”, so each diagnosed case had to be reported by doctors and laboratories. For the first decade of reporting, there were roughly 6,000 deaths each year. From 1912 to 1963, the year when a vaccine was developed for the measles, between 3 and 4 million people contracted the measles every year. Hospitalization, encephalitis (brain swelling) and even death were common complications. As a result, it’s important to remember that over the last 20 years, vaccination has prevented about 71 million cases of the measles and almost 9 million hospitalizations. Before the vaccine, the measles would cause about 3 million cases a year, 48,000 hospitalizations and 500 deaths.

By 2000, the U.S. experienced an absence of continuous disease transmission for greater than 12 months due to decades of vaccination efforts, meaning that the measles were considered to be eliminated. However, in recent years, parents have not vaccinated their children against the measles due

to the spread of vaccination myths. These myths have opened the door to the comeback of

the disease.

What is the Measles?The measles is a highly contagious, viral disease; its most common symptoms include high fever, a rash of small red

spots, runny nose and red eyes. More serious complications include ear infections,

deafness, diarrhea, dehydration, pneumonia, encephalitis and even death. In fact, 10 to 20 out of

10,000 children who contract measles will die from it, according to the CDC. Children are most commonly affected by the virus, but non-immunized adults can also develop it.

How Contagious is the Measles? The measles spreads when an infected person sneezes or coughs without covering their mouth or touches objects that other people may touch such as door-knobs, shopping carts, desks or other surfaces. If a person breathes infected air or touches an infected surface, they can also contract the disease.

In fact, the measles is so contagious that 90% of people who are not vaccinated who come into contact with an infected person will develop the disease. While infected people are the most contagious when they have a fever, runny nose and cough, they are also contagious from 4 days before the rash appears until about 4 days after. You or your children can be exposed to someone with the measles while they are contagious before they even know they have it. This is why up to 18 people can be infected by one person.

C L I N I C A L U P D AT E

Measles on the Rise – What You Need to Know

See Measles, page 4


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What to Do If You or a Loved One Gets the MeaslesIf you or your child contracts the measles, stay in touch with your health care provider for the duration of the disease, as it can cause dangerous side effects like brain swelling or even death. If you or your child display the following symptoms, you may need to go to the hospital for further evaluation:

n Chest pain

n Wheezing

n High fever

n Frequent colds

n Shortness of breath that comes with little or no exertion

n Phlegm or mucus produced for two or more weeks

n A cough that lasts two weeks or produces blood

A persistent cough with a fever, for instance, could be a sign of pneumonia. See your doctor right away if you have any of these symptoms. The earlier you catch problems, the more easily they can be treated.

Because the measles is a viral infection, no treat-ment can cure an established infection. However, a doctor can prescribe relief for the symptoms, such as:n Fever reducers like acetaminophen or ibuprofen.

Do not give aspirin to anyone under the age of 20 because of the risk of Reye syndrome.

n Antibiotics for bacterial infections like pneumonia, if they develop.

n Vitamin A.n Staying home and getting the rest you need. It is

one of the best ways to deal with the measles, and it keeps you from spreading the illness to other people.

n Drinking extra fluids. Warm fluids are soothing, especially if your throat is irritated. Drinking adequate fluids is important to prevent dehydration when you have a fever.

n Sleeping with your head elevated to relieve nasal congestion. For adults, over-the-counter decongestants can be used. Be sure to follow the recommended dosage and precautions.

n Using a humidifier to relieve cough and sore throat.

How to Protect Yourself and Your Family from Getting the MeaslesThe measles can be easily prevented with the MMR (measles, mumps and rubella) vaccine. One dose of the MMR vaccine is 93% effective at preventing the measles; two doses are 97% effective. Children should receive their first dose of the MMR vaccine between 12 and 15 months of age and the second dose at four to six years of age. Children may receive the second dose earlier as long as it is 28 days after the first dose. Infants who are traveling can receive the MMR vaccine as early as six months old.

Most people have no side effects from receiving the vaccine. Redness or swelling at the injection site may occur for one or two days. Occasionally, fever and muscle aches may also be present. On very rare occasions, allergic reactions or seizures may occur.

AliCare Medical Management: Your PartnerFor questions or concerns about immunizations, contagious diseases, aches and pains and general pediatric and adult health, AMM offers Nurse HelpLine and Health Information Services under its Care Management programs, which are accredited pursuant to URAC’s Health Call Center Standards. Currently, over two million people have access to our Nurse HelpLine.

Experienced, registered nurses are available via a specially assigned toll-free telephone number for each client or group, 24 hours a day, seven days a week, 365 days a year. Using advanced clinical criteria, Nurse HelpLine staff can provide health information and education to patients and their families. Telephone triage and health care counseling assesses health status and provides immediate health information, directing patients to the appropriate level of care and reducing health care costs. In addition, all of our Care Management programs provide physician back-up availability if needed.

AMM’s Health Information Library includes over 1,000 pre-recorded health related messages, available in English and Spanish. A website library is also available.

The Nurse HelpLine program helps reduce unnecessary emergency room and physician visits and provides patients with around-the-clock access to care.

For more information about AliCare Medical Management’s services, visit www.alicaremed.com. •

M E A S L E S

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P R E S I D E N T ’ S M E S S A G E

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considered when standard therapies have failed.Clearly, clinical trials are a useful alternative to

standard care. Their coverage under the ACA began when Section 2709 of the Public Health Service (PHS) Act was amended to mandate that as of January 1, 2014, non-grandfathered health plans (i.e. those that were not in place before March 23, 2010) cannot deny a qualified individual participation in an approved clinical trial or deny or limit the coverage of routine patient costs in connection with participation in the trial. Generally speaking, there are two types of costs associated with a clinical trial: patient care costs and research costs. The intent of PHS section 2709 is to cover the patient care costs incurred in clinical trials while excluding the research costs. Research costs, however, may be covered by a trial’s sponsor.

Unfortunately, sometimes a health plan may elect to not provide coverage related to a patient requesting a clinical trial. When that happens, a patient or a provider may file an appeal. The appeal must be submitted to the health plan that denied

the coverage and should request they reconsider the denial and provide coverage for the requested treatment. The appeal should be based on the medical necessity of the clinical trial and why the physician feels a clinical trial is the best treatment option for the patient. If the internal appeal options are denied, the patient or their attending physician is permitted to file an external appeal based upon rights established both by federal and state law. In fact, the ACA expanded the rights for most individuals to file an external appeal outside of the health plan.

In the post-ACA world, case managers and care management programs are uniquely positioned to help coordinate with doctors, financial counselors, the clinical trial research team, health plan administrators, hospital staff, both network and non-network providers and others to make sure the right information is getting to the right person at the right time. Care management firms like AliCare Medical Management can use their utilization management, case management and external review expertise to steer patients toward the best care options, address questions regarding medical necessity and scope of benefits and act as an invaluable partner for anyone seeking guidance on their clinical trials coverage. •

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AMM’s President, Julie O’Brien, noted that delivering excellence in its care management services is its top priority and pointed to two recent achievements as evidence. “In 2014, we celebrated 20 years of URAC accreditation, attesting to our meeting URAC’s quality-based standards for a two-decade period,” said O’Brien, noting that the firm holds URAC-approved accreditation for its Utilization Management, Case Management, 24/7 Nurse Helpline and Independent Review services.

O’Brien also cited another important distinction that AMM received in 2014. “Last year also marked our receipt of two prestigious Case in Point Platinum Awards. These awards were given to us by Dorland

Health at its 5th Annual Care Coordination Summit in May 2014. We received one Platinum Award for our 24/7 Nurse HelpLine, and Barbara Schaeffer, our Director of Case Management, received a Platinum Award for Leader in the individual professional category.” These were not the first Platinum Awards received by AMM. In 2013, the company’s Diabetic Management Program was honored with a Case in Point Platinum Award.

In addition to care management, utilization management, independent physician review and Nurse HelpLine, AMM offers disease management, hospital readmission management, maternity management, health information service, wellness health coaching, medical claims review and hospital bill auditing. These robust solutions, combined with its high caliber team of experienced health care professionals, have made AMM the “go to” resource for health care providers and plan sponsors, including Taft-Hartley multi-employer unions and diverse businesses. •


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P R I M A R Y C O N TA C T S

Julie O’Brien President

A D D R E S S

AliCare Medical Management, Inc.8 C Industrial Way Salem, NH 03079 (800) 863-8688

W E B S I T E

www.alicaremed.com

E D I T O R

Garry Carneal, JD, [email protected]

[email protected]

Editing and Production Schooner Strategies

© 2015 AliCare Medical Management. All Rights Reserved.

Mental Health Services Can be Hard to Come By, Despite Law Requiring ParityThanks to the Mental Health Parity Act, state and federal insurers are required to offer equal coverage for medical and mental health services. However, a recent report by the National Alliance on Mental Illness found that there are still several barriers to care—including one-third of respondents who said they were denied care for their mental illness because it was deemed “not medically necessary.” Visit www.baltimoresun.com for more information. •

Drug-resistant Stomach Bug Causing Illness in AmericansHealth officials recently stated that a “nasty” stomach bug has been imported into the U.S. This drug-resistant bacteria has sickened 243 people and causes unpleasant symptoms like diarrhea. Luckily for most people, this illness is temporary and can be treated

with over-the-counter medicines like Pepto-Bismol or antibiotics. Read more about the superbug on www.modernhealthcare.com. •

Spring Allergies Strike AgainMore than 40 million Americans suffer from spring allergies, which began in late March this year. Many allergy sufferers experience a range of symptoms: from runny nose and watery eyes to sneezing and itchy eyes. As allergy season could last a few weeks, doctors recommend taking over-the-counter allergy medications to ease symptoms or seeing a specialist. Go to www.cbsnews.com for more information. •

M E D I C A L M A N A G E M E N T N E W S

About AliCare Medical Management www.alicaremed.com

AliCare Medical Management (AMM), a member of the Amalgamated Family of Companies, is a national leader in developing care management solutions that promote cost savings and patient satisfaction. AMM’s call center is open 24 hours a day, 365 days a year to provide maximum access and assure optimum program effectiveness. The company’s services include: 24-hour Nurse HelpLine, Utilization Management, Maternity Management, Case Management, Disease Management, Health Coaching and Wellness, Independent Physician Review, Medical Claims Review and Hospital Bill Auditing. AMM holds four URAC accreditations for Utilization Management, Case Management, Health Call Center and Independent Review. •

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