Ohio KePRO Motion October 2004

Ohio KePRO's Review Depar tment is working
with providers throughout the state to
improve quality of care delivered to Medicare
beneficiaries. The quality improvement plan
is a valuable tool used by the Review
Department to help correct issues of concern
related to quality, utilization, and coding.

Typically, a physician-reviewer or review
coordinator determines from beneficiar y
complaints or char t reviews that there
might be an instance or pattern of care
that merits inter vention. Ohio KePRO's
Medical Director then sends a letter to
the provider outlining the concern(s) and
requests a Quality Improvement Plan be
implemented to address the area of
concern and improve the process. If
necessar y, Ohio KePRO helps the provider
develop the quality improvement plan. Ohio
KePRO is required to notify the Centers for
Medicare & Medicaid Ser vices (CMS) if a
provider refuses to par ticipate in the
development of a quality improvement plan.

Quality Improvement Plans must contain
the following elements:
  I A description of expected outcomes
   and goals. These must be measurable.
  I A description of actions to be taken to
   correct the quality concern.
  I A timeframe for initiating and
   completing the plan.
  I A description of the process for
   ensuring the actions resolve the
   pattern of concern.

At predetermined inter vals, Ohio KePRO
monitors the progress of the quality
improvement plan. After successful
completion of the quality improvement plan,
Ohio KePRO sends a letter to the provider
indicating the case has been closed. I

ver y year doctors, other health-
care providers, and the media
ur ge you to get a flu shot. Getting a flu
shot is extremely impor tant because
during a typical year, 36,000 people in
the U.S. will die from the flu, according
to the Centers for Disease Control and
Prevention (CDC). The pneumonia shot,
which receives less attention from the
media, is another impor tant shot about
which you should ask your doctor.

The pneumonia shot is ver y ef fective
in preventing some of the serious
complications of pneumonia. Pneumonia
is an infection of the lungs. There are
two main types of pneumonia: bacterial
and viral. Of these, bacterial pneumonia
is the more serious. The bacteria that
cause pneumonia can also lead to other
serious infections such as bacteremia
(infection of the blood stream) and
meningitis (infection of the brain).
Pneumonia kills more people each
year in the U.S. than all other vaccine-
preventable diseases combined.

As many as two-thirds of patients
hospitalized with pneumonia had been
hospitalized at least once in the
previous 3 to 5 years and could have
received the vaccine. Although the
vaccine does not completely prevent
the disease, it does reduce the likeli-
hood of contracting the illness and its
serious complications.

There are many strains of bacterial
pneumonia. The pneumonia shot
protects you against most but not all
of these strains, so you should receive
the vaccine even if you have had
pneumonia in the past. Side ef fects
may include redness, swelling, and
soreness at the injection site.
However, it is extremely safe to
receive this vaccination.

Who should get a pneumonia shot?
You can get a pneumonia shot in
outpatient settings such as your doctor's
of fice or at clinics. The Centers for
Medicare & Medicaid Ser vices (CMS)
recommends that your vaccination status
be reviewed if you are hospitalized for
any reason and that you are of fered the
pneumonia vaccine prior to dischar ge
from the hospital if you meet one of the
criteria from the Advisor y Committee
on Immunization Practices:
  I Adults 65 years of age or older.
  I People 2-64 years of age with
   chronic illnesses.
  I People 2-64 years of age with
   special risk factors (e.g., sickle
   cell disease, those with weak
   immune systems, or those without
   a spleen).
The pneumonia vaccine is usually given
only once. The Advisor y Committee on
Immunizations Practices recommends
the following individuals should receive
a second pneumonia shot:
  I Individuals at high risk who
   received the vaccine 5 or more
   years earlier.
  I Individuals 65 years of age or older
   who received their first vaccine
   prior to age 65 and 5 or more
   years have elapsed.
  I Individuals who do not know if they
   ever received a pneumonia shot.

Covered by Medicare
If you fall into any of the above
categories or are not sure if you do,
ask your doctor about receiving this
life-saving vaccine. Remember, it is
impossible to get pneumonia from the
pneumonia shot. Both the flu and
pneumonia shots are covered under
Medicare. There is no char ge for either
shot and the Par t B deductible is
waived. If you are in a Medicare HMO,
please check with your plan before
getting a flu or pneumonia shot.

A Letter to the Editor

Medicare Minutes October is Breast Cancer Awareness

By Alice Stollenwerk Petrulis, MD, FACP
Medical Director

I continue to read with both interest and
concern recent ar ticles debating the benefit
of screening mammography, and find
October's obser vance of National Breast
Cancer Awareness Month an ideal time to
reemphasize the impor tance of early
detection of breast cancer.

Misconceptions about breast cancer risk
and mammography may impede a woman
from following through on the guidelines
reaffirmed by the American Cancer Society
in 2003 to receive a screening mammogram
ever y year. Statistics show that one out of
ever y eight women will be diagnosed with
breast cancer in their lifetime, and this risk
increases with age.

Mammography is the most effective method
of diagnosing breast cancer, detecting about
90% of breast cancers in asymptomatic
women. Moreover, mor tality from breast
cancer is strongly associated with staging
of the cancer, and women whose cancer is
detected at earlier stages ultimately have
better prognoses.

Early detection is a woman's best protection.
Ohio KePRO suppor ts and encourages
mammography for all women aged 40 and
older to identify breast cancer at its earliest
stages, when it is most treatable.

Ohio KePRO, the quality improvement
organization for Medicare in Ohio, administers
a project to reduce the incidence of breast
cancer among female Medicare beneficiaries
and increase the use of screening
mammography. I

Month Know the Facts

Myth: Breast cancer can't happen to me.
I don't have any of the risk factors.
Fact: Just being a woman and aging are the
two greatest risk factors for getting breast
cancer. Most women who develop breast
cancer also have no family histor y of
the disease.

Myth: Mammograms are unsafe and
too painful.
Fact: Some pressure on the breasts is needed
during the mammogram in order to get a clear
x-ray, but it only lasts a few minutes. A woman
can tell the mammography technician to
decrease the pressure if it becomes too
uncomfor table. And mammograms give only
minimal exposure to radiation.

Myth: If I get breast cancer, I'll die from it.
Fact: A mammogram is the best way to find
breast cancer in its earliest, most treatable
stage, before it can be felt. Screening mam-
mography has been shown to reduce mor tality
from breast cancer by 20% to 39% among
women aged 50 years and older.

Myth: I've had one mammogram; that's all
I need.
Fact: Breast cancer can occur at any time.
The American Cancer Society recommends
that women aged 40 and older have a mam-
mogram ever y year. Annual mammograms allow
a doctor to compare x-rays from year to year
to more easily identify changes in the breasts
and detect breast cancer in its earliest stages.

Myth: I can't af ford to have a mammogram.
Fact: Medicare helps pay for women aged 40
and older who are covered under the program
to have a screening mammogram once ever y
12 months. The woman's por tion of the
payment is usually about $16 and may var y
slightly according to region. Most insurance
companies also help pay for mammograms.

Ohio KePRO is the quality improvement
organization (QIO) for Medicare in Ohio and
spearheads a healthcare project to promote
breast cancer screening for beneficiaries. I

Don't Forget About the Pneumonia Shot (cont.)

Medicare beneficiaries, and will be encour-
aged to update their vaccination status
with their physician.

Joseph Sopko, MD, the Director of the
Depar tment of Medicine at St. Vincent
Charity Hospital in Cleveland, will
represent Ohio KePRO as its pulmonar y
consultant in an upcoming television
segment to promote pneumococcal and
influenza vaccination. Dr. Sopko will be
a guest on "Golden Oppor tunities" on
WKYC-TV 3 in Cleveland on Sunday,
October 17, 2004 at 12:30 p.m. Viewers
will be invited to receive free of char ge the
Ohio KePRO "The Pneumonia Vaccine
Could Save Your Life" brochure for

Ohio residents outside the viewing area of
WKYC can still obtain this free brochure by
calling the Ohio KePRO Medicare Beneficiar y
Help Line at 1-800-589-7337 or through the
Shopping Bag feature on the Ohio KePRO
Web site at www.ohiokepro.com. Following
the show's airdate, a transcript of the show
will be posted on the "Golden Oppor tunities"
Web site at www.goldenoppor tunities.tv. I

Executive Editor : Suzana C. Iveljic, MBA

Editor : Daniel B. Moss, BSBA

e-mail: dmoss@ohqio.sdps.org

T H E O C T O B E R E D I T I O N O F O H I O Ke P RO M O T I O N H A S A R R I V E D !
Your News Source for Health & Rights Information for Ohio's Medicare Beneficiaries

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Publication No. 4123-OH-009-10/2004. This material was prepared by Ohio KePRO, the Medicare Quality Improvement Organization for Ohio, under contract with
the Centers for Medicare & Medicaid Ser vices (CMS), an agency of the U. S. Depar tment of Health and Human Ser vices. The contents presented do not
necessarily reflect CMS policy. For more information, please call 1-800-MEDICARE (1-800-633-4227), or visit the CMS Web site at www.medicare.gov.