SCOPE | Provider Update
February 2025
Clinical Matters
February is Cancer Prevention Month: outcomes are improving, but there's still work to do
Growing evidence suggests an association between engagement in primary care before cancer diagnosis with improved cancer outcomes for several different cancer types.
The month of February is Cancer Prevention Month, and World Cancer Day 2025 is February 4. During the month, themes focus on prevention education, as well as different dimensions of person-centered cancer care, recognizing each person’s needs are unique.
Appropriately, cancer prevention remains a national health priority. The nation’s data-drive national objectives to improve health and well-being, described in Healthy People 2030, include a set of objectives focused on reducing new cases of cancer and cancer-related illness, disability, and death over the next ten years.
Since successful cancer prevention reduces cancer mortality through reduction in cancer incidence, an important indicator of progress in the fight against cancer includes incidence and mortality trends over time. According to the National Center for Health Statistics, over two million new cancer cases occurred in 2024. The age-adjusted death rate from cancer among all people has declined from 193.9 per 100,000 population in 1950 to 146.2 per 100,000 population in 2019 nationally and 126.9 per 100,000 population in 2020 for New York State. As of 2022, this translates into nearly 4.5 million cancer deaths avoided since 1991. This improvement over time is multifactorial and includes evolution of more effective and earlier detection, management, and treatment at the population level.
Evidence-based primary and secondary prevention interventions, often initiated in primary care, are making a difference. These interventions include cancer screening, cancer risk assessment and management, such as medications, lifestyle and health behavior opportunities, as well as vaccination. Clear medical record documentation of efforts and outcomes assists care coordination and helps ensure providers receive credit for the high-quality care they provide.
Although cancer-related outcomes are overall trending in a positive direction, there is still much work to do. For example, disparities persist across race, ethnicity, and gender. Growing scientific evidence supports that primary care providers are central to the success of cancer prevention and provide consistent opportunities for adherence to cancer prevention guidelines and needed follow-up care. Growing evidence suggests an association between engagement in primary care before cancer diagnosis with improved cancer outcomes for several different cancer types.
To assist with cancer prevention efforts, CDC offers a variety of up-to-date evidence-based cancer resources to Primary Care Providers, including toolkits and CME opportunities:
- Health Care Provider Resources
- Cancer Prevention Overview (PDQ®) - NCI.
- Cancer Information crafted for patients
- View more information about World Cancer Day 2025
Taking prevention to heart during Heart Health Month
Managing symptoms, blood pressure and lab results will help patients' heart health.
According to the Centers for Disease Control (CDC) 2025, heart disease is the leading cause of death for men, women, and people of most racial and ethnic groups in the United States. One person dies every 33 seconds in the United States from cardiovascular disease. About 695,000 people in the United States died from heart disease in 2021—that’s 1 in every 5 deaths.
High blood pressure, high blood cholesterol, and smoking are key risk factors for heart disease.
Several other medical conditions and lifestyle choices can also put people at a higher risk for heart disease, including, but not limited to:
The good news is that individuals can significantly lower their risk for heart disease by making lifestyle changes, and by getting the education, resources, and support they need.
Identify patients with hypertension and other cardiovascular disease (CVD) risk factors.
Manage symptoms, blood pressure and lab results, as indicated, according to evidence based guidelines.
Visit the CDC's American Heart Month Communications Toolkit to learn more about Cardiovascular Management, as well as obtain education, tools, and resources for:
- Lifestyle Changes
- Health Equity
- Blood Pressure monitoring
- Medication Adherence
- Standardized care
- Identifying patients with hypertension
Testing for kidney function especially important for patients with diabetes
Members who have type 1 or type 2 diabetes should get a kidney health evaluation annually to check for signs of chronic kidney disease.
Chronic kidney disease (CKD) occurs when an individual's kidneys are damaged and unable to filter blood as well as usual, causing a loss of function over time. CKD increases the risk of heart disease, stroke and/or kidney failure.
Why is a kidney health evaluation important?
Diabetes is the leading cause of CKD. Up to a third of adults with diabetes have CKD. It often develops slowly and with few or no symptoms. Up to 90% of people with CKD may not realize they have it until it’s advanced, requiring specific treatments like dialysis (a treatment that filters the blood) or a kidney transplant. Early detection and follow up on kidney problems can help slow or stop further kidney damage, helping to prevent complications.
What is a kidney health evaluation?
A kidney health evaluation helps determine if members have evidence of CKD and if so, how significant it is. The kidney health evaluation uses results from the following:
- A blood test for kidney function (estimated glomerular filtration rate [eGFR]): Kidneys remove waste, toxins and extra fluid from the blood. A blood test checks the member's kidney function. The blood test will show how well the kidneys are doing their job and how effectively the waste is being removed.
- A urine test for kidney damage (urine albumin-creatinine ratio [uACR]): One of the earliest signs of kidney disease is when protein leaks into the urine. Urine test to check for protein in the patient's urine is also necessary.
Results from these tests can help identify chronic kidney disease early so you and your patients can develop a treatment plan, which might include additional tests, lifestyle changes and good control of other chronic conditions like high blood pressure or high cholesterol.
Members who have type 1 or type 2 diabetes should get a kidney health evaluation annually to check for signs of chronic kidney disease.
For more tools and resources, please visit: Guidelines – KDIGO
View our HEDIS Reference manual when logged into the provider portal. It is under the Policies and Guidelines tab.
NYS Smokers’ Quitline remains a vital resource to help patients quit tobacco
Despite decline in smoking rates, tobacco remains leading preventable cause of death in the US. Here are ways to help patients in their efforts to quit.
As we enter Heart Health Month and Cancer Prevention Month 2025, it is a good time to renew efforts to address risky factors, such as use of tobacco and/or e-cigarettes. Although smoking rates continue to decline, tobacco remains the leading preventable cause of disease and death in the United States. Just under 500,000 people die each year from smoking-related illnesses such as heart disease, stroke, and cancer. Smoking causes around 20% of all cancers in the United States, about 80% of lung cancers, and increases risk for other cancers as well.
As we know, quitting tobacco can be very challenging for patients. Best evidence supports that normalizing the quitting process in a nonjudgmental way can be effective, acknowledging that the journey may be long and resilience can be key to the process. Multiple quit attempts and relapses are common and can be considered learning opportunities for patients (and providers!) on the road to ultimate success.
The New York State Smokers’ Quitline has helped many people across New York successfully quit smoking or vaping. The Quitline offers free resources, including the Patient Referral Program, connecting your patients to evidence-based coaching, digital quit-support, and a supply of nicotine replacement medications.
In addition, the Quitline has an array of educational tools and tips to assist in motivating and supporting your patients' quit attempts. A variety of free office materials are also available to order.
The Quitline is accessible seven days a week by calling 1-866-NY-QUITS (1-866-697-8487), by texting QUITNOW (English) or D JELO YA NY (Spanish) to 333888 to enroll in Learn2QuitNY, or by visiting nysmokefree.com.
Office Matters
Two-factor authentication security coming to the provider portal in March
As of March 3, 2025, portal users will have to enter a code along with their password to access the provider portal.
As we announced in the fall, Independent Health will add a layer of security to the provider portal by requiring two-factor authentication.
Once this security step is in place on March 3, it will require portal users to confirm their identities by providing two separate credentials: by entering their current password, and by entering a code they receive by email or text message.
When current users log in on March 3, they will have to indicate their preference to receive the code: either by providing their phone number to receive a text, or by their email.
Two-factor authentication makes it harder for unauthorized users to gain access to a person's devices or online accounts, because the authorized user’s password alone is not enough to pass the authentication check.
To prepare for this change, portal administrators should review their organization’s portal accounts and users to make sure the individuals who have portal accounts are still current and active at their organization.
Continuing Medical Education opportunity through University at Buffalo
Variety of programs is designed to meet changes in legislation, provide updates on guidelines and treatment therapies, and meet professional development needs.
Did you know that the University at Buffalo School of Pharmacy and Pharmaceutical Sciences Office of Continuing Pharmacy Education provides convenient continuing education (CE) activities?
Although these activities are designed and accredited to meet the educational needs of pharmacists, topics are often interdisciplinary in nature and are available to and accredited for other health professionals as well. Programs are offered as live in-person, live via webinar, or on-demand home study (enduring online) and are designed to meet changes in legislation, provide updates on guidelines and treatment therapies, and meet professional development needs.
The offering of activities has a broad scope, and includes topics such as:
- Clinical Assessment of Concussion
- Antibiotic Stewardship
- Biosimilar FDA pathways
- Metabolic Health
- Opioid Prescriber Education Program (meets MATE Act training requirements).
There is a mix of fee-based and non-fee-based programs available for participants.
Registering for activities is straightforward and just takes a few minutes. To find out more, visit University at Buffalo’s Office of Continuing Pharmacy Education.
Cost share waived on Individual plans for diabetes-related services & pregnant individuals
Remember to waive the cost share for eligible patients. This article includes how to check eligibility.
As of January 1, 2025, Qualified Health Plans available on the New York State of Health (NYSOH) Official Online Marketplace waive the in-network cost-sharing such as deductibles, copayments, and coinsurance for Qualified Health Plan (QHP) enrollees who have a primary diagnosis of diabetes, and for outpatient maternity care services.
For QHPs, this program is available to individuals who are enrolled in an Individual On-Exchange, standard and/or nonstandard plan, except for catastrophic plans.
Diabetes cost share waiver: This program applies to specific items and services and includes medical care, prescription drugs, supplies, and diagnostics, related to the primary diagnosis of diabetes. View the full list of $0 services for these plans here.
- What this means to providers: if the individual has a primary care visit and the primary diagnosis is diabetes, the provider must not charge the member the copay.
Maternity cost share waiver: For pregnancy and postpartum enrollees in Qualified Health Plans (QHPs), NY State of Health will cover the in-network cost-sharing such as deductibles, copayments, and coinsurance for most services. For QHPs, this program will be available to pregnant members who are enrolled in an Individual On-Exchange, standard and/or nonstandard plan, except for catastrophic plans. This initiative waives cost-sharing for all diagnosis and services for individuals during pregnancy and through 12 month postpartum, except for services listed here: cost share waivers for individuals here.
- What this means to providers: the provider must not charge the member the copay during pregnancy and through 12 months postpartum. Cost-sharing will still apply to physician, nurse practitioner and midwife services for delivery as well as inpatient hospital and birthing center services for delivery.
Check WNYHEALTHeNET for eligibility
Please be sure to check Additional Info under Plan Details. The message for an eligible member will state: “Member may be eligible for a NY State Diabetic/Maternity Cost Share Waiver plan (excludes Standard Catastrophic), please call for specific benefit information.”
View more details, including FAQs on our secure portal page: under Resources/Cost Share Waivers effective 1/1/25.
Annual reminder of Independent Health's Member Rights & Responsibilities
As part of our required annual communications, we are posting our members’ rights and responsibilities for providers’ reference.
Independent Health annually shares our members’ rights and responsibilities to participating providers who treat our members.
Our members have:
- The right to receive information about the organization, its services, its practitioners and providers, and member rights and responsibilities.
- The right to be treated with respect and recognition of their dignity and their right to privacy.
- The right to participate with practitioners in making decisions about their health care.
- The right to a candid discussion of appropriate or medically necessary treatment options for their conditions, regardless of cost or benefit coverage.
- The right to voice complaints or appeals about the organization or the care it provides.
- The right to make recommendations regarding the organization’s member rights and responsibilities policy.
- The responsibility to supply information (to the extent possible) that the organization and its practitioners and providers need in order to provide care.
- The responsibility to follow plans and instructions for care that they have agreed to with their practitioners.
- The responsibility to understand their health problems and participate in developing mutually agreed-upon treatment goals, to the degree possible.
The Independent Health Member Rights & Responsibilities policy is also accessible in our secure provider portal under “Policies & Guidelines” and “Appeals & Grievances”.
Upcoming member campaigns to encourage our members to take greater control of their health
Throughout the year, the Quality Management and Population Health Management Departments deploy various tactics to encourage members to take a more active role in their health.
Osteoporosis Management in Woman Who Had a Fracture (OMW) Member Outreach
Independent Health’s Case Manager will outreach telephonically to Medicare members that fall into the Osteoporosis Management in Woman Who Had a Fracture (OMW) measure.
- Target population: The OMW measure focuses on females 67 to 85 years of age who had a fracture and have six months following the fracture to close the gap by having a bone density scan, filling a script for an osteoporosis medication, or receiving an injection for osteoporosis treatment.
Independent Health’s Case Manager will contact members to discuss the member’s fracture, provide education on fractures and falls prevention, and discuss options for gap closure.
The Case Manager will discuss the option of an in-home heel ultrasound with Stall Senior Medical (SSM). If the member is interested, the Case Manager will ask for consent for the member to be contacted by the SSM team and then SSM will call the member to schedule the appointment. All results will be sent to the member’s Primary Care Physician (PCP) for follow-up.
The Case Manager will also discuss other options for gap closure, depending on the member’s preference, and refer back to the member’s PCP. Each call will be individualized based on the member’s needs.
- Timeframe: This outreach is on-going. Monthly, new members who fall into this measure are called.
CAHPS Just-In-Time Outreach Calls and Letters
Independent Health’s Member Success team will outreach by phone to targeted members to highlight plan benefits, address any concerns, and encourage members to respond to the CAHPS survey.
- Targeted Cohort: Medicare HMO & PPO members
- Launch Date: January/February 2025
Pharmacy Updates
Formulary and Policy Changes
Remember to view our up-to-date policies online.
Drug Formulary Changes
- Medicare Advantage formulary deletions for individual & group plan members, effective Feb. 1, 2025.
- Pharmacy Benefit Dimensions 3-Tier formulary deletions, effective Feb. 1, 2025.
- Pharmacy Benefit Dimensions 5-Tier formulary deletions, effective Feb. 1, 2025.
Access Independent Health's drug formularies here.
Drug Policies
Search for and view the most current versions of all drug policies when logged in to our provider portal.
Prime Therapeutics (formerly Magellan Rx) reviews select specialty drug prior authorization requests on Independent Health’s behalf. View Prime Therapeutics policies for the drugs that they review.
To obtain a hard copy, please contact Independent Health Provider Relations by calling (716) 631-3282 or 1-800-736-5771, Monday through Friday from 8 a.m. to 5 p.m.
Spotlight
Top Takeaways this Month
February 2025 Policy Updates: (Posted as Monthly Policy Updates under the News tab in the secure portal). It is very important to review the monthly updates.
Register now for Office Matters for Adult PCP Practices on Feb. 12 at 7:30 a.m. For details, visit the registration page.