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L I F E , H E A LT H & W E L L N E S S
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How is this possible, I’ve never even smoked a cigarette?
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Network Health member, Erin Sarauer, after being diagnosed with lung cancer.
3 Letter from the President and CEO
4 Setting Healthy 2019 Goals
E DITORIAL STAFF
Management
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5 Personalized One-on-One Care
President Coreen and CEO Dicus-Johnson
Chief Administrative Penny Ransom Officer
Access to Network Health Care Management Employees and Services
Marketing Becky Pashouwer Coordinator
Lead Designer Debra Sutton
6 Keeping Your Bones Strong
E DITORIAL
6 Approaching 65?
Katie Sharratt, Melanie Draheim, Stacy Schwandner, Alice Parks, Theodore Regalia, Kimberly Swanson, Kacey Werner, Angela Keenan
Network Health Has You Covered
COVER STORY
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Ending the
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Stigma
Emergency Room, Urgent Care or 17 Your Right to Request an Virtual Visit Independent Review
13 How to Stay Active During the
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Cold Winter Months
14 MDLIVE® Virtual Doctor Visits
15 Opioid Awareness
17 How Health Plan Make Decisions
18 A Focus on Quality Health Care
19 Your Annual Wellness Visit
19 Clinical Practice Guidelines
20 NEW and Built-by-You,
15 Access to Care 16 The Service You Deserve
Network Health Member Portal
Network Health complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. If you, or someone you’re helping, has questions about Network Health, you have the right to get help and information in your language at no cost. To talk to an interpreter, call 800-826-0940. Spanish: Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de Network Health, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 800-826-0940. Hmong: Yog koj, los yog tej tus neeg uas koj pab ntawd, muaj lus nug txog Network Health, koj muaj cai kom lawv muab cov ntshiab lus qhia uas tau muab sau ua koj hom lus pub dawb rau koj. Yog koj xav nrog ib tug neeg txhais lus tham, hu rau 800-826-0940. 1746-01a-1218 2 | balance • W i n t e r 2 01 8
BOARD
Balance is published by Network Health. The health information contained in Balance is meant to supplement, not replace, the advice of health care professionals. © 2018 Network Health. No portion of this newsletter may be reproduced without written permission from Network Health.
TELL US WHAT YOU THINK If you have questions or suggestions or would like to tell us how Network Health improved your life, send us an email at
marketing@networkhealth.com. You can also write to us at: Network Health Attention: Katie Sharratt 1570 Midway Pl. Menasha, WI 54952
HAVE A QUESTION?
Call our highly rated customer service team. HOURS Monday, Wednesday–Friday: 8 a.m. to 5 p.m. Tuesday: 8 a.m. to 4 p.m. PLANS THROUGH AN EMPLOYER 800-826-0940 PLANS FOR INDIVIDUALS AND FAMILIES 855-275-1400 STATE OF WISCONSIN EMPLOYEES/MEMBERS 844-625-2208 Monday–Thursday: 7:30 a.m. to 5 p.m. Friday: 7:30 a.m. to 4:30 p.m.
WANT MORE HEALTH TIPS? Check out our blog at copilotwi.com.
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life. health. wellness. Letter from the President and CEO
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hank you for being a member of Network Health. To ensure you are using the benefits available to you through your Network Health plan, this edition of Balance is filled with essential information to guide you on your wellness journey. At Network Health, our mission is to create healthy and strong Wisconsin communities. One way you can create a healthy lifestyle is to schedule your annual wellness visit in 2019. A wellness visit will help maintain your health and can aid in the early detection of a potentially serious condition. If you do not have a personal doctor, please take steps to make an appointment with a provider from our network of highly-qualified physicians who will focus on getting you the care you need, when you need it. Network Health is a provider-owned health care insurer, and our network of providers will deliver continuity of care throughout all aspects of your health care journey. We look forward to another year of providing exceptional one-on-one service. From all of us at Network Health—we wish you a healthy new year. Sincerely,
Coreen Dicus-Johnson President and Chief Executive Officer
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life. health. wellness.
SETTING HEALTHY O
ne of the most popular New Year’s resolutions is to get healthy, which includes losing weight and/or getting in shape. Everyone knows the benefits of getting healthy, and most of us want to do it. Many times, the mental challenge can be just as difficult to overcome as the physical challenge. Try these helpful tips to get motivated and stay motivated all year.
Start Small
People often give up on their health goals because they set unrealistic expectations at the beginning. If it’s been years since you’ve run, don’t plan to run a marathon in a month. Start small by making a few simple diet or exercise changes each week. Over time, those small changes can add up to big results. By setting realistic goals for yourself, you will be more likely to succeed.
Move More, Sit Less
Sitting all day has negative effects on your health. To combat these effects, make a conscious effort to move more every day, especially if you regularly sit for long periods of time. Incorporate movement into your daily activities. For example, park at the back of the parking lot at work or take the stairs instead of the elevator to your meeting. When you see an opportunity to move, take it.
Manage Temptation
Nobody is perfect. Remember, you will have days when you don’t make it to the gym or you indulge in foods that aren’t on your diet. Don’t be too hard on yourself. Accept that you will have bad days and commit to be better the rest of the week. Take steps to prevent lapses. Don’t surround yourself with junk food, instead snack on fruits and veggies. If you know you’ll have to miss a workout, take a quick walk over your lunch hour or right when you get home. Even a little exercise is better than none.
Celebrate Milestones
It’s easy to get caught up with reaching a specific health goal. Instead of focusing all your attention on your end goal, celebrate positive experiences you have along the way. Don’t allow yourself to overlook or ignore important milestones because you haven’t quite reached your goal. Take time to reflect on what’s gone right along your journey to a healthier you and celebrate your accomplishments.
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Care managers are available by calling 800-236-0208, Monday–Friday, from 8 a.m. to 5 p.m.
Personalized One-on-One Care Management N
etwork Health offers care management services to members at no additional cost. Through this program, experienced nurses and social workers, also known as care managers, can support you with the following.
Improving your overall health Navigating the health care system Coordinating community resources Getting needed services in optimal, cost-effective settings
If you are eligible and agree to participate, you can be enrolled into the program. When enrolled, a care manager works with you to identify your health care needs, develop goals based on your values and assists you in meeting those goals. If you have complex chronic conditions or illnesses that could lead to high-risk conditions or an increased use of health care services, you may benefit from care management. These conditions could include any of the following.
Complex chronic diseases, such as metastatic cancer or end-stage renal disease Catastrophic or rare conditions, such as premature infancy, high-risk pregnancy, trauma or spinal cord injury Conditions requiring an organ or stem cell transplant Major complications from a surgery or an extended hospital stay Multiple physician specialists involved in care Multiple specialty equipment needs at home
Those who might benefit from care management can be referred to us by their personal doctor or caregiver, or you can refer yourself. Network Health might also identify you as a candidate for services through claims or utilization processes.
Yvonne, RN Nurse Care Manager at Network Health
Access to Network Health Care Management Employees and Services Network Health assures access to medical and behavioral health care management employees for you, your personal doctor and provider office staff seeking information about our care management and utilization management programs. If you have questions about the utilization or care management process, or to request a copy of specific utilization criteria, please contact care management at 920-720-1600 or 800-236-0208. For questions specific to behavioral health utilization, call 920-720-1340 or 800-555-3616.
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life. health. wellness.
Keeping Your Bones Strong By: Carol Hirn RN/BSN with Network Health
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o matter your age or activity level, a fall can result in broken bones, hospitalization and in some cases, even death. The weakening of bones significantly increases your risk for an injury or fall. You can take simple steps to reduce your risk of falling and improve your bone health.
First – Take Action
1. Speak up – Discuss your mobility, risk factors and medications with your personal doctor. 2. Keep moving – Stay active by walking, hiking, lifting weights and/or doing flexibility workouts. Always discuss your exercise program with your personal doctor. 3. Vision Exam – Have your vision checked once a year. 4. Home Safety Check – Eliminate household hazards such as poor lighting and clutter.
Second – Promote Healthy Bones
Discuss your risk of weak bones with your personal doctor. Risks include heredity, diet and family history—this becomes increasingly important in women, as they age and approach menopause. If your doctor determines you are at a higher risk, he or she may consider doing a bone density screening. You also can improve your bone health by making certain lifestyle choices. This includes eating a well-balanced diet, exercising regularly and being tobacco free. If you are interested in learning more about preventing falls and bone health, we have educational programs available through a free online learning tool, Emmi®. Visit www.goemmi.com and enter the code NHP-BONE to access more information related to bone health. S AY W H AT ?
A bone density test measures the amount of bone mineral in your bone tissue, determining the density of bones and the chances of a bone being broken. A bone density test is recommended for most women age 65 or older, or younger for those at risk and/or those who have had a recent fracture.
Approaching 65? Network Health Has You Covered* If you or someone you know is turning 65, make sure you review our Medicare Advantage plans. You will receive the same exceptional one-on-one service you’ve experienced for years and we make enrolling in a Medicare plan easy. As good as Original Medicare is, it will not cover all your health care expenses. Most people who are eligible for Medicare choose to get their benefits through private health insurance companies to help cover costs. With a Network Health Medicare Advantage plan, you’ll get extra benefits that Original Medicare doesn’t cover. Learn more about Network Health Medicare Advantage Plans by calling 866-755-5233 or visiting networkhealth.com and selecting Medicare Plans. *Network Health Medicare Advantage plans are not available for State of Wisconsin employees. 6 | balance • W i n t e r 2 01 8
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EMERGENCY ROOM
URGENT CARE or
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f you or a loved one are hurt or ill, panic and confusion can make it difficult to know what to do. If you feel you’re experiencing a medical emergency, it’s important to get to the nearest emergency room or call 911. Sometimes you might not be sure if your condition is considered an emergency. If it’s not, you can get the necessary care through your personal doctor, a virtual visit or an urgent care walk-in clinic. Two questions can help you determine which type of care is right for you.
What’s the difference between emergency care, urgent care and virtual visits?
VIRTUAL VISIT or
Don’t forget to ask questions Anytime you visit the emergency room, a walk-in clinic or see your personal doctor, don’t be afraid to ask questions. Asking questions about your care is the best thing you can do to ensure your safety. There’s no such thing as a dumb question, especially when it comes to your health. If something doesn’t seem right or make sense, ask about it. Your coverage for each of these services varies depending on your plan. Be sure to call customer service department at the number on the back of your member ID card to verify your benefits. Whichever form of care you choose, make sure to share information about the visit with your personal doctor.
An emergency is an illness, injury, symptom or condition so serious, that a reasonable person would seek care right away to avoid serious harm. You typically receive emergency care at the emergency room. Urgent care is for an unexpected injury or illness that is not life threatening, but still needs attention quickly so it doesn’t develop into a serious problem. You may get urgent care at your personal doctor’s office, a walk-in clinic or an urgent care facility. Another option for care is a virtual visit with MDLIVE®. A virtual visit is a convenient way to get care by phone, secure video or the MDLIVE app for non-emergency conditions. Plus, virtual visits for medical services cost $41 or less, compared to over $200 for the average primary doctor visit. See page 14 for how to activate you account.
What if I’m not sure if it’s an emergency? Being prepared and knowing what to do before an emergency can help you make the right decision quickly. For help determining if your situation is an emergency, you can contact your personal doctor or the call Network Health Nurse Line at 888-879-8960.
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Ending the Stig
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t started as a dry, persistent cough that wouldn’t go away. Then, there was a straining pain in her neck. Those were the only two symptoms Network Health member, Erin Sarauer, experienced. As the mother of three boys, Erin takes care of herself by having annual wellness appointments and staying active. She knows how important it is to stay healthy for her children and her husband, who is legally blind and has his own daily struggles. Erin figured that she had no history of illness, so it couldn’t be anything serious and she decided to wait for the cough to go away on its own.
A month later, Erin continued to cough and have the straining pain in her neck. She grew tired of coughing and decided it was time to go to the local walk-in clinic where she had a chest x-ray. Erin was diagnosed with pneumonia and received a prescription for an antibiotic. After a few days, her condition hadn’t improved, so she went back to the doctor and was given a hospital-grade antibiotic. Despite this diagnosis, Erin was convinced that she had a blockage or that something else was going on in her chest, so she made an appointment with her ear, nose and throat doctor who did a scope and found nothing irregular. Erin couldn’t ignore the feeling that something wasn’t right, so she made an appointment with her advanced practice nurse prescriber (APNP), Sandra Zernzach Schertz with Ascension Medical Group in Oshkosh. Sandy agreed that Erin’s cough was concerning so she scheduled a chest CT scan two weeks later. Continued on next page...
By Becky Pashouwer Photographs by Beth DesJardin, Trove Photography
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gma
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Before she could make it to that appointment, Erin was at work and started coughing so hard she couldn’t talk. Erin called her APNP’s office and was advised to go to the emergency room (ER). Initially, Erin didn’t want to go to the ER, so she left work to go home. On the drive home, she was having a hard time breathing so she went to the ER at Ascension NE Wisconsin Mercy Hospital (formerly Mercy Medical Center) in Oshkosh. The physician’s assistant immediately ordered a CT scan. The results showed a mass on her lung. The doctor didn’t give her information about the size of the mass or what it meant for her; he simply stated that they were bringing in the lung specialist. Erin had never been a smoker, so the lung specialist believed she had fungal pneumonia and asked if she had been tubing down the Wolf River because there had been a recent outbreak of fungal pneumonia. She had, so his hypothesis seemed correct. The doctor suggested making an appointment with a pulmonologist at Ascension NE Wisconsin St. Elizabeth Hospital.
fungal pneumonia by inhaling spores of specific fungi. It is not a contagious disease. The next day, Erin received a call from Dr. Avery’s nurse to review the results of her biopsy. She scheduled the appointment for 5 p.m. that day, expecting treatment and prescriptions for fungal pneumonia. Dr. Avery sat down next to her and said, “I have tough news for you kiddo, you have cancer.” Upon hearing this news, she passed out. When Erin came to, she was shocked. “How is this possible, I’ve never even smoked a cigarette?” Dr. Avery was stumped. He also didn’t understand why a young, healthy, non-smoker would be afflicted with lung cancer, since most of his patients were smokers. They were surprised to learn that 10 to 15 percent of new lung cancer cases every year are among people that have never smoked. Now that Erin had her diagnosis, the next step in her journey was to determine the stage of her cancer with a PET scan. Prior to the PET scan, Erin had some irregularities with her heart, so she made an appointment with Dr. Zenoun Abouzelam, a cardiothoracic surgeon at St. Elizabeth Hospital, to get an electrocardiogram (EKG). During her appointment, fluid was found around her heart, which is a common occurrence for someone with cancer. Because our bodies are prone to fight off infection, the collection of fluid around her heart was her body’s way of protecting itself from the cancer. Erin scheduled the surgery to remove the fluid around her heart in preparation for the PET scan. Erin was seeing Dr. Kamal Abbi as her oncologist. He would be the doctor to review the results of her PET scan and put her on the road to recovery. Erin says, “I feel so lucky that I was paired with Dr. Abbi at St. Elizabeth. He’s the most compassionate, kindest oncologist.”
Chris Draft, former NFL linebacker and lung cancer advocate, talks to Erin, a member of his ambassador team.
On the next business day, Erin called the pulmonology office to make an appointment, and scheduled it for that afternoon. At her appointment, Dr. Bryan Avery examined her and agreed with the diagnosis of fungal pneumonia, but since there was also a possibility she could have lung disease or a small chance it could be cancer, he recommended a bronchoscopy and lung biopsy. The following day, Dr. Avery performed Erin’s bronchoscopy and lung biopsy. After the procedure, Erin was in the recovery room with her mom and husband. The nurse came in and told her that upon initial review, it wasn’t cancer. This further confirmed the diagnosis of fungal pneumonia. Dr. Avery informed Erin that the treatment could take up to six months and it would be even longer for her to fully recover. According to the Centers for Disease Control (CDC), fungal pneumonia has symptoms similar to other common illnesses (fever, cough, headache, rash, muscle aches or joint pain). Because of this, it can be hard to diagnose and can lead to chronic pneumonia, meningitis or even death. People become infected with 10 | balance • W i n t e r 2 01 8
Erin anxiously waited for the results of her PET scan. She was concerned because the neck pain she had been experiencing was probably related to the cancer reaching her lymph nodes. Dr. Abbi returned to her room and said the words that Erin will never forget, “Unfortunately, your cancer has metastasized. It has spread to your lymph nodes, spine, ribs and sacrum.” Erin was devastated. She says, “As a patient you have two choices, either you’re going to fight this and educate yourself, or you’re just going to let the decisions be made for you.” Erin was not going to give up. While Erin was in the hospital recovering from her procedures, she was visited by Yvonne Morrow, a nurse care manager with Network Health. Erin knew about care managers from reading Balance and thought it was a great service that Network Health provides to help members manage their chronic diseases. Erin was extremely impressed that she didn’t need to request a care manager. Yvonne showed up and told Erin that she would be there to support her on her journey. Yvonne remembers her trip to the hospital to meet Erin. She says, “The first meeting with a member is very important. I remember meeting Erin that day. I knew she was going to fight this cancer with
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everything she had. I wanted her to know that my job was to support her on that journey. As care managers, we are a trusted resource for a person who is going through the worst time of his or her life.” Erin thought that her relationship with Yvonne would consist of discussions about deductibles and out-of-pocket maximums. Whenever Yvonne would call to check in with Erin, she was always concerned about Erin’s health and well-being. Yvonne focused on the mind/body connection and helped Erin deal with stress while providing consistent support. Yvonne helped Erin manage her symptoms and provided advice and direction. After recovering from her procedures, Erin remembers being discharged. “I didn’t realize how bad this was until the nurse that had been taking care of me came in and had tears in her eyes,” she said.
Unknown to Erin, her husband had been doing research to educate himself about lung cancer and what was happening to Erin. He began to ask questions about genomic testing of the tumor. Erin didn’t really understand what that meant, but it sounded like the cause of her cancer could be a genomic mutation. In the meantime, Erin scheduled her IV chemotherapy.
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The general public believes, even subconsciously, that people who smoke get lung cancer and people who get lung cancer deserve it. There’s a lot less research, funding and awareness about it. Network Health member, Erin Sarauer
Later that week, Dr. Abbi’s nurse called and told Erin that she needed to come in to discuss treatment options. Dr. Avery had been proactive and sent her tissue sample from the bronchoscopy for genomic testing and the results had come back quickly. It turns out Erin was Epidermal Growth Factor Receptor (EGFR) positive. The EGFR mutation is present in about 15 percent of people with lung cancer in the United States. This new information gave Erin options. She could either continue with her scheduled IV chemotherapy or she could take an oral chemotherapy, called a targeted therapy. Targeted therapy targets the tumor cells instead of killing all the cells like IV chemotherapy. Between Erin and her husband, they determined she would go with the targeted therapy treatment option. She was prescribed Tarceva® (erlotinib). Erin still didn’t quite understand what it meant. “I did not know that having this mutation was a good thing until the nurse came in to educate me and she was so smiley and happy.” After being on Tarceva for three months, Erin brought her parents to her first follow-up scan. The results showed that all the cancer cells had shrunk. Her mom was so happy she started crying. Erin looked at her mom and said, “Mom, it’s only temporary.” Erin knows that there is no cure for lung cancer. She attributes that to the stigma associated with lung cancer. She says, “The general public believes, even subconsciously, that people who smoke get lung cancer and people who get lung cancer deserve it. There’s a lot less research, funding and awareness about it.” About a year and a half into her treatment, Erin became dizzy, had blurred vision and couldn’t walk. The St. Elizabeth ER gave her a high dose steroid, anti-nausea medication and made an appointment for an MRI the following day. The MRI showed that Erin had developed 24 brain metastases (mets). Because of all the research
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To remove the two remaining brain mets, Dr. Abbi recommended whole brain radiation. The day before her radiation began, Erin attended a dinner in Chicago sponsored by The Chris Draft Family Foundation. This foundation empowers families to live healthy lifestyles through self-awareness and education. Former NFL
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Unfortunately, only 19 percent of people diagnosed with lung cancer survive five years or more. Erin was given only six to twelve months to live.
they did, Erin and her husband knew it was very common for lung cancer to spread to the brain. Dr. Abbi switched her to Tagrisso, which is a precision medication that targets cancer cells in patients who test positive for the EGFR mutation. Tagrisso is similar to the Tarceva she had been taking, but with less harsh side effects. When she went back for her rescan 17 days later, Erin learned that 22 of the 24 mets had been eliminated. Erin is still on Tagrisso today.
player Chris Draft started this foundation as a tribute to his late wife Lakeasha “Keasha” Rutledge Draft, whom he lost to cancer in December 2011. Like Erin, Keasha was a young, healthy, non-smoker diagnosed with stage four lung cancer that had spread to her brain. Unlike Erin, Keasha’s cancer was not genomic and she didn’t have a targeted therapy option available. “The doctor sent [Keasha’s] tissue sample right away. The key was that they did the test. They gave her a chance,” says Chris. At the dinner, Erin met Dr. Philip Bonomi, an oncologist at Rush Clinic in Chicago. Erin and her husband agreed to get a second opinion, so Erin scheduled an appointment with Dr. Bonomi and the radiologist on his team, Dr. Gaurav Marwaha. St. Elizabeth Hospital provided all the necessary records, scans and information to Rush prior to her appointment. Erin was impressed with how quickly and efficiently everything was handled.
She met with Dr. Bonomi and Dr. Marwaha. After reviewing Erin’s records and assessing her health, they gave her two additional options.
S AY W H AT ?
Genomic mutation - A permanent change in the DNA that makes up a gene.
Metastases (Mets) - Cancer cells that travel through the blood or lymphatic system (which transports infection-fighting white blood cells throughout the body) to form a new tumor in other organs or tissues.
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life. health. wellness. She could have the tumor removed via gamma knife or undergo Stereotactic Body Radiation Therapy (SBRT). Both of these options would allow the doctors to specifically target the brain tumors with radiation, however SBRT is a less invasive procedure. The main difference between the two surgeries is that gamma knife treats brain and cervical spine tumors, whereas SBRT can treat cancer throughout the entire body. Erin selected the SBRT option. She scheduled her appointment with Dr. Christopher Schulz and Dr. Robert Mueller, a radiation oncologist and brain surgeon team at Froedtert Hospital. Prior to the procedure, Erin had an MRI. During that appointment, Dr. Schulz said something to her that she will never forget. He said, “Erin, most cancer patients are interesting in a bad way. You’re interesting in a good way. Twentytwo of your 24 brain mets are gone. There’s no evidence of them whatsoever.” The Tagrisso medication had done its job.
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In addition to Dr. Abbi, Erin also met many influential people (including Dr. Bonomi) through Team Draft, an initiative of The Chris Draft Family Foundation. Before Chris’ wife passed away, she asked Chris to use her experience to work toward finding a cure for lung cancer. One of the first steps is to end the association of lung cancer with smoking. Chris knew that he could use the NFL as a platform to increase awareness. “But I still had to decide that I was ready to be an advocate,” Chris said. “Could I accept that anything I did moving forward would not bring Keasha back? Could I be happy for someone who is doing well?” Chris found the strength to honor his late wife’s request. “When I see Erin, I’m excited about her progress. I appreciate it. I’m willing to fight for it,” says Chris. Through his foundation, Chris has worked with countless people and organizations to promote lung cancer awareness.
Team Draft identifies stand-out survivors throughout the United States. He refers to these people as Draft’s PicksTM; they act as advocates and provide support to lung cancer patients in their area. Erin has been named as one of Chris’ survivor advocates. He knows that knowledge When I tell people about my story, is the only way his foundation can end the stigma that lung cancer is a smoker’s disease. Chris says, “It’s only I say a football player saved my life. recently that doctors would even think of lung cancer as That’s the God’s honest truth. being something that could be hereditary. They weren’t looking for that. The public decided a long time ago that Chris Draft saved my life. if we could get people to quit smoking, we could stop lung cancer.” Chris will continue to empower lung cancer Network Health member, Erin Sarauer patients and survivors while attempting to get funding for research to keep his promise to Keasha.
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Erin received SBRT for the two remaining brain mets as an outpatient procedure. She returned to work the next day. Attending the dinner sponsored by The Chris Draft Family Foundation was a turning point in Erin’s treatment. Meeting Dr. Bonomi gave her the second opinion leading her to the SBRT treatment. “When I tell people about my story, I say a football player saved my life. That’s the God’s honest truth. Chris Draft saved my life,” says Erin. Erin’s follow-up appointment with Dr. Abbi’s team gave her a new outlook on life. At the appointment, they informed her that they were changing the protocol for lung cancer patients who get brain metastases. Erin felt a huge sense of strength and accomplishment. She had made a difference. Because of her experience, future non-smoking EGFR positive patients would be offered the option of targeted therapy rather whole brain radiation. Erin wanted to work with doctors and other lung cancer patients to raise awareness, educate and update standards of practice. That was the moment she became an advocate.
Today, Erin’s cancer is in remission. She is passionate about raising awareness of lung cancer by sharing her story. She has spoken at churches, the St. Elizabeth Hospital Foundation Health Outing and she cohosted the Shine the Light on Lung Cancer event in November 2018. Erin has traveled to Washington D.C. to meet with other survivors to break down the barriers for lung cancer research. “It’s my goal, and my next step, to form a support group for cancer patients in this area. Not a lot exist for this particular type of diagnosis, in terms of support in the Fox Valley Area, so I’m really hoping to get something started through St. Elizabeth to have some greater support networks and activities.”
Erin’s relationship with Dr. Abbi was instrumental in her journey to advocacy. Throughout the course of Erin’s treatment, he acted as a partner. Erin and her husband would regularly bring research and articles to him for review. He spent time answering questions and explaining processes in a way Erin and her husband could understand. Most importantly, Dr. Abbi was willing to learn and use Erin’s experience to update protocols to provide better treatment options to his patients.
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How to Stay Active During the Cold Winter Months
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t can be hard to stay active when it’s cold, wet and dark outside. But, physical activity is essential to your health, and the release of endorphins can offset the winter blues which occur from lack of sunlight during the winter months. Exercise can also help balance any holiday overindulgence and put you on the path to a healthier 2019.
Below are some suggestions for fun options to keep yourself active this winter. Participate in winter sports. Try an outside winter sport, such as ice skating, skiing (cross-country or downhill), ice fishing or snowshoeing.
Play an indoor sport. The winter months are a great time to play indoor sports. Many local fitness centers offer indoor basketball and volleyball courts.
Join a gym. Choose one that is conveniently located so the inconvenience of driving in the winter won’t keep you from going. Encourage a friend to go with you as a fun way to keep yourself motivated.
Join/start a step challenge. You can challenge your family, friends or coworkers. This could be a long-term challenge (months) or short-term (one week).
Walk at the mall. Many malls, including the Fox River Mall in Appleton, the Mayfair Mall in Wauwatosa and the Brookfield Mall offer early morning access to people in the community. Malls are a great way to walk in the winter if you’re bored by treadmills or don’t have access to a gym. Exercise at home. Purchase a yoga mat and/or hand weights to create a home gym. Try using YouTube or fitness apps to find new exercise routines.
Enjoy time outdoors. Spend time outside with your children or grandchildren and build a snowman, make snow angels and/or go sledding. This will keep you moving while getting to spend quality time with your family. Staying active doesn’t have to be a chore. You can make it fun and keep it interesting by engaging in one or more of these activities. Take care of yourself by stretching before and after activity and drinking plenty of fluids while you’re being active.
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life. health. wellness.
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The whole process took about 10 minutes, and all I paid was the $10 copayment for the visit and the $3 copayment for my medication.
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VIRTUAL DOCTOR VISITS
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etwork Health wants to create an excellent user experience, so we ask our members to share their feedback about services we offer. Recently, a Network Health member used a virtual visit through MDLIVE® and she provided a recap on how it works. She had been coughing and feeling sinus pressure for about two weeks. Finally, when she had to stay home from work because of her illness, she knew she needed medical attention. “I decided to try MDLIVE because I didn’t want to wait for a doctor’s appointment, but it wasn’t serious enough for urgent care or the ER,” she says. She activated her MDLIVE account through the Network Health member portal at login.networkhealth.com. Members can also visit MDLIVE.com/ networkhealth, call 877-958-5455 or download the MDLIVE app on a tablet or smartphone.
“It was really easy to use,” she says. “I filled out an online form and let them know when I would be available for an appointment. MDLIVE texted me with an appointment time.” The online form asks for medical history, symptoms and preferred pharmacy, in case a prescription is needed. “The doctor called at the designated time, diagnosed me with a sinus infection and called the prescription into my pharmacy,” she says. “The whole process took about 10 minutes, and all I paid was the $10 copayment for the visit and the $3 copayment for my medication.” She highly recommends the MDLIVE virtual visit as a fast, inexpensive treatment option. “As long as your condition isn’t life-threatening, it’s worth the 10 minutes to talk with one of the doctors.”
Activate your account today by texting NETWORK to 635483, call 877-958-5455 or visit MDLIVE.com/networkhealth.com. 14 | balance • W i n t e r 2 01 8
networkhealth.com
Opioid Awareness
O
pioid abuse continues to be a growing problem in Wisconsin. Opioids are narcotic medications used to treat mild to severe pain. Unfortunately, because of the addictive nature of opioids, any of us could fall victim to opioid dependency, not just drug users and abusers. By arming yourself with information about opioids, you can keep yourself and your family safe.
Use Prescribed Opioids Safely Because we are on a mission to create healthy and strong Wisconsin communities, Network Health is doing everything we can to decrease the growing epidemic of opioid abuse in Wisconsin. Beginning April 1, 2019, Network Health will be imposing limits on opioid prescriptions for our employer-sponsored health insurance members. We are working with our provider partners to limit the quantity and frequency of opioids that are prescribed by doctors within our network.
Do you have any of these medications in your home?
If you are prescribed opioids, use them only until pain is manageable with non-narcotic pain relievers. For the safety of yourself and your family, keep your opioid medications locked up and dispose of unused medications when they are no longer needed. Resist the urge to save them “just in case,” and never share unused medications with anybody.
oxycodone morphine fentanyl methadone
hydrocodone codeine hydromorphone tramadol
These painkillers are some of the most commonly used opioids.
Make sure you dispose of the drugs properly. Check the medication label for disposal instructions or look for drug take-back programs near you. For additional information about how and where to dispose of unused medications, go to https://www.fda.gov/drugs/resourcesforyou/consumers/ and under Using Medicine Safely, select Safe Disposal of Medicines. To learn more about the dangers associated with opioid usage, visit the Dose of Reality website at https://doseofrealitywi.gov/.
Access to Care Network Health ensures continuity and coordination of medical and behavioral care through changes and settings of care. This means you get the care and services you need and your provider(s) get the information they need to give you the best care possible. We work with doctors and hospitals to ensure you can get the necessary medical care in a timely manner, whether it’s access to after-hours, urgent, routine or preventive care. Because you should always be able to get the care you need, we require our providers to offer access to medical and behavioral health services without excessive scheduling delays. Our standards for timeliness of appointments and office waits are shared with our provider network. If you don’t feel your need for urgent, routine or preventive care is being handled in a timely manner, please contact us at the number listed on the back of your member ID card. We’re here to help you get the care you need, when you need it.
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life. health. wellness.
THE
service deserve YOU
A
t Network Health, we want to ensure you’re receiving the service you need and deserve. If you have concerns, we want to make sure you understand all your options. If you do not agree with Network Health’s decisions about your care or what’s covered, you have the right to file an appeal or grievance. We have a team of appeals and grievance specialists who will work with you throughout this process.
When do I file an appeal?
You have the right to file an appeal if you do not agree with Network Health’s decisions about your health care. You can submit an appeal in writing within 60 calendar days from the date you receive the claim denial. Your written appeal should include your full name, member ID and information about what you are appealing. You may also include any comments, documents, records or other information you would like Network Health to consider in its review. These are examples of situations appropriate for an appeal. Network Health will not approve care it should cover. Network Health is stopping care you still need. Network Health has denied payment for services or items you have received and you think they should be covered.
Who may file an appeal?
You or someone you name to act for you (called your representative) may file an appeal. To name your representative, call customer service at the number listed on the back of your member ID card to obtain an Appointment of Representative Form.
What happens after I file an appeal?
When you file appeal, you are formally requesting Network Health to
review our decision. We will acknowledge your appeal within five business days of receiving it. The Appeals and Grievance Committee will schedule a hearing to review your case and you will be notified at least seven days prior to that meeting. You have the right to submit written comments, documents, records and information relevant to your appeal. You may attend the appeal meeting in person or telephonically to present any additional information. After the hearing, the Appeals and Grievance Committee will address your appeal and provide a written response within 30 calendar days for a preservice claim or 60 calendar days for a post service claim.
How are medication appeals handled?
Medication appeals are reviewed by a Network Health Pharmacist and Network Health Medical Director, as needed. The pharmacist communicates with the prescribing provider if additional information is needed or discusses alternative covered medications. Our pharmacists have a goal of addressing medication appeals within four hours and have been successful over 90 percent of the time.
When do I file a grievance?
If you’re dissatisfied with the service or quality provided by your plan or doctor, we’re here to work with you through any issues. You have the right to file a grievance (a formal complaint) about the service you received from Network Health, our vendors or contracted providers. These are examples of situations that are appropriate for a grievance. Difficulty getting through on the phone Concerns about the quality of care or services provided Interpersonal aspects of care (for example, rudeness of a provider or staff) Failure to respect your rights
S AY W H AT ?
Preservice claim is prior authorization of a service or procedure Post service claim is a claim that is processed after the service has been performed 16 | balance • W i n t e r 2 01 8
networkhealth.com
Your Right to Request an Independent Review
W
e work hard to ensure your satisfaction, but it’s important to know you have the right to request an independent organization examine certain final decisions made by Network Health. Reviews are completed at no cost to you, including any filing fees. Decisions eligible for review are those where Network Health determined the requested care or services did not meet our requirements for the following.
Medical necessity (care that is reasonable, necessary or appropriate based on proven clinical standards) Health care setting Level of care Effectiveness Experimental treatment Appropriateness Cancellation of a policy or a certificate Coverage denial determination based on pre-existing condition exclusion.
For more information about the independent review process at Network Health, refer to your plan materials or contact our customer service department at the phone number listed on the back of your member ID card.
How Health Plans Make Decisions N
etwork Health makes decisions on the appropriateness of care and service through a process called utilization management. Care and service include medical procedures, behavioral health procedures, pharmaceuticals and devices. Decisions are based on written criteria established from sound clinical evidence and the benefits outlined in your coverage document. The written criteria are reviewed and approved annually by actively-participating practitioners. Criteria are available to you upon request. Requests for criteria can be submitted via telephone, fax, electronically or USPS, as indicated below. Once the request is received, care management associates send the requested criteria to the requestor via fax, electronically or USPS. Network Health does not reward practitioners or other individuals conducting utilization review for denying coverage for care or service. Network Health does not prohibit providers from advocating on behalf of members within the utilization management program.
n e t w o r k h e a l t h . c o m
Network Health does not use incentives to encourage barriers to care and service and it does not make decisions about hiring, promoting or terminating practitioners or other associates based on the likelihood, or the perceived likelihood, that the practitioner or associate supports, or tends to support, denial of benefits. In addition, the medical director, associates (or designees), care management staff and supervisors of this staff receive no financial incentive to encourage decisions that result in underutilization. If you have questions about the utilization process, a utilization management decision or would like a copy of specific utilization criteria you may call care management at 920-720-1600 or 800-236-0208, Monday–Friday, from 8 a.m. to 5 p.m. For questions specific to behavioral health utilization, call 920-720-1340 or 800-555-3616. Callers may leave a message 24 hours a day, seven days a week.
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life. health. wellness.
A Focus on Quality Health Care W
hen it comes to quality, Network Health ranks higher than Wisconsin and national averages in several categories. We evaluate the quality of care and services provided using two nationally recognized tests, the Healthcare Effectiveness Data and Information Set (HEDIS®) and the Consumer Assessment of Healthcare Providers and Systems (CAHPS®). Each test scores our services in a different way. HEDIS measures preventive care and care for chronic diseases. CAHPS evaluates customer satisfaction with services provided by customer service, claims and physicians.
How We’re Doing
2018 Reporting Year Network Health HMO/POS (Commercial) HEDIS Results
Network Health Combined Results
Wisconsin Health Plans Average Results
National Average Results
Colorectal Cancer Screening
71.96%
66.50%
61.05%
Controlling High Blood Pressure
73.31%
64.76%
58.48%
Comprehensive Diabetes Care – Eye Exams
65.69%
57.29%
51.92%
Comprehensive Diabetes Care – Controlled HbA1c (Less tha 8.0 percent)
68.25%
52.91%
52.63%
Prenatal Care
93.20%
79.49%
80.57%
Post Partum Care
89.80%
79.03%
71.03%
Childhood Immunization Status – Combo 10
64.10%
59.67%
50.55%
Immunizations for Adolescents – Meningococcal Conjugate and Tdap
84.15%
80.97%
77.94%
Well-Child Visits for Ages 3-6
81.63%
80.30%
75.93%
Category/ Measure
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ). 18 | balance • W i n t e r 2 01 8
How You Rate Us 2018 Reporting Year Network Health HMO/POS (Commercial) CAHPS Results
Network Health Combined Results
Wisconsin Health Plans Average Results
National Average Results
How often did you get an appointment for check-up or routine care at a doctor’s office or clinic as soon as you needed?
84.57%
84.29%
82.38%
How often did you get an appointment to see a specialist as soon as you needed?
87.82%
85.94%
84.37%
How often did your personal doctor seem informed and upto-date about the care you got from these doctors or other health providers?
86.67%
84.16%
82.23%
When you needed care right away, how often did you 91.61% get care as soon as you needed?
88.68%
88.68%
How often did the written materials or the Internet provide the information you needed about how your health plan works?
70.21%
65.95%
65.95%
How often did your health plan handle your claims correctly?
91.41%
90.25%
90.25%
How often did your personal doctor explain things in a way that was easy to understand?
96.81%
96.33%
96.33%
Category/ Measure
networkhealth.com
Your Annual Wellness Visit This is a great time of year to schedule your 2019 annual wellness visit with your personal doctor. What is an annual wellness visit?
An annual wellness visit is an appointment with your personal doctor to discuss your health history, receive a physical examination, preventive screenings and immunizations. Because some conditions don’t show early symptoms, staying up-to-date on preventive screenings is one of the most important things you can do for your health. The annual wellness visit performed by your doctor will help with the early detection of conditions that could put your health at risk. By understanding your risk factors, in the event of an illness, you can seek early treatment which will ultimately save you money on your medical costs. Because Network Health cares about your health and well-being, your annual wellness visit is considered a preventive service, and is covered by your Network Health plan with an in-network provider.
How do I choose or change my personal doctor?
It’s important to select a personal doctor that you trust to coordinate your care. This doctor should be given access to all your medical records so he or she can provide recommendations based on your medical history. The goal of your personal doctor is to make sure you improve or maintain your physical health by providing access to the care you need. You can designate your personal doctor through the member portal at login.networkhealth.com. Once logged in, click your name in the upper right corner to bring up your profile. Select Change My Personal Doctor and follow the steps that appear. If your child is a young adult, he or she may be ready to transition from a pediatrician to a family practice doctor. Although pediatricians are trained to discuss things like puberty, depression and other issues that young adults may face, your child may feel more comfortable seeing a different doctor as he or she gets older. If you haven’t selected a personal doctor for your child, ask the pediatrician for a referral. Your child’s pediatrician knows his or her history and is aware of any conditions that will require special care. Be sure to verify the referral is in-network by visiting networkhealth.com and using the Find a Doctor search.
S AY W H AT ?
Preventive care – includes health services like screenings, check-ups and patient counseling to prevent and detect illnesses, disease and other health problems.
Clinical Practice Guidelines Network Health provides clinical practice guidelines to help you and your health care team make decisions regarding appropriate care for specific circumstances. These guidelines are selected after careful consideration by a panel of physicians on Network Health’s Medical Policy Committee. Guidelines are available for conditions that may be medically acute or chronic in nature, such as low back pain, diabetes, tobacco cessation or depression. These guidelines are updated as new ones become available. These evidence-based guidelines are available to both you and your n e t w o r k h e a l t h . c o m
provider on Network Health’s website. To access the guidelines, go to networkhealth.com and click Employer Plans. Choose Member Resources and select Clinical Practice Guidelines under the Additional Resources heading. To view the guidelines for a specific condition, click the condition and you will be redirected to a page containing the necessary information. If you would prefer a printed copy of these guidelines, call our customer service department at the number listed on the back of your member ID card. W i n t e r 2 01 8
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1570 Midway Pl. Menasha, WI 54952
MAILED ON 12/31/18
NEW and Built-by-You, Network Health
Member Portal W
e’ve gathered and incorporated customer feedback to deliver a new member portal that’s centered on you. The new portal is easier to navigate and you’ll find tools, tips and important information to help get the most out of your benefits. The portal is also mobile responsive so you can access your important health insurance plan information 24/7 from any device. Create your new account today at login.networkhealth.com. The first time you visit the new portal, you’ll need to create a new account, regardless of if you had an account in the old portal. Once signed in, you’ll see a customized dashboard specific to you and your plan. From this dashboard, you can view benefit information, view out-of-pocket expenses, reorder an ID card, access plan materials and more. You can also select communication preferences, so you can choose to receive your Explanation of Benefits (EOB) statements by email instead of mail. Set up your new account today at login.networkhealth.com so you can easily access everything you need to manage your plan.
Once you are logged in, you’ll find all this and more. Benefits and coverage overview Out-of-pocket expenses tracker Claims detail and status Authorization information and status Mobile access to view or order an ID card Plan-related materials and forms Secure messaging with our customer service team Wellness programs and tools Find a Doctor, Find a Pharmacy, Look Up Medication searches