L I F E , H E A LT H & W E L L N E S S
SPRING 2019
The Real Strength of a Man Member Lee Hillstrom shares his story about the importance ? preventive screenings. of
PAGE 8 Everything You Need to Know About One of the Heart’s Most Complex Valves PAGE 10 Prevent or Manage Type 2 Diabetes with Exercise BACK COVER Get Social (For Real)
A PUBLICATION OF
Exclusive Reduced Rates for Network Health Medicare Advantage Plan Members For ticket information, visit networkhealth.com/offers Fox Cities Performing Arts Center - Appleton, Wisconsin THE PLAY THAT GOES WRONG – May 5 at 1 p.m. Tickets on sale now. Offer expires April 22, 2019. Subject to availability. Marcus Center - Milwaukee, Wisconsin GLENN MILLER ORCHESTRA – May 24 at 7:30 p.m. Priority seating. Tickets on sale now. Offer expires May 23, 2019. Subject to availability.
ANASTASIA – July 28 at 1 p.m.
Priority seating. Tickets on sale now. Offer expires July 19, 2019. Subject to availability.
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5 Don’t Brush Off Dental Care 5 An Ounce of Prevention … 6 A Coach Makes a Difference 7 A Focus on Quality Health Care 8 Everything You Need to Know About One of the Heart’s Most Complex Valves
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3 Letter from the President and CEO 4 Top 10 Reasons to Register for the Online Member Portal
10 Prevent or Manage Type 2 Diabetes with Exercise 10 Your Opinion Matters 11 Dispensing Knowledge 12 I Don’t Feel Well 12 Is It a Routine Eye Exam or a Medical Eye Exam? 13 How to Read Your Explanation of Benefits
14 Reminder - Schedule Your Annual Wellness Visit 14 My Doctor Visit Checklist 15 Helping You Control Your Health 16 FEATURE The Real Strength of a Man 20 The Talk: Advance Care Planning – Why It Matters to Have It Now 21 Transition of Care 22 Don’t Let Running to the Bathroom Run Your Life 23 Network Health Makes Decisions Based on Appropriateness of Care BACK COVER Get Social (For Real).
H5215_1550-03-0319_C EDITORIAL STAFF President and CEO Coreen Dicus-Johnson Chief Administrative Officer Penny Ransom Marketing Coordinator Romi Norton Lead Designer Debra Sutton
ASK NETWORK HEALTH If you have questions about anything you read in this issue of Concierge, call customer service at 800-378-5234 (TTY 800-947-3529) Monday–Friday, 8 a.m. to 8 p.m. You can also learn more at networkhealth.com. Concierge is a biannual publication of Network Health. The health information contained in Concierge is meant to supplement, not replace, the advice of health care professionals. © 2019 Network Health Insurance Corporation. No portion of this newsletter may be reproduced without written permission from Network Health Insurance Corporation.
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 800-378-5234 (TTY 800-947-3529). 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 800-378-5234 (TTY 800-947-3529). 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 800-378-5234 (TTY 800-947-3529). 2 | C oncierge
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life. health. wellness.
Letter from the President and CEO
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etwork Health’s mission is to create healthy and strong Wisconsin communities.
For more than 35 years, we have been living and working in the communities we serve. We feel a responsibility to be your health and wellness partner. Our mission calls us to provide you with resources to support your health care decisions. In this edition of Concierge, there are articles that we hope you find educational and that will aid you in making informed choices related to your health care coverage. We encourage you to take advantage of local community events taking place near you. Please refer to the back cover for information on these events. Best regards,
Coreen Dicus-Johnson President and Chief Executive Officer
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life. health. wellness.
Top 10 Reasons to Register for the Online Member Portal 10. You want easy access to your plan-specific health care coverage information.
9. You have a non-emergency illness and would like
to try an online doctor visit, so you don’t even have to leave your home to see a doctor.
8. You like exploring websites and sharing feedback—your feedback helps us make important improvements. 7. You have a customer service question and you’d
prefer to send an email, instead of calling.
6. You’ve misplaced your ID card and have an
upcoming appointment. You can show your mobile ID card when you check in for your appointment.
5. Your personal doctor has changed, and you need to update your information. 4. Your child or grandchild helped you register.
Next time they visit you can show them how much you learned.
3. You want to pay your monthly premium online.
(If you prefer to set up recurring payments, use the payment option form found in the back pocket of your new member guide or in the My Materials section of the portal.)
2. Take your health risk assessment. (See the article on page 6 to find out why this is important to your overall health.) 1. Save paper. You can elect to receive your
Explanation of Benefits (EOBs) online. When you have an EOB available, you’ll receive an email notification. Click your first name in the upper right corner and find this option under My Communication Preferences. Visit login.networkhealth.com today to get started.
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Don’t Brush Off Dental Care By Delta Dental of Wisconsin
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Lingering plaque can cause gingivitis, which ou may have dental concerns that can’t be causes your gums to become red, swollen and to bleed. resolved by just brushing, flossing and regular cleanings at your dentist’s office. Many common dental Keep your dentures clean and free of food health issues arise later in life, such as dry mouth, gum particles. Have your dentist show you how to disease or dentures. clean and wear them properly. When you go to Always maintain good dental care to keep your teeth sleep, remove your dentures and put them in water and gums healthy, no matter what concerns you have. or a denture-cleaning liquid.
If you experience dry mouth, take frequent sips of water and limit your intake of alcohol, caffeine, carbonated drinks and tobacco. Sugar-free gum or sugar-free hard candy can be helpful. It’s important to rinse away food particles from your teeth to avoid the risk of developing tooth decay. Be sure to mention any issues to your dentist. The key to preventing gum disease is to brush and floss regularly to remove plaque from your teeth.
In addition to the suggestions above, it is important to keep up your healthy habits. Brush your teeth gently at least twice a day and floss daily. Drink fluoridated water and use fluoride toothpaste. Eat a balanced diet. Avoid tobacco. Have regular dental checkups and cleanings.
An Ounce of Prevention … By Lisa Boucher, BS, accreditation program manager for Network Health and Michele Eggers, RN, BSN, quality integration coordinator for Network Health
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enjamin Franklin once said, “An ounce of prevention is worth a pound of cure.”
Preventive care helps prevent illness and keep you healthy. Preventive screenings and tests can help find health problems early, when treatment works best, and can keep you from getting certain diseases. Preventive care includes annual wellness visits, vaccinations, labs and screenings, as well as programs to monitor your health and health education. The appropriate services vary depending on age, gender, current health status and individual risk factors. Your personal doctor can help you determine which services are right for you. It can be tough keeping the recommended preventive care and screenings straight. Your 2019 Network Health
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Member Guide includes a Preventive Health Checklist in the back pocket to assist you with keeping track of which services you have had and which you still need. You’ll find commonly recommended preventive services, categorized and grouped by medical issue. Your personal doctor may recommend additional exams or tests, or a different frequency than the general recommendations. Take the checklist to your appointments to discuss next steps with your personal doctor to ensure you are taking advantage of all the preventive services available to you.
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A Coach Makes a Difference By Mark Geiger, quality health integration supervisor for Network Health (and pictured above)
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ou hear about Network Health nurses helping our members with complex conditions, but did you know we have health coaches to help you quit smoking, stay up-to-date with preventive screenings and even lose weight?
How Can Health Coaching Help?
Health coaching provides the following, at no cost. Direction, motivation, accountability and support from a wellness expert Convenient and flexible appointments over the phone Proven and personalized tips and techniques to maintain and improve your health Personal attention with a caring approach Complete confidentiality; your personal health information is not shared without your permission
How Do I Get Started?
The first step is to complete your health risk assessment. You can find your health risk assessment in your online member portal. Visit login.networkhealth.com and log in. Click on the My Wellness tab, then select My Health Questionnaire in the drop-down menu.
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Once you complete your health risk assessment, our health coaches review your responses to determine if they can assist you with the following. Nicotine Use – Through the health risk assessment and claims review, Network Health identifies nicotine users and new Chantix prescription members to help them through the process of quitting Preventive Screening Reminder – Health coaches look closely at preventive screenings to ensure members stay up-to-date with flu shots, mammograms and colonoscopies Exercise and Nutrition – Health coaches help determine which exercises or nutrition changes can be made to improve your health Weight Management – Health coaches help create a weight management plan focusing on exercise and nutrition
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Meet Your Network Health Coaches Sam
Hello, I’m Sam. I provide one-on-one support to help members achieve their health and wellness goals. During each coaching session, I offer members encouragement and guidance for maintaining a healthy lifestyle. Sometimes this means identifying current obstacles to a health goal and discussing healthy approaches to overcoming them. In my spare time, I enjoy running, playing softball, exploring the outdoors and spending time with my husband and puppy. When I am not playing sports, you might hear me cheering for the Packers or one of our other Wisconsin-based sports teams. Sam graduated from Lakeland College with a bachelor’s degree in exercise science and sports studies.
Jennifer
Hello, I’m Jennifer. I build relationships with members to help them use their personal strengths to meet their individual health goals. I show members how they can improve their longevity and quality of life with targeted behavior changes and healthy lifestyle choices. In my spare time, I enjoy many outdoor activities, including jogging, kayaking and fishing. I also spend time planting and harvesting produce from my garden. I enjoy playing cards or board games, and I like working on arts and crafts projects. My sweet weakness is dark chocolate. Jennifer holds a bachelor’s degree in health promotion and wellness with a minor in psychology from the University of Wisconsin-Stevens Point.
To learn more about health coaching, please call 800-378-5234 (TTY 800-947-3529), Monday–Friday from 8 a.m. to 4 p.m.
A Focus on Quality Health Care By Lisa Boucher, BS, accreditation program manager for Network Health At Network Health, our commitment to quality isn’t about awards, ratings or accreditations. We will continue to exceed the industry’s high standards because we put the spotlight on you. Our quality department focuses on improving the health care services you receive every day and ensuring your experience with Network Health surpasses your expectations.
Our quality programs concentrate on the following. Delivering high-quality, safe and cost-effective health care and collaborating with our provider-owners.
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Improving the member experience, access and availability to necessary care. Enhancing the personal wellness of our members and communities. Ensuring coordination of care within our provider network. Every year, we assess our member demographics including age, gender, ethnicity, social and environmental factors, living conditions and potential health differences to identify and address cultural, racial and language needs. This insight allows us to implement and adjust processes and resources, clinical and service programs, communications and member materials based on the specific needs of our members. C oncierge | 7
life. health. wellness.
Everything You Need to Know About One of the Heart’s Most Complex Valves By Froedtert Health
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n estimated five million people in the United States have heart valve disease. It can affect people of all ages, but it becomes more common as you age. In fact, more than one in eight people aged 75 or older has a moderate or severe valve disease.1
The heart has four valves, the one most commonly affected is the mitral valve. The mitral valve is located between the left atrium and the left ventricle; it opens to allow blood to flow from the atrium to the ventricle and then closes when the ventricle contracts to send blood to the body.
Mitral valve problems fall into three main categories. 1. Stenosis
Narrowing of the mitral valve.
2. Prolapse
Enlarging or bulging of one or both valve’s leaflets, allowing a small amount of blood to flow back into the atrium.
3. Regurgitation
Incomplete closing of the valve’s leaflets due to hereditary causes or disease. Severe cases can lead to heart failure.
Symptoms
Diagnosis
When the mitral valve malfunctions, it places extra strain on the heart and lungs.
Sophisticated diagnostic imaging, such as an echocardiogram (commonly called an echo), can pinpoint trouble. The noninvasive test evaluates heart and valve function by using sound waves.
“The first thing that happens is that people become short of breath with something that requires minor effort,” said Paul Pearson, MD, Froedtert & the Medical College of Wisconsin cardiothoracic surgeon. Fatigue and dizziness are common for a person with valve disease, but it is possible for a person to have severe valve disease and for symptoms to go unnoticed. If left untreated, heart valve disease can lead to other heart problems, including heart failure and stroke. 88 || C Concierge oncierge
“The biggest advancement is three-dimensional echocardiography, called transesophageal echocardiogram,” Dr. Pearson said. “We obtain a 3D image, as if in the heart, to help us determine if the valve can be repaired or needs replacing.”
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Treatment
“Treatment options for mitral valve disease include an open, traditional procedure; medicine alone; and, increasingly, minimally invasive procedures through an artery or a vein, often referred to as transcatheter procedures,” said Michael Salinger, MD, a Froedtert & MCW interventional cardiologist. The type of treatment is based primarily on the person’s age but is tailored to the individual. When possible, surgeons prefer to repair the valve by rebuilding its chords and leaflets and tightening the frame around it. If a valve needs to be replaced, surgeons can implant a bioprosthesis valve made of animal tissue or a manufactured valve, typically made from metal. Manufactured valves are the most durable, but can form clots, so recipients must take bloodthinning medication. Tissue valves generally do not require blood thinners but eventually wear out.
Prevention Heart valve disease can be hereditary or can develop. In many cases, age-related changes in the body can lead to the deterioration of heart valves. You can help control your risk of heart valve disease by maintaining a healthy weight, consuming a diet low in salt and cholesterol, not smoking and promptly treating any bacterial infections, which can damage tissues in the heart. “We use the latest research and weekly valve conferences to gather multiple opinions to ensure patients get the most appropriate treatment recommendations,” Dr. Salinger said. “We also participate in significant clinical research trials to find new and more effective treatments for heart and vascular disease.” “When you use a heart team approach, with that amount of expertise around the table on the patient’s behalf, we leave no stone unturned,” said Peter Mason, MD, MPH, RPVI, a Froedtert & MCW interventional cardiologist. To learn more about mitral valve treatments, visit www.froedtert.com/mitral-valve. https://www.sciencedirect.com/science/article/pii/ S0140673606692088?via%3Dihub
1
WHAT’S THAT? A VALVE LEAFLET is any small, leaf-like structure such as the cusps of a heart or other valve. networkhealth.com
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life. health. wellness.
Prevent or Manage Type 2 Diabetes with Exercise By SilverSneakers®
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t’s the perfect time of year to make your health a priority. Instead of just trying to “do better,” make a lifelong commitment to leading a healthy lifestyle. There are a lot of great reasons to exercise and eat healthy. For many people, preventing or managing diabetes tops the list. There are more than 12 million Americans over 65 with type two diabetes. If you have this condition, your doctor has probably recommended that you eat healthier and exercise to prevent or manage your condition. A fitness program is a great place to start. (Always talk with your doctor before starting an exercise program.)
These fitness activities can help manage diabetes. Aerobic exercise – Activities like brisk walking (outdoors or on a treadmill), cardio classes, swimming and cycling help your body use insulin more efficiently, aid in weight loss and improve heart health and blood circulation. Resistance training – Building muscle burns glycogen during exercise and helps with
blood glucose management. Gaining and maintaining muscle mass is important, especially if you have diabetes. Lifting weights and using resistance bands, machines and your own body weight are great ways to build muscle
Balance and flexibility training – Exercises that build balance and increase flexibility
can help reduce your risk of falling. Balancing on one leg at a time, attending strength and balance group classes, doing yoga and stretching are great exercises to incorporate into your daily routine.
Your Opinion Matters If you like to give feedback and enjoy engaging your Medicare Advantage plan, we invite you to serve on our member advisory council. This group of members helps shape our decisions, so we continue to offer the quality service and Medicare Advantage plans that fit your needs. To find out more, contact a member of the health care concierge team today at 800-378-5234 (TTY 800-947-3529). 8 || C 10 Concierge oncierge
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Dispensing Knowledge
Tools are available online at networkhealth.com to find a pharmacy and look up medications.
By Anna Peterson Sanders, PharmD, pharmacist for Network Health
Did You Know? Network Health has expanded tier 1 generic medications to include over 100 additional medications. Tier 1 medications are now also available by mail order for $0 for a 90-day supply. To set up your prescriptions with mail order, call Express Scripts Pharmacy Mail Order at 800-316-3107. Our pharmacists can review your medications and discuss strategies for lowering your costs. If you have concerns about affording your medications, call your health care concierge team at 800-378-5234 (TTY 800-947-3529) or send a message through your online member portal and ask to speak directly with a pharmacist. We offer a Medication Therapy Management (MTM) program. If you have at least three long-term medical conditions and take seven or more daily medications, you may have the opportunity to speak with a pharmacist about your medications. Network Health pharmacists understand your Medicare Advantage plan so they can review cost-saving opportunities and collaborate with your pharmacy and doctor. Eligible members receive an invitation to participate, then get a call from a pharmacist to review medications. To reach out to the Network Health pharmacists, call your health care concierge team at 800-378-5234 (TTY 800-947-3529) or send an email through your online member portal. In light of the opioid crisis, tactics have been created by state and federal governments, health care providers and insurance companies including Network Health. These tactics help to prevent overprescribing and overuse of opioids. With guidance from the Centers for Medicare and Medicaid Services, Network Health has implemented programs to keep our members and communities safe. Members with new opioid medications will be limited to a seven-day supply. These medications must be below a certain dose or a prior authorization must be submitted by your provider. Members currently receiving opioid medications will continue to receive them unless the dose is above a certain limit, at which point a prior authorization must be submitted by your provider for continued coverage. Network Health members that inform us that they reside in a nursing home, are on hospice or have cancer are excluded from this program. Stay safe by practicing proper storage and disposal of medications. For additional information visit https://doseofrealitywi.gov/ and https://www.cdc.gov/drugoverdose/opioids/index.html. networkhealth.com
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life. health. wellness.
By Pat Frisque, retired account executive for Network Health
I
woke up on a Saturday not feeling well. It was the kind of sick where I felt like I needed to see a doctor, not the kind where I could just let it pass. Being a Saturday, I knew my personal doctor wasn’t available. I didn’t want to go to urgent care and I didn’t want to wait to schedule an appointment for Monday. I remembered reading material about MDLIVE® online doctor visits. I decided to give it a try. I called the 800 number and the person asked if I had preregistered. I told her I hadn’t, so she offered to walk me through the registration on the phone. She asked a few questions, including my insurance information and my symptoms. Then she said a doctor would call me back within an hour. I asked for a smaller window of time when I could expect the call, she said probably within a half hour. Within 10 minutes, I received a call back from a doctor who discussed my symptoms with me and then prescribed an antibiotic. He called it into my preferred pharmacy and
by the time I was ready to go pick it up, I had a text from my pharmacy saying it was ready. MDLIVE was very convenient, easy and cost-effective. I will use it again if I need care and can’t get to my personal doctor.
To access MDLIVE, call 877-958-5455, visit MDLIVE.com/nhmedicare or log in to your member portal account
Is It a Routine Eye Exam or a Medical Eye Exam?
P
eople age 65 and older are more than twice as likely to need glasses or contacts than people in other age groups. How do you know what type of exam you need and what type of coverage will apply? Routine Eye Exam – Screens for eye diseases and provides measurements for eye glasses and/or contacts. When do you need a routine eye exam? Your vision is blurry You have trouble reading up close You find yourself squinting to see far away Annually, even if you don’t experience issues
Is this type of exam covered by your Network Health Medicare Advantage plan? Yes. New for 2019, you have coverage for a routine eye exam for $10 as well as discounts on glasses and contact lenses with an EyeMed provider. Find an EyeMed provider at networkhealth.com, select Medicare Plans, 12 | C oncierge
choose Dental, Hearing and Vision and select Find a Vision Provider. Medical Eye Exam – Performed to evaluate abnormal findings and to monitor existing medical conditions. When would you need a routine eye exam? You have cataracts You have diabetes You have glaucoma You have macular degeneration Is this type of exam covered by your Network Health Medicare Advantage Plan? Yes. This is considered a Medicare covered exam, and a copayment will apply. You can find a provider by visiting networkhealth.com, select Find a Doctor, enter your zip code and select your plan, then choose the specialty Optometry or Ophthalmology. networkhealth.com
How to Read Your Explanation of Benefits W
hen you use your Network Health Medicare Advantage Plan, you’ll receive an Explanation of Benefits (EOB). This statement is not a bill. It explains the services you received, costs of each service and the amount covered by your Medicare Advantage plan through Network Health. Here’s a quick guide on how to read your EOB. The full version can be found in your online member portal at login.networkhealth.com under My Materials. Plus, click your first name in the upper right corner and see My Communication Preferences to elect to get your EOBs via email, instead of mail. Patient:
John A Smith 123 Main St Apt XXX Happyville, WI 59999
Member ID: 9999999999 Explanation of Benefits This is not a bill
Servicing Provider: Date of Service
1
2 8
Total Charges
6
7
Copay
9
MM/DD/YYYY $999,999.99 $99,999.99 Reason Codes: 15 Description of Service: 16 Claim Primary Payor Adjustment:
3
Coinsurance $999,999.99
$999,999.99
4
$999,999.99 $99,999.99 $999,999.99 the plan providing coverage.
Codes: AReason number generated to identify the claim. xxx1 xxx2 The date xxx3
the
Claim Number: Claim 2 Benefit Plan: Benefit Plan
Patient Responsibility
the provider submitting the 1 Names Claim claim Totals:for $999,999.99 services. $99,999.99 $999,999.99 Grand Totals: 2 Names
EOB Date:
Description EOB Description was generated. Description
10
Non-Covered
Deductible
$999,999.99
$99,999.99
11
3 Plan Disallow
4
Claim Processed: Amount Paid
5
Remarks
13
12 $999,999.99
$999,999.99
14 XXXXX 999
that is not eligible for payment under 11 An amount $99,999.99 $999,999.99 $999,999.99
$999,999.99 your
plan. Any explanation is noted in the Remark/ Reason$99,999.99 Codes. $999,999.99 $999,999.99 $999,999.99
12 The amount of money you pay before Network Health begins paying for services.
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13 The amount that Network Health paid your doctor. The date the claim was processed. Benefit Accumulator for Plan Year starting 01/01/9999 an explanation code. Details can be found on Plan Limit Applied This isRemaining 14 The date the service was provided. the last page of your EOB.
7
The total amount billed for the service. Out-of-Pocket Costs - OON
8
Breaks down your share of the original bill.
9
A fixed fee you pay for services.
5
Out-of-Pocket Costs
15
A code the provider uses to indicate the reason for Page 2 the service.
16 A brief description of the service you received.
10 The amount you pay for specific services. networkhealth.com
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life. health. wellness.
REMINDER– Schedule Your Annual Wellness Visit By Mark Geiger, quality health integration supervisor for Network Health
T
his is a great time of the year to schedule your 2019 annual wellness visit with your personal doctor. At this visit, you and your doctor will discuss your health history, medications, preventive screenings and immunizations. Annual wellness visits help you and your doctor understand your health risks and discover any new or developing conditions. Early detection can provide better outcomes, which ultimately saves you money. Because Network Health cares about maintaining and improving your health, the annual wellness visit is considered a preventive service and is covered at no cost to you. Your doctor may offer additional services during the annual wellness visit as a convenience to you, such as reviewing specific medical conditions, refilling medications and discussing concerns you have. It’s a good idea to bring up concerns as early as possible but be aware that these additional services may result in other charges or copayments. To avoid surprises, ask your doctor at the start of the visit what is covered as a wellness visit and what is not. Remember, an office visit copayment is much less expensive than an emergency room visit.
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My Doctor Visit Checklist It can be difficult to discuss certain topics with your doctor, especially if you’re concerned about costs. It’s important to address concerns as early as possible, because they may be the symptom of a larger issue.
Consider this guide for your next visit. I am experiencing the following. Persistent sad or empty feelings, lasting more than two weeks Falling, dizziness or instability Shortness of breath Excessive sweating More frequent bathroom visits Tingling of feet or hands Trouble with medication(s) Loss of or increased appetite Loss of or increased weight If you’re experiencing any of these issues, please share this information with your personal doctor. This can be the first step to feeling better.
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By Alice Parks, RN, BSN, JD, director population health for Network Health
D
id you know Network Health offers personal wellness, care management and condition management services at no cost to you? Our health management team is here to help put you in control of your health. Whether you’re seeking health advice or dealing with an unexpected health issue, a chronic disease or a complex diagnosis, we can help you manage your health to increase your sense of well-being. Health management begins with a one-on-one phone conversation between you and one of our health coaches, condition managers or care managers. If you choose to participate, your health coach or manager will work with you to meet your health goals. He or she can also assist you with the following.
If you need assistance quitting smoking, eating healthier, controlling blood pressure, or learning about easy ways to exercise, our health coaches will support your journey to a healthier life.
If you feel you could benefit from health coaching, condition or care management support or would like to learn more about our programs, call 866-709-0019 (TTY 800-947-3529), Monday–Friday from 8 a.m. to 5 p.m. Callers may leave a message 24 hours a day, seven days a week. You can also get more information about our programs by visiting networkhealth.com, select Medicare Plans and choose Wellness Programs. You may opt out of any program at any time by calling your health care concierge team at 800-378-5234 (TTY 800-947-3529).
Review your medications and treatment plans. Help you identify signs that your health condition is worsening and understand when to act, including when to contact your personal doctor. Work with your personal doctor to ensure they are aware of changes in your health.
Ensure you and/or your caregivers feel included in your health care decisions.
Help you maintain or improve your health by setting healthy goals.
Help coordinate care with your personal doctor and community services. Answer any questions you may have.
If you have diabetes, heart disease, heart failure, chronic obstructive pulmonary disease (COPD) or depression, our condition management team can provide educational resources specific to your diagnosis.
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COVER STORY
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The Real STRENGTH of a Man
By Romi Norton, Photography by Beth DesJardin, Trove Photography
You see the mailings that remind you to schedule your preventive screenings. Your doctor talks about the services that help maintain and improve your health. Even if you’re healthy, you should take action. That’s exactly what Network Health Medicare Advantage member Lee Hillstrom did, and it may have saved his life.
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life. health. wellness.
I
n 2008, Lee took advantage of a free screening for all the cancer. Every day you wonder what that test will prostate cancer. Even though he didn’t have any show,” says Lee. symptoms, he decided to have the screening because Lee journaled his experience over his seven and a half his brother had been diagnosed with prostate cancer. weeks of radiation treatments. “The conversations I had “That’s the thing with prostate cancer. There aren’t each day with the radiation therapists, the men I met in any early symptoms. Without the screening or the the waiting room and my own feelings were written in a uncomfortable doctor visit—you may not know.” Lee journal that I gave my cancer navigator,” says Lee. continued, “I wasn’t getting regular check-ups, I was a He continued, “I had a difficult time when my typical man. I felt great, no reason to worry. I never had treatments suddenly stopped. I wondered if the radiation any health issues.” worked and what would be next if it didn’t. My navigator The diagnosis left Lee with questions. “I thought to was nice enough to meet with me several times and asked myself, what could I have possibly done differently? So if I would be willing to meet with a cancer counselor. That many things ran through my mind, should I have eaten was a huge step for me, but I was willing to try.” more vegetables? I thought I ate well enough,” he laughed. According to his doctor, Lee wasn’t the typical prostate cancer patient. He and his wife Joy ate well, exercised and didn’t smoke or drink. He did have a family The mental battle is history, and men with an immediate a huge part of this relative with prostate cancer are twice as process. I show people likely to develop the disease. the Balancing Rx Lee decided on a surgical treatment Bracelet I got from my plan; he was determined to win his battle. counselor. Each color And he did—for a short time. His cancer stands for something returned in the fall of 2014. and helps me focus. In the spring of 2014 Joy experienced her own health scare—she had a heart attack while running on the treadmill. Lee says, “She called me at work and said she The counseling experience exceeded Lee’s expectations didn’t feel right. I came home and took her to the clinic. and helped him to discover a different way to live his life They did an EKG and that’s when they said she’s having a and change his priorities. After reading Lee’s journal and heart attack. She was taken to the hospital by ambulance.” working with him, his navigator and counselor asked him Like Lee, Joy didn’t fit the traditional heart attack to consider leading a prostate cancer support group. patient. She’s an avid runner and has run 26 marathons. “Here I was, someone who hated public speaking and Just a few months earlier, she qualified for the Boston had no medical background other than having been a Marathon—again. Joy sailed through rehab and was cancer patient twice. I had no idea what to do at a support cleared to run in the late summer. In September of 2014, group meeting. I did some research and started the Us Joy ran a half marathon, finishing sixth in her age group. TOO Fox Cities Chapter,” says Lee. When Lee’s prostate cancer returned, radiation was his In November of 2015, he hosted the first meeting. Lee only treatment option. Throughout his daily treatments and had low expectations at the beginning because it’s such with a 50 percent chance of success, Lee continued to be a difficult topic to talk about. The first night, 10 people optimistic. showed up and that number has grown to 48, depending on At that time, many of today’s technologies weren’t the topic for the meeting. available, and the list of side effects was quite lengthy. He “My chapter meetings are held at a fire station. The often looked at the list and wondered which ones he would neutral location allows us to have speakers from several experience. After radiation treatment, the waiting game local cancer centers around the area. I also think my began. “You have to wait three months to see if they got
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personal experience brings trust to the people that attend. I understand the fear and emotions cancer brings to men. This can make life difficult for us since we’re supposed to be in control and strong. I have learned that I am not weak by getting help. I share that message and help men understand they are brave and in control by seeking ways to make themselves healthy again. “The mental battle is a huge part of this process. I show people the Balancing Rx Bracelet I got from my counselor. Each color stands for something and helps me focus. It’s important to understand that mental health is another part of the body that needs to supported, not something to fear making you look weak. You have to take care of yourself and not worry about people who don’t walk in your shoes.” The goal of the support group is to offer help and educate members, ranging from those exploring treatment options to those who are in advanced stages of cancer. Some nights they learn from a guest speaker, some nights they learn from each other and other nights they celebrate with food and relaxation. “At our first Christmas party, I noticed one of our older members sitting by himself at a table. I went over and sat down to talk. I asked if he had enough food. He said he did and that it was wonderful. He then took my hands, looked me in the eyes and thanked me for giving him this opportunity. His wife had passed away and he wasn’t sure he would enjoy coming alone. Everything about the evening, including conversations with other attendees, helped him feel happy for a change, even though he was facing some difficult health issues of his own.” Lee’s desire to share his message and his encouragement for people to tell their own stories is the reason that the Fox Cities Chapter is so successful. “I really enjoy speaking privately with the man with cancer and his family members because they are all affected. They have so many questions about what to do, treatment options, and potential side effects. We’ll sit and talk for hours to go over everything. I don’t tell them what to do; I just tell them what I have gone through and what others have gone through. They find comfort in hearing from people with similar experiences.” Lee’s opportunity to support others took another turn last year when Joy learned she had breast cancer. Joy made the decision to have surgery for her cancer and the weekend before her surgery, she ran a half marathon.
Joy’s surgery went well, and she attended her granddaughter’s soccer game the same day. Lee says, “I have learned to never underestimate my wife. She can do anything.” Through all of this, medical bills have never been a concern. “You hear about people losing their homes or declaring bankruptcy because of medical bills, yet we have been very happy with how Network Health has helped and protected us. Being on Medicare gives us the opportunity to change health insurance each year, but because we are treated well and charged a reasonable premium, we keep coming back.” Lee continues to run his support group and looks for other ways to help the community. “I am looking forward to spending time with my family, getting more exercise and doing more work with cancer. I want to start another support group to cover more than just prostate cancer and/ or host an all cancer symposium. “As you age, sometimes you wonder if there is purpose to your life. Is there a reason you are here, and will it benefit others? Cancer is a life-changing experience and can be extremely difficult at times. It also allows you to appreciate what you have and to share what you have learned with others. Lee shares some final thoughts, “How much one person can do, no matter how small an act of kindness or support for someone with cancer is never insignificant. Men need to get over being afraid of shame and embarrassment. Don’t be afraid to seek help in all the ways that are available. The help for both physical and emotional needs should not be ignored.”
To find an Us TOO support group near you visit
www.ustoo.org/Support-Group-Near-You/United States/Wisconsin. networkhealth.com
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life. health. wellness.
The Talk:
Advance Care Planning – Why It Matters to Have It Now By Alice Parks, RN, BSN, JD, director population health for Network Health
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ational Health Care Decisions Day is April 16. Mark your calendar to share your advance care plan with your family and loved ones. This day exists to educate and empower the public and providers about the importance of advance care planning.
What is advance care planning?
You may not have heard of advance care planning, but it affects each of us. It’s a way for you to plan and make decisions now, to guide your health care in the future if you are ever unable to speak for yourself or make your own decisions.
Why is advance care planning important?
Usually, only you can make important decisions about your health. There are situations where you may not be able to do so, such as an accident or illness that causes confusion or affects your ability to communicate your wishes to your health care team. It’s hard to think about that type of situation, but if it were to happen, who would you want to make health decisions for you? And how would that person know what your wishes are? The talk about advance care planning helps prepare your health care providers and the person you choose to make your health care decisions by discussing what is important to you and what you value in life. It allows you to decide the care you want to receive if you become unable to speak for yourself. You can leave instructions that take your values and preferences into account and eliminate uncertainty for your doctors and family members. Advance care planning instructions can give peace of mind to you, your family, and those making important decisions on your behalf.
When is the ideal time to have the talk?
You may not need to use the advance care plan for a while, but it’s important to have a plan. The best time to talk about it is when you feel well and can clearly state 20 | C oncierge
your wishes. Like a retirement plan, things can change, so you might need to revisit it occasionally and have further discussions with your personal doctor and family. Remember, your advance care plan is only used when you are unable to make your own health care decisions. At that point, your appointed decision maker will reference your wishes, values and beliefs before making health care decisions on your behalf.
How is advance care planning different than an advance directive?
The two are related, but an advance directive is different than advance care planning. An advance directive is a legal document that becomes effective if you are incapacitated and unable to speak for yourself. Advance directives include the following. A living will – This allows you to specify whether or not you would like to receive emergency treatments, such as CPR, artificial nutrition or hydration, use of ventilators or comfort care, that could be offered if you are dying or permanently unconscious. Durable power of attorney – A durable power of attorney allows you to name a health care proxy—a person who knows your wishes and will make treatment decisions for you if you are unable to do so. Do not resuscitate (DNR) or do not intubate (DNI) orders. We recommend regularly reviewing and updating legal documents. Make sure to discuss any changes with your personal doctor and family.
Want more information?
Talk with your personal doctor, a social worker or call a health care concierge at 800-378-5234 (TTY 800-947-3529) and request to speak with a care manager. networkhealth.com
Transition of Care By Alice Parks, RN, BSN, JD, director population health for Network Health
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oing home from the hospital can be overwhelming, whether your hospital stay was planned or unplanned. Network Health is here to support you with a smooth transition by making sure your needs are met. This can reduce the chances you’ll return to the hospital. You may have a new diagnosis, treatment or other changes in your health that affect your ability to manage your condition. Since you are the only constant in your health care journey, it’s important for you to have the right tools.
What can you do to ensure a safe and effective transition from the hospital to home? Always ask questions any time you’re unsure of instructions or what you should do. Know which medications—both prescription and over-the-counter medications—you should continue to take and which you should stop. It can help to think about medications you took before you went to the hospital and medications that were started while you were in the hospital. Properly dispose of any medications you no longer need. Ask for a written list of medications, any changes that were made and potential side effects. Ask the hospital pharmacist to review the list with you before you leave the hospital. Know which doctors and health care providers you need to follow up with. Be sure to schedule and keep the appointments. Find out if you will be notified of test results or if you need to schedule any additional tests. Understand if any special arrangements are needed. This could include home care nurses, therapists or networkhealth.com
medical equipment. The hospital case manager or discharge planner will help set up any service(s) you may need. He or she should also let you know how to contact the home care providers or when they will contact you. Discuss which warning signs may indicate your health is taking a turn for the worse, what you should do, which doctor(s) to call and how to contact them. Examples of warning signs include worsening pain, swelling, changes in memory, thinking or behavior. Keep your own health records with a copy of your current medications, doctors you see and other important health care information. You may also want to track your weight, blood sugar or blood pressure, if necessary. Have a family member or someone you trust help you with care at home, transportation to doctor visits, meal preparation and other daily tasks if needed. Call your Network Health care manager if you need help arranging care or have questions about your insurance or resources available. You can reach care management by calling the health care concierge team at 800-378-5234 (TTY 800-947-3529). 21 C oncierge | 13
life. health. wellness.
Don’t Let Running to the Bathroom Run Your Life By Michele Eggers, RN, BSN, quality improvement coordinator for Network Health
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oss of bladder control, also known as urinary incontinence, is a common problem. Symptoms may include leaking urine during normal activities or having to go urgently or often. Although you may feel embarrassed about these symptoms, it is important to talk with your doctor about any bladder control issues you experience.
Types of urinary incontinence Stress incontinence – Urine leaks when coughing, sneezing, laughing, exercising or lifting something heavy Urge incontinence – Having a sudden urge to urinate or needing to urinate often, including through the night Overflow incontinence – Frequent or constant dribbling of urine caused by not completely emptying the bladder Functional incontinence – Physical problems that make it difficult to get to the bathroom in time or get clothing off in time Mixed incontinence – Experiencing more than one type of urinary incontinence
Causes of urinary incontinence
Certain drinks, foods and medications may cause an increase in urine production Easily treatable medical problems such as urinary tract infections or constipation
Physical changes such as pregnancy, childbirth, aging, menopause, hysterectomy, prostate problems or neurological disorders Being overweight or smoking
Why it’s important to see your doctor if you experience urinary incontinence It may affect your daily activities and prevent you from spending time with family and friends It may prevent you from getting a good night sleep It may increase risk of falls if you are rushing to the bathroom It may indicate a more serious problem Urinary incontinence is a symptom, not a disease. Discussing symptoms and treatment with your doctor and having a thorough evaluation can help determine the cause and may resolve your symptoms.
Sources: https://www.mayoclinic.org/diseases-conditions/urinary-incontinence/symptoms-causes/syc-20352808 and https://medlineplus.gov/urinaryincontinence.html 22 | C oncierge
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Network Health Makes Decisions Based on Appropriateness of Care Prior authorization process ensures members receive best care possible
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ealth care treatment options are always evolving, and there is often more than one type of service that can be effective in managing your health care or treating your condition. With so many choices available, Network Health ensures that you receive the best care possible by requiring your doctors to seek approval for certain types of care and services. Care and services might include medical procedures such as surgery, behavioral health procedures such as therapy, medical devices like wheelchairs or prescription drugs. Network Health stays up-to-date on the latest treatment options available. Our utilization management team makes prior authorization decisions based on the right type of care or service for each individual case. We want you to receive the right care, at the right time and in the right medical setting. Our doctors and nurses review each request considering only the appropriateness of care and the benefits covered in your plan. This way, members benefit from high-quality medical care and cost-effective treatment plans. These authorization decisions are made using written criteria that is based in clinical evidence such as medical research or trials, peer-reviewed studies or proven medical practices. Written criteria are reviewed and approved annually by doctors who actively participate in the health plan. You can find the written criteria outlined in your benefits and plan coverage documents. The criteria are also available upon request to doctors, practitioners and members/participants. Network Health does not reward decision makers (practitioners or other individuals) for denying coverage, nor do we use incentives to encourage barriers to care or service. Network Health does not make employment decisions based on the likelihood that an employee might support denial of benefits. Decision makers for utilization management receive no financial incentive
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nor encouragement to make decisions that may result in underutilization. Network Health also does not prohibit treating doctors from advocating on behalf of members/participants within the utilization management program. In fact, we encourage treating doctors to seek peer-to-peer review of cases when they believe a treatment option should be reconsidered or reviewed for medical necessity. Treating practitioners may discuss medical necessity denial determinations with the physician review medical director by contacting us at the numbers below. Medicare: 920-720-1602 or 866-709-0019 (TTY 800-947-3529). For questions specific to behavioral health utilization, call 920-720-1340 or 800-555-3616 (TTY 800-947-3529). Callers have the option to leave a message, 24 hours a day, seven days a week. Messages are retrieved at 8 a.m., Monday through Friday, as well as periodically during the business day. All calls are returned promptly. Calls received after business hours are returned the next business day. Members, practitioners and/or providers may also send inquiries to the care management department via fax, courier system and U.S. mail. You can fax the Medicare care management department at 920-720-1916. Requests for criteria can be submitted via telephone, fax, electronically or U.S. mail. Once the request is received, care management associates send the requested criteria via fax, electronically or U.S. mail. C oncierge | 23
PRESORT STD US POSTAGE PAID GREEN BAY, WI PERMIT NO. 1033
1570 Midway Pl. Menasha, WI 54952 NE
Get Social (For Real) W
e want you to venture out and explore the real world. Below, you will find a brief highlight of special events in our community. For more outdoor fun, follow Network Health Wisconsin on Facebook.
WHEN April 28 May 4 May 4 May 5 May 11 May 16 May 18 May 19 May 25 May 25
WHAT Oshkosh Half Marathon, Relay and 5k www.visitoshkosh.com/events/oshkosh-marathon-half-marathon NAMI Oshkosh 5k for Mental Health and Suicide Awareness www.namioshkosh.org/5k-run-walk
WHERE
Spring into Style, Ladies Day www.appeltondowntown.org/upcoming-events
Downtown, College Avenue Shops Appleton
Sweet Home Green Bay 5k www.runsignup.com/Race/WI/GreenBay/SweetHomeGreenBay5k Sole Burner 5K Walk-Run www.community.acsevents.org/site/TR?pg=entry&fr_id=93946 Buddha Bowls Cooking Workshop www.nutritionalhealingllc.com/community/ Cellcom Green Bay 5k www.cellcomgreenbaymarathon.com/cellcom-5k/ Cellcom Green Bay Marathon, Half Marathon www.cellcomgreenbaymarathon.com/half-marathon/ Casco 5k/10k Run, 5k Walk - www.cascorunwalk.com Sam I Am. Tumors I Do Not Like Them Run Walk www.littlesttumor.org/events/sam-tumors-not-like-run-walk/
Thursdays Lunchtime Live! Concerts May 30– www.appletondowntown.org/upcoming-events August 29 Thursdays Heid Music Summer Concert Series May 30– www.appletondowntown.org/upcoming-events August 29 June 8 Bellin Run 10k, 5k Walk - www.bellinrun.com June 8 Elkhart Lake Triathlon - www.eklhartlake.com/events/ June 9 HFM Maritime Marathon - www.maritimemarathon.org Saturdays Downtown Appleton Farm Market June 15– www.appletondowntown.org/upcoming-events October 26 Listed events are accurate at the time of printing.
Oshkosh Oshkosh
Green Bay Appleton Nutritional Healing, Appleton Green Bay Green Bay Casco Appleton Houdini Plaza, Appleton Downtown Appleton Green Bay Elkhart Lake Manitowoc College Avenue, Appleton
Network Health Medicare Advantage Plans include MSA, HMO and PPO plans with a Medicare contract. NetworkCares is a PPO SNP plan with a Medicare contract and a contract with the Wisconsin Medicaid program. Enrollment in Network Health Medicare Advantage Plans depends on contract renewal. H5215_1550-03-0319_C