Health
A Publication for Teachers Health Trust Participants
raxx
Fall 2016 │Volume 15, Issue 3 For Teachers by Teachers
when you speak THE TRUST LISTENS
understanding VOLUME 15, ISSUE 3
THE PATIENT-CENTERED MEDICAL HOME
open enrollment WHAT YOU NEED TO KNOW
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FALL 2016 | HEALTH TRAXX TEACHERSHEALTHTRUST.ORG
contents FALL 2016
VOLUME 15, ISSUE 3
16
7
12
in this issue LETTERS 4 BOARD OF TRUSTEES 5 FROM THE CEO
FEATURES 6 BACK TO SCHOOL
We started the school year off on a healthy note!
8 AUTUMN ANXIETY
Why our mood sometimes falls along with the leaves.
10 WHAT’S YOUR RISK?
20 OPEN ENROLLMENT 2017
12 PATIENT-CENTERED MEDICAL HOME
22 PROSTATE HEALTH
How to protect yourself against breast cancer.
Everything you need to know for Open Enrollment.
A handy infographic for men.
How does the PCMH work?
23 PRIOR AUTHORIZATION
How the Trust spent its summer.
24 UNDERSTANDING AUTISM
14 THE TRUST LISTENS 16 OVARIAN CANCER
Learn early symptoms and risks.
Which procedures require prior authorization.
A handy guide on diagnosis and early signs.
19 PREMATURE BABIES
November is National Prematurity Awareness Month FALL 2016 | HEALTH TRAXX TEACHERSHEALTHTRUST.ORG
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LETTERS
FROM THE BOARD
Health Traxx is published quarterly by the Teachers Health Trust to help participants make life-saving decisions about health care. Although editorial content is based on sound medical information, we ask that you consult a health care professional regarding all medical concerns. We encourage you to keep copies of this news publication for the purpose of building a handy home medical reference guide or to recycle issues to friends and family. Any opinions expressed by an author/source whose article appears in this publication are solely the opinions of the author/source and do not necessarily reflect the views of the Trust. If you have questions or comments regarding this issue, e-mail the Trust at wellness@ teachershealthtrust.org, or write to Teachers Health Trust c/o Philip DiGiacomo, P.O. Box 96238, Las Vegas, NV 89193-6238.
CHAIRPERSON Michael Steinbrink VICE CHAIRPERSON Isela Stellato BOARD OF TRUSTEES David Tatlock Jodi Brant Cindy Johnson Molly Lehman Kerri Martinez Najera Cynthia Rapazzini Vikki Courtney, CCEA President CEO Gary Earl DIRECTOR OF COMMUNICATIONS Philip DiGiacomo ADVERTISEMENTS
This publication is made in part by the generous donations of network providers and non-profit community organizations. Individuals or companies interested in advertising opportunities in Health Traxx should contact Philip DiGiacomo, Director of Communications, at wellness@teachershealthtrust. org or contact the Teachers Health Trust Wellness Division at (702) 866-6192. An advertisement in the Health Traxx publication does not mean the Trust endorses the provider or service. Ad purchase space is based on a first-come, first-served basis, and advertisers are preferred to be a part of the Teachers Health Trust Provider Network. Other organizations, such as non-profit local or national health agencies or for-profit companies with a valid business license, may advertise once approved by the Teachers Health Trust Special Events Committee.
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FALL 2016 | HEALTH TRAXX TEACHERSHEALTHTRUST.ORG
What Constitutes Progress For Our Healthcare? The fall session is now in motion and the majority of you, like us, have been completely absorbed in all of the tasks and needs that come with getting our classrooms fully operational. For most of us, though, as hard as we may try, the first day of class always seems to come with a few more tasks to complete and a few more challenges to overcome before we can truly feel that we are ready to take on the school year. I believe that it is fair to say that we never quite get our classrooms to a point that we perceive as being 100 percent ready. I further believe that this is because we are all striving to improve a little more, to continue to make progress. It is in our nature. It is part of the DNA that creates strong teachers. The need to continue to work towards greater progress is likely what brings many of us to a point that we accept the responsibility of sitting as one of your trustees. It is rarely easy and, at times, seems like it is full of tasks that can never fully be completed. We are fortunate, though, in that we can be a driving force in the task of progressing our healthcare plan in a direction that benefits us all. The question that now arises is just what constitutes progress for our healthcare? I know we can all agree that the current plan needs refinement. That being said, when you look back over the last 12 months with a discerning eye, it is difficult to not see the great strides that we have made. Just one year ago, we were facing across-the-board coinsurance increases coupled with the imminent closure of our Trust, thus faced with the likely possibility of being forced into a for-profit carrier. We need to look no further than our colleagues in the Support Staff to recognize the perils that move would have wrought. Indeed, just one year ago, it appeared that all we have built was in danger of dying. But here we are, by no means at the finish line, yet miles ahead of where we were: • Our Trust has stabilized both operationally and financially. • Our new CEO has established a direct line of communication, both personally and via his executive team, with any participant who wishes to engage with him. • The network is now being expanded with month-over-month net additions. • The prescription benefits are being revamped to decrease out-of-pocket costs and improve access. • Resources and technologies, such as Population Health Management and Telemedicine, are finally bringing us into the modern age of health and wellbeing. Our plan’s progress, like our classroom, is never truly complete. We have challenges before us that we must overcome as well as lingering concerns that must be addressed. At the end of the day, though, our Trust is working diligently, under our watchful eyes, to keep improving our insurance plan. Every day, we get better, and stand firm in the knowledge that we are among the best. We encourage each and every one to take part in the conversation, make yourself heard, and be part of the progress. Michael Steinbrink, Chairman Board of Trustees Teachers Health Trust
Message from the CEO
Gary Earl
Health and Economic Improvement – Our Single Focus and Commitment to You In my inaugural letter to you for the June edition of Health Traxx, I shared a brief overview of both the opportunity as well as the challenges that have arisen while implementing a complex system-design renovation and transformation project at the Trust. I also openly expressed that, although change was needed and necessary, our levels of success and measurable evidence of positive outcomes were far from being felt. Knowing as well that systemic change engages the entire system, I invited your important voice, that of the consumer and customer, the teacher and your family into the process as an essential partner in the transformation process. I am delighted to report that I have heard from hundreds of people since the initial launch who have each made a momentous contribution toward our journey en route to success and significance. In this, the fall edition of Health Traxx, I am pleased to report that you will be exposed to a number of very encouraging, positive and validated updates on our progress; updates that not only speak to the assiduous efforts of the Trust and partner teams, but also to the measurable and meaningful results that are occurring and emerging each and every day. The re-engineering projects that were launched in this year’s late winter and early spring season have taken root and begun to flourish over the summer season. The Trust has quickly evolved and surpassed our initial projections and is rapidly maturing, providing our leadership with a certain confidence that the Trust is on track to not only meet, but exceed expectations, resulting in improved benefits that you and your family have earned. A sampling of success is charted below:
Performance Category
February 2016
August 2016
Member Service Speed to Answer Calls
> 60 MINUTES
24.3 SECONDS
Abandoned (Lost) Calls
42+%
7.3%
Provider Claim Payments
26,285
47,054
Negative
Positive
Financial Position
Above and beyond our commitment and success of improving on the core basics of service delivery and operational excellence, the Trust has made significant gains in improving our ability to communicate and educate through our new website (www. teachershealthtrust.org) and newly established Communications Committee. We have also made additional investments in the important areas of health maintenance and condition improvement via our Population Health, Telemedicine and Medical Management processes and programs. The Trust has worked to improve access to qualified and quality-based health professionals and has been successful at expanding both provider and hospital network access in not only Las Vegas, but the important neighboring communities of Mesquite, Laughlin and Bullhead City, Arizona. Along with our strategic partners, we have also tactically and successfully achieved our goal of creating innovations that will ultimately, and in the very near future, enhance the existing programs, including our pharmacy benefit program, thus providing you and your family with additional benefits at more affordable costs. These are but a sampling of the many enhancements that are being made on your behalf and a brief glimpse into how the Trust staff and its partners spent our summer. Despite our recent and significant success, admittedly, we still face a number of challenges and have obstacles yet to overcome. However, we have momentum on our side, a solid and innovative strategy to guide us forward as well as a collection of committed, dedicated and passionate colleagues and partners who embody a daily focus on one goal – impacting and improving the health and economic conditions for our valued teachers, their families and the communities we serve. It is an honor to play a role in the process, to serve with such a troop of wonderful people, and to be able to live a life of purpose in our servanthood to you. On behalf of our family at the Trust and our most valued partners, we wish you a productive, successful and healthy fall season.
Gary Earl, CEO GEarl@teachershealthtrust.org
FALL 2016 | HEALTH TRAXX TEACHERSHEALTHTRUST.ORG
BACK TO SCHOOL
FEATURES
6
Teachers Health Trust participants started the new school year off on a healthy note at the Back to School Health Fair on August 6 at the University of Nevada, Las Vegas Student Union Ballroom. Nearly 30 health and wellness vendors from multiple specialties were at the event, handing out information on how the whole family can stay healthy, happy, and active throughout the school year. In addition to all the vendors, Trust CEO, Gary Earl, lead an informative panel discussion that included Dr. Lisa Lyons from WellHealth Primary Care, fielding health and illness-related questions; Brenda Masterson-Brodie, MSW, LSW, CSW-I from Human Behavior Institute, answering behavioral and psychological questions; Alissa Dougherty, MS, RD, LDN from WellHealth Endocrinology, answering questions from a dietary perspective; Adam Volker, Manager of Health Advocacy at WellHealth Quality Care, answering questions regarding healthcare advocates and telemedicine; and Isela Stellato, a CCSD middle school teacher sharing tips and tricks on how to stay organized throughout the school year from a teacher’s perspective. The event ended with more than 40 participants winning prizes to local restaurants, hotels, and family fun businesses. Additionally, 16 teachers were chosen to participate in the inaugural Shop with a Teacher and received a gift card to purchase supplies needed for their classrooms for the upcoming school year.
FALL 2016 | HEALTH TRAXX TEACHERSHEALTHTRUST.ORG
shopwith a teacher Sixteen Clark County School District teachers had the shopping spree of a lifetime before the school year started at the inaugural Shop with a Teacher on Wednesday, August 10 at the Office Max on Fort Apache and Tropicana.
Each teacher at the event received a $500 gift card to purchase school supplies needed for a successful school year, including paper, writing utensils, art supplies, tablets and more. Each participant won their spot for Shop with a Teacher at the Back to School Health Fair on Saturday, August 6. “We are so very proud of the incredible level of passion and commitment that our community educators and our Trust partners bring to the classroom and our students,” remarked Trust CEO, Gary Earl. “Working alongside WellHealth and the many additional community investors, we believe that we will improve not only health and economic conditions in Southern Nevada, but educational outcomes as well.” A special thanks to our wonderful sponsors who made this event possible, including WellHealth Quality Care, Steinberg Diagnostic Medical Imaging Centers, Quest Diagnostics, Truman Orthodontics, Desert Springs Dental Care, HCA Healthcare, and Las Vegas Woman Magazine.
FALL 2016 | HEALTH TRAXX TEACHERSHEALTHTRUST.ORG
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autumn
ANXIETY
Why does our mood fall along with the leaves and what can we do? By Brenda Masterson-Brodie, MSW, LSW, CSW-I
A
re you tired, restless, on edge, irritable, or maybe even find yourself not wanting to socialize and enjoy life? Are you rationalizing to yourself that your low mood and weight gain are simply a result of your busy schedule? Don’t brush these symptoms off! They could be indicative of a condition referred to as Seasonal Affective Disorder. It’s not a coincidence that the acronym for Seasonal Affect Disorder is SAD. Many refer to this time of year as Late Fall Lethargy, or the Winter Blues. But, your low sad mood, decreased energy, sleeping difficulties, sluggishness, lack of concentration, agitation, body aches and pains, and craving for carbohydrates are not necessarily a result of your busy, back-toschool schedule. But, rather warning signs that you could be experiencing a mood or anxiety disorder. Ask yourself, “Is my melancholia or bluish attitude getting in the way of my life? Am I having trouble getting through the day, connecting with others, tired all of the time, and perhaps packing on some pounds? Have people told me that I’m coming off as hypersensitive or reactive, and that I haven’t been myself lately? Have I been experiencing these symptoms for a long time?” If so, your Autumn Anxiety or Winter Blues may actually be a Seasonal Affective Disorder (SAD) such as Major Depressive Disorder (MDD) and/or an anxiety disorder referred to as, Generalized Anxiety Disorder (GAD).
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It is common around this time of year for people to feel stressed with schedules, getting the children off to school, coping with poor weather conditions such as gray skies, rain, wet leaves, and the natural pruning of our once, beautiful, plush outdoor scenic landscape. Instead, we’re left with puddles, sticks, crumbling, dead leaves and windrelated allergies. Autumn reminds us of the cycle of life. In order to see the growth that comes from the sun, we must also see the loss that arrives with the cold. Autumn also provides us with a lens, or sneak peek, of what’s to come. The fall and winter are full of festive gatherings, sugary snacks, gifts galore and quality time spent with family. However, these happy moments are not always full of bliss for those who are isolated, disconnected, detached from family, or who constantly struggle with their mental and emotional health. For these individuals, fall and winter are a magnifying glass for what should have been, could’ve been, and still should be. This emptiness fills the waiting rooms in therapy and psychiatry offices alike. Clients report that they feel a sense of helplessness, hopelessness and purposelessness in their lives. Therapists often hear things like, “I don’t know what’s wrong, but I don’t see it getting any better. I just want to be alone. There is no sense in leaving my house, as I have nowhere to go, and no one to go to.” The holidays of the season are not happy for all. They are glaring reminders of the
emotional voids, which have yet to, or may never be filled. It’s hard to believe that these deep, psychological and emotional feelings can be triggered by a change in season. Yet, it is also impossible to ignore the emotional dysregulation that we see all around us during the fall and winter months. In particular, children often become attention seeking, behaviorally disruptive and are easily frustrated with the normal, daily routine. These children are often referred to psychiatric practitioners for impulsivity disorders, ADHD and/or Oppositional Defiant Disorder. However, our children don’t always have the words to describe how they feel, so they show us through their behavior. Adults become more agitated, easily annoyed, fatigued, gain weight, and make somatic complaints that their arms and legs feel leaden. Since psychiatric symptoms often present in a physical form, an adult may receive a diagnosis of Fibromyalgia, Chronic Fatigue Syndrome, or an unknown/ unfound demyelinating disease by a primary care provider. However, the truth and root of these symptoms for both children and adults can be, and usually is, our deeply embedded, unmet, psychological and emotional needs. Fall and Winter Seasonal Affective Disorder is a possible result of unaddressed and potentially ignored mental health symptoms
FEATURES
that have manifested into a physical form. It is easier to talk about aches, pains and weight gain, than to talk about the emotional emptiness and isolation that many experience during the dark and cold seasons. The good news is that there are things you can do to maintain your mental and emotional health during the fall and winter.
Make sure to get a healthy dose of sunlight.
carbohydrate cravings is that we don’t recognize them as a symptom of SAD. Unfortunately, by the time we realize that our mood is low, and we’ve lost interest in once enjoyable activities, we’ve gained ten to fifteen pounds! Stick with colorful foods. Take a chance and fill your stomach with sweet potatoes, pumpkin, apples, pears and figs; all available during this season!
Clinicians refer to this as phototherapy, as sunlight is imperative to maintain the healthy brain chemicals needed to enhance mood. Become an early riser! Take long walks, go to the park, but try to spend at least two hours per day outside, even when it’s cloudy! Meditate or join a yoga class. Exercise helps our brain to release dopamine, which is why it is commonly known as a natural antidepressant.
Holistic approaches to healthy lifestyles are wonderful and easily accessible. However, if your Autumn Anxiety and/or Winter Blues do not dissipate along with the implementation of positive lifestyle changes, it is time to see a clinician for a comprehensive mental health assessment to rule in or out a possible mood or anxiety disorder.
Avoid alcohol and carbohydrates.
If your tiredness, low mood, irritability, hypersensitivity, physical complaints and carbohydrate cravings have persisted for two or more weeks, it is time to meet with a doctor and/or a therapist. Early intervention is essential and results in positive outcomes. Unaddressed symptoms of Seasonal Affective Disorder (SAD) can lead to suicidal thoughts or behavior, social withdrawal, school and work performance issues and substance abuse. Please seek help; it is never too late to seek assistance!
Alcohol is a central nervous system depressant. The initial feel-good effects of alcohol do not last. You may think you feel better, more relaxed, less tense, but the alcohol is actually worsening your mood and disabling your brain’s natural ability to secrete the amino acids required to elevate mood. Carbohydrates are a great, quick fix for low energy. We crave them when we experience lethargy and exhaustion. Carbohydrates produce tryptophan, which is the precursor to the production of serotonin, which elevates mood. The problem with
Follow the two-week rule.
BRENDA MASTERSON-BRODIE is the Clinical Social Work Intern, Clinical Intake Supervisor, & Community Liaison at the Human Behavior Institute in Las Vegas and was a panel member at the Back to School Health Fair. She holds a bachelor’s degree in psychology and a minor in ethics & philosophy from Clark University in Worcester, Massachusetts, where she was a merit scholar and a teaching assistant in the philosophy department. In 2003, she completed her master’s degree in social work/welfare at Stony Brook University in New York. While at Stony Brook, Brenda was awarded two graduate research assistantships as well as bestowed the Reginald C. Wells Fellowship. She works with children, adolescents, and adults with emotional and behavioral dysregulation. She completes diagnostic mental health assessments and provides therapy and crisis intervention to individuals, couples, and families.
FALL 2016 | HEALTH TRAXX TEACHERSHEALTHTRUST.ORG
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FEATURES
what’s your risk for
?
breast cancer About one in eight women in the United States will develop breast cancer over the course of her lifetime.
While breast cancer has one of the most successful survival rates, many providers urge women to understand it has such a high rate of survival because women are educating themselves and taking the steps they need to catch a potentially life-threatening disease in the early stages.
Know Your Risk Getting Older The risk of breast cancer increases with age; most breast cancers are diagnosed at or after the age of 50. Genetic Mutations Inherited changes in certain genes, such as BRCA 1 and 2 in women have an inherited risk of breast or ovarian cancer. Family History If someone in your immediate family (mother, sister, aunt, etc.) on your mother’s or father’s side has had breast cancer, you are at a higher risk than most. Taking Oral Contraceptives (Birth Control Pills) Certain forms of oral contraceptives have been found to raise the risk of breast cancer. Late or No Pregnancy Having your first pregnancy after the age of 30 and never having a full-term pregnancy can increase your risk for breast cancer.
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Not Being Physically Active Aim for 30-minutes, five-times a week. Personal History If you have had breast cancer, you are more likely to get breast cancer for the second time.
Recommended Screening Guidelines Mammography The most important screening test for breast cancer is the mammogram. A mammogram is an X-ray of the breast. It can detect breast cancer up to two years before you or your doctor can feel the tumor. • Women age 40 or older with an average risk of breast cancer should have a mammogram once a year. • Women at high risk should have yearly mammograms along with an MRI starting at age 30. Monthly At-Home Self Checks After your first menstrual cycle, performing monthly at-home selfchecks can increase your ability to catch abnormalities in your breasts, which can increase your survival rate if caught early.
5 THINGS YOU NEED TO KNOW ABOUT
3Dmammography
There is so much information out there today regarding screening mammography that it’s difficult to know what to do. And with the recent introduction of 3D mammography into the picture, now there’s one more thing to consider. So we thought we would try to help clear up the confusion and give you the facts about this new technology.
40% increase in Cancer Detection
Not all 3D is the Same
15% Decrease in false positives.
Are You Dense?
Need we say more? As a stand-alone statistic, this really says it all. 3D Mammography, or Digital Breast Tomosynthesis, is a breakthrough in breast cancer detection. When combined with standard 2D mammography, studies show up to a 40% increase in breast cancer detection as compared to using 2D mammography alone. This is a game-changer for women, especially those who have already been diagnosed with breast cancer and will need more frequent screening, and added peace of mind.
A false positive is when a study is interpreted as showing an abnormality when in reality the study was normal. Tomosynthesis is an especially effective screening technique for women with dense breast tissue, and has demonstrated a reduction in false positives by approximately 15 percent.
10% Decrease in subsequent imaging.
Because standard 2D mammography is not as accurate as 3D, patients are called back to conduct additional exams such as breast ultrasounds, breast MRI and breast biopsies. As a patient, when you get that call to say that you need to come back for further testing, it causes a great deal of stress and anxiety. 3D mammography has been shown to decrease these stressful subsequent exams by 10 percent.
When evaluating the different 3D technology, one brand stood out – the GE SenoClaire system. Only GE’s system delivers a screening mammogram with no more radiation than standard 2D mammography. Unlike the Hologic “Genius” system, GE’s SenoClaire 3D exam is conducted simultaneously with the 2D mammogram, so it delivers NO more radiation than your previous 2D digital mammogram, and only takes a few minutes more. In this case, LESS is definitely MORE!
Forty percent of women in the U.S. have dense breast tissue. And dense breast tissue is the Achilles heel of standard digital mammography. Dense tissue shows up as white on a mammogram, as does cancer. 3D mammography overcomes this issue in the way that it creates the images. As the scanner sweeps over the breast in an arc, it takes the images (called slices) of the breast from all different angles, making it harder for cancer to hide. This greatly enhances our radiologists’ ability to detect abnormalities and identify suspicious structures in the breast more easily.
Still not sure if 3D Mammography is for you?
Don’t hesitate to call us with your questions, or get more information at: www.sdmi-lv.com/3Dmammogram. 3D mammography is available at all seven Steinberg Diagnostic Medical Imaging locations. Physician referral required. Call (702) 732-6000 to schedule yours today.
FALL 2016 | HEALTH TRAXX
Sponsored by Steinberg Diagnostic Medical Imaging TEACHERSHEALTHTRUST.ORG
your
PATIENT-CENTERED MEDICAL HOME Seeing The Whole You
Design & Purpose of the Home Each individual’s healthcare needs are unique. Whether you visit the doctor only when you are sick, once a year for an annual exam, or a lot more often for more complex healthcare concerns; healthcare as a whole can be difficult, complicated, and frustrating. Most teachers know how hard it can be to get an immediate appointment, let alone the struggle of seeing a provider altogether. You take time off from work just to sit in a waiting room for a rushed 10 minutes with your provider. To add to this, if you have to go to the emergency room or a specialist, no one provider knows what the other is doing; They’re all just looking at a piece of you, and no one sees the whole picture. Understanding these challenges, the Patient-Centered Medical Home (PCMH) was created to rein in costs, coordinate care, and improve outcomes and overall satisfaction for insurance companies, providers, and participants alike. Endorsed by the American Academy of Family Physicians, the American College of Physicians, the American Academy of Pediatrics, and the American Osteopathic Association, the PCMH connects patients to a Primary Care Physician (PCP) that is responsible for working together with the patient and other care team members comprised of whoever you need, and this team changes as your health changes. With this model, Electronic Health Records and Electronic Referral Management systems help to coordinate your care and keep your providers connected. The PCMH places your total medical care into the hands of your caregiver as well as yourself, resulting in a healthy and active relationship with your PCMH provider. The goal of the PCMH is to provide seamless and coordinated care in order to help patients navigate an increasingly complex healthcare system. The model aims to drive patient-centered care as opposed to the traditional doctorcentered model, which means that providers are encouraged and incentivized to focus on more thorough care rather than volume of patients seen, and to provide better and more timely access to care.
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Additionally, virtual care allows for 24/7 access to care from the comfort of your home or anywhere you may be, and WellHealth Healthcare Advocates can assist in scheduling same-day appointments for you during a crisis. Patient-centered care is not just about providing care when you need it, but also about preventing problems so you stay healthy. Participants are encouraged to become engaged with their providers and become partners in their care before emergencies arise. Annual exams and needed vaccinations are encouraged, and family history and chronic illnesses are taken into consideration to create a more holistic picture, so you and your provider can make informed decisions together regarding your care. Those with chronic illnesses, such as asthma, diabetes, high blood pressure, and even high-risk pregnancy are incentivized through lowered copayments to see their providers more often in order to reduce risk. For further information regarding co-pays and the PCMH, please refer to the Copay & Coinsurance Overview found in the Performance Plus Plan Document.
How & When to Choose / Change Your PCMH Provider All participants are required to select a PCMH provider, which is a PCP for adults and a Pediatrician or Family Doctor for children/families. These providers are typically listed under the specialties of Internal Medicine, General Family Practice, or Pediatrics. When you select your PCMH doctor, you are choosing a personal partner to manage your healthcare needs. We understand that, on occasion, some patient-doctor relationships are not an exact match. The program allows you to change any of your PCMH providers once per quarter, with that change being effective the following quarter. A Provider Change Request Form must be completed and emailed to expedite this process.
FEATURES
You will not need to both call and email; you can choose whichever option is more convenient for you. The systems and processes that are in place, which make the PCMH model possible are complex; changing a provider is not as simple as clicking a button – it requires the linking of multiple systems, platforms, and communications systems – which is why the option of changing your PCMH provider at will is not possible. If you need to change your PCMH doctor, please be aware of the timeline regarding your change request. For example, if you change your provider in February, the change will not be effective in the system until April 1. In this same example, if you see your new provider prior to April 1, you will be subject to higher copayments
REFERRALS & PRIOR AUTHORIZATION: Understanding the Difference REFERRALS
Some form of requirement when accessing specialist care is part of most health plans today. The Performance Plus Plan’s PCMH model uses a referral-oriented system in order to better coordinate and manage your care. The referral process is an integral part of the PCMH and allows your primary care physician to direct, document, and evaluate your specialist visit(s). Referrals are sent electronically via the par8o system by your provider to another provider, which further helps to schedule and coordinate your specialist visit by sending information directly to you via text message. When a referral has been sent on your behalf, you will receive a notification by text with helpful details about the referral and direct contact information. A referral in the Performance Plus Plan does not require approval by anyone. Every referral request by your PCMH provider is delivered
directly to the specialist physician on your behalf. Furthermore, the referral does not delay or deny you care to see your specialist. Please note that specialists do not issue referrals, only your PCMH provider can issue a referral on your behalf. Should you need emergent care with a specialist and it is not possible to obtain one from your PCMH in a timely manner, a referral can be generated after the visit by your PCMH provider. This is called a retroactive referral. You should notify your PCMH provider as soon as possible following your emergent specialist visit in order for them to create a referral in the system for you. Of course, in a true emergency, please go directly to the Emergency Room – no referral is needed. Remember that a referral is not a prior authorization, which is required for certain procedures.
PRIOR AUTHORIZATIONS
Certain procedures and special services require Prior Authorizations to evaluate the medical necessity of the service. TRISTAR is an independent third-party administrator for the Teachers Health Trust and handles all prior authorization requests. Any provider may request a prior authorization for an indicated procedure or special service (teachershealthtrust.org/provider/forms/priorauthorization). The turnaround time is generally 48 hours unless additional documentation is required. Once the prior authorization is obtained, the provider should be able to schedule the procedure or special service without difficulty. On rare occasions, you and/or your provider may disagree with the authorization decision that you receive. Should this occur, the provider may appeal the decision to TRISTAR in writing. Often, the issue is only that additional information is required to support the initial request. Also, please note that Outpatient Perinatology has recently been added to the prior authorization list. You may obtain the list of procedures requiring a prior authorization by going to the new Trust website or see page 23. FALL 2016 | HEALTH TRAXX TEACHERSHEALTHTRUST.ORG
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When You Speak:
The Trust Listens This past April, the Trust commenced a long-term initiative to elevate participant outreach to a primary need. As teachers began winding down the Spring 2016 semester, the Trust was gearing up to ensure that the summer would be dedicated to improving not only the Performance Plus Plan, but the very organization from top to bottom. In order to do so, though, it was essential to make ourselves available to you in as many places and ways as possible. Your voice had to be heard in order to guide our efforts. By the close of the semester, the Trust:
99Held multiple open discussions at schools with Gary Earl, CEO. 99 Hosted town hall events at schools along with leadership from WellHealth and CCEA. 99 Began one-on-one leadership meetings with any participant wishing to discuss personal challenges with the plan. Throughout these efforts, the goal was to ensure you knew the Trust was both listening and dedicated to improvement. Nonetheless, with the new semester underway, most rightfully just want to know how we will be applying what we heard. This is a fair and important response; one worth discussing. During the summer, we gathered a large group of professionals internally as well as within the community with one goal, begin laying out a road map of improvements that focused upon the most prominent and critical issues. By the close of summer, the Trust had initiated a vast array of changes that ranged from infrastructure and operations updates to plan benefits and Patient-Centered Medical Home revisions. The following are just some of the most critical results. FALL 2016 | HEALTH TRAXX TEACHERSHEALTHTRUST.ORG
or How the Trust Spent its Summer
Updated Technology
Modernized Website
Any participant who has been with the Trust for more than a few years knows that the systems being used had not grown with the times. The fact of the matter is that both our operations and systems were built on pre-millennium technology. The Trust simply had not updated in years for many reasons and our teachers were suffering because of it.
Updating the phone and software systems was critical, but it was only one piece in modernizing your experience.
As we transitioned to the Performance Plus Plan, the first and most critical issues of an aging system had an immediate negative impact on our participants. The Trust’s phone and data systems were rapidly shown to be unable to handle the load. As a result, hold times rocketed to over an hour or more. The Trust reacted as quickly as possible and has since:
The new site launched over the summer with a modern look as well as an updated set of directory and portal access functions. While we will continue to update and refine, we encourage you to experience the vast amount of information now available in an easy-toaccess manner. Be sure to set-up your portal account to gain access to your personal health information whenever and wherever you need it.
99Updated all internal systems with fiber-optic data lines, improving both system speed and access. 99 Converted to a modern telephone system, allowing for faster call routing in order to minimize hold times and transfer rates. 99 Upgraded both the software and hardware used by Trust staff, providing them with the ability to more rapidly access and act upon incoming information. These updates, coupled with a greatly increased Customer Service Team has resulted in bringing down your hold times considerably as we are now averaging less than two minutes.
In today’s world, our participants need greater access to their plan and personal health information. The new Trust website meets this need and can provide full-featured functionality.
Expanded Rural Network Participants in outlying areas of Clark County, such as Mesquite and Laughlin, shared their challenges with having many services available only in the Las Vegas area. It was clear that network access outside Las Vegas was simply insufficient. In order to improve access to services, we went to work on negotiating with numerous providers outside of Las Vegas. Our work proved successful and, beginning in October, participants will receive detailed information on the numerous providers and facilities being added to the network. The additional providers coming to the network in the outlying areas should all but eliminate the need to schedule services far from home. Additionally, hospital facilities in both Bullhead City and St. George will be made available as part of this network expansion.
Improved Rx Benefits
Rx Savings Solutions
It came as little surprise that the most prevalent topic of conversations was the prescription benefits. A significant number of the people we spoke with shared their consistent challenges in respect to prescription access and affordability.
In addition to the above change in provider, the Trust will also begin offering access to Rx Savings Solutions, a prescription savings tool available on home computers and mobile devices
Soon after our town hall events, prescription benefit improvement became the single greatest focal point for the Trust and its partners. Finding a proper balance between cost and access continues to be daunting, but essential. Fortunately, we are confident that the solutions we will implement for 2017 will greatly reduce challenges in respect to medication cost and access.
Rx Savings Solutions offers innovative and patented software designed to keep you informed on valuable cost savings opportunities and alternatives for your prescription medications. This system was created and is managed by a team of pharmacists and software engineers to support a cost-saving solution for purchasing prescription drugs. The Rx Solutions Savings tool will be made available to all participants who wish to opt in to the service, free of charge, in January of 2017.
Expanded Formulary
WellDyne Rx In 2017, WellDyne Rx will become the primary provider to specialty drug and mail order prescriptions. This move will provide both a greater level of service and accessibility for maintenance medications as well as make mail order prescriptions much more manageable. Along with improved customer service, WellDyne Rx will provide our participants with access to their Intercept program. This program was created to serve as the front line in minimizing out-of-pocket costs for prescriptions. The primary benefit of the Intercept program is that it automatically searches and applies the best possible savings available for a number of medications at the time you are filling the prescription order. This means that your out-of-pocket costs for many specialty drugs will consistently be lowered. A significant number of participants should immediately see lower out-of-pocket costs with WellDyne Rx.
The addition of these tools and providers has allowed us to begin determining the overall cost savings to both the Trust and our participants. We are working with our partners to apply these savings towards adding additional prescription drugs to the current formulary. After completion of this update, the Trust will present a new formulary that will provide access to a greater number of prescription drugs than currently offered.
The Road Ahead The Trust is making many positive changes, but we are far from done. The effort will continue with more announced updates prior to the end of 2016.
2016 Progress UPDATES
Updated Technology ◊ Building now fully equipped with fiber-optic data lines. ◊ New phone & operating systems have reduced average hold time to less than two minutes. ◊ Modernized website/portal provides expanded access with improved usability. Expanded Network ◊ Expanded rural network will add numerous providers for outlying areas in October. ◊ Hospital facilities in Bullhead City & St. George to be added. Improved Rx Benefits ◊ New Specialty Drug & Mail Order Provider for 2017 will help lower costs & improve access.
The most important to know is that the Trust takes your feedback seriously. When you speak, we listen, and that continues to be key to our work each and every day.
◊ Adding access to Rx Savings Solutions software, which is dedicated to lowering outof-pocket prescription costs.
Philip DiGiacomo, Director of Communications Teachers Health Trust
◊ Prescription savings to be reinvested into an expanded formulary, adding additional medications to the plan. FALL 2016 | HEALTH TRAXX TEACHERSHEALTHTRUST.ORG
FEATURES
what’s your risk for
ovarian cancer
It’s the fifth largest killer of women in the United States, learn the risk factors and early symptoms. Characterized as growth of abnormal cells that originate in the ovaries, ovarian cancer claims the lives of over half of women who are diagnosed. Understanding the risks and early symptoms means quicker treatment and a better chance at beating this disease.
Who is at risk for ovarian cancer? Genetics Approximately 20-25 percent of women diagnosed with ovarian cancer have a hereditary disposition. BRCA1 and BRCA2 (breast cancer genes) have been identified in a significant amount of diagnoses. Family History If ovarian cancer runs in the family, your risk for ovarian cancer is higher than women who do not have ovarian cancer in their family history.
Obesity Obesity has been linked to ovarian cancer, increasing the risk up to 80 percent in women after the age of 50.
Increasing Age All women are at risk of developing ovarian cancer regardless of age. However, most women who are diagnosed are typically between 55 and 64 years old.
How is ovarian cancer treated?
Reproductive History & Infertility Research suggests a relationship between the number of menstrual cycles in a woman’s lifetime and her risk of developing ovarian cancer. A woman is at an increased risk if she: • • • • • • •
Started menstruating before the age of 12 Has not given birth to any children Had first child after the age of 35 Experienced menopause after the age of 50 Has never taken oral contraceptives Has had fertility complications Has had Hormone Replacement Therapy (HRT)
HRT may be prescribed to women who suffer from symptoms of menopause. However, studies indicate that a combination of estrogen and progestin for five or more years significantly increases the risk of ovarian cancer in women who have not had a hysterectomy.
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The most common form of treatments for ovarian cancer are surgery, where doctors attempt to remove all visible tumors, and chemotherapy to kill any cancer cells that may be left in the body.
Are there any signs & symptoms of ovarian cancer? For years, women have known that ovarian cancer was not the silent killer it was said to be. The Ovarian Cancer National Alliance (OCNA) brings light to some common symptoms associated with ovarian cancer: • • • •
Bloating Pelvic / abdominal pain Difficultly eating or feeling full quickly Urinary symptoms (urgency or frequency)
See your doctor if you have these symptoms more than 12 times during the course of one month and they are new or unusual for you. To learn more about risk factors and early symptoms, visit ovariancancer.org.
FALL 2016 | HEALTH TRAXX TEACHERSHEALTHTRUST.ORG
FALL 2016 | HEALTH TRAXX TEACHERSHEALTHTRUST.ORG
FEATURES NOVEMBER IS NATIONAL
prematurity awareness MONTH About one in 10 babies is born prematurely each year in the United States.
T
he March of Dimes is one of the leading organizations in the United States working to decrease premature birth by implementing awareness programs. Preterm birth is defined as occurring between 20 to 37 weeks of pregnancy. March of Dimes states “preterm labor is labor that happens before 37 weeks of pregnancy. This is too early for your baby to be born. Babies born too soon can have lifelong or life-threatening health problems.”
What are the risk factors for a premature birth?
According to the American Congress of Obstetrics and Gynecology (ACOG), risk factors that may increase the risk of preterm birth include: Having a previous preterm birth Having a short cervix Short interval between pregnancies History of certain types of surgery on the uterus or cervix Certain pregnancy complications, multiple pregnancy, and vaginal bleeding • Lifestyle factors include low pre-pregnancy weight, smoking during pregnancy, and substance abuse during pregnancy • • • • •
What are the warning signs of preterm labor? According to the Centers for Disease Control (CDC), listed below are warning signs that you may have preterm labor: • Contractions (your belly tightens like a fist) every 10 minutes or more often • Change in vaginal discharge (leaking fluid or bleeding from your vagina) • Pelvic pressure—the feeling that your baby is pushing down
• Low, dull backache • Cramps that feel like your period • Belly cramps with or without diarrhea If you are experiencing any of the above warning signs, even one preterm labor sign, please call your physician or go to the hospital immediately.
Follow your physician’s instructions. He/she may tell you to: • • • •
Report to the office for a checkup Go immediately to the hospital to be evaluated Stop whatever you are doing and rest on your left side for one hour Drink two to three glasses of water or juice (not coffee or soda)
If your signs and symptoms get worse or do not go away after one hour, call your physician immediately or go directly to the hospital. For more resources, visit marchofdimes.org, acog.org or cdc.gov.
FALL 2016 | HEALTH TRAXX TEACHERSHEALTHTRUST.ORG
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2017 ONLINE
OPEN ENROLLMENT Open Enrollment for all participants will begin November 1, 2016. All changes will become effective January 1, 2017. All participants may make changes to their current plan by utilizing the 2017 Online Open Enrollment Tool. Participants may begin utilizing this tool by logging on to teachershealthtrust.org on November 1, 2016. For any changes to be effective, you must have your open enrollment completed, including all change forms, no later than November 30, 2016.
If you do not have online access and/or ability to complete the process online, you may contact the Trust Service Department via phone at 702-794-0272 to request a Change Form be sent or e-mailed to you. If you add any new dependents, you may submit the required documents to the Trust: • • •
By fax at 702-794-2093 By e-mail at serviceteam@teachershealthtrust.org In-person at the Trust office
All supporting required documents (marriage certificates, birth certificates, etc.) must be received by the Trust no later than Friday, December 16, 2016. Any document received between December 17 and December 31, 2016 are subject to a $100 administration fee. Please note that no supporting documentation for open enrollment will be accepted after December 31, 2016.
FOR MORE INFORMATION The Trust will be providing additional information for the 2017 Open Enrollment beginning October 24, 2016. Please be sure to have your preferred e-mail updated with the Trust or visit teachershealthtrust.org regularly for the most up-to-date information. If you have any questions or require additional information, please contact the Trust Service Department at 702-794-0272 or 800-432-5859 between 7:00 a.m. and 5:45 p.m., Monday through Friday. You may also e-mail the Service Team at serviceteam@teachershealthtrust.org.
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FALL 2016 | HEALTH TRAXX TEACHERSHEALTHTRUST.ORG
FALL 2016 | HEALTH TRAXX TEACHERSHEALTHTRUST.ORG
FEATURES SERVICES REQUIRING
prior authorization
Certain procedures and services require prior authorization to evaluate the medical necessity and appropriateness of the service. Accredited medical and behavioral health organizations conduct these reviews for the Trust. Regardless of what the reviewing organization recommends, it is always up to you and your doctor to decide what, if any, care you receive. In the event you and/or your physician do not agree with the authorization decision that you receive, your physician may appeal the decision to the reviewing organization by providing (in writing) additional information to support the initial request for authorization. You should advise your physician to obtain Prior Authorization on your behalf if the services require it. If Prior Authorization is not obtained, benefits for the service may be greatly reduced or not paid at all. Prior Authorization does not guarantee payment of benefits or determine what level of Plan benefits will apply. MENTAL HEALTH/CHEMICAL DEPENDENCY Mental health/chemical dependency services are covered under the Performance Plus Plan. Services obtained by mental health/chemical dependency providers, such as counselors and psychiatrists, do not require a referral from the participant’s PCMH physician, but prior authorization for medical necessity from Human Behavior Institute (HBI) applies. See below. • • • • • • • • • • •
Counselor Visits (after 24 sessions) Detoxification Medications Group Therapy Visits (after 24 sessions) Inpatient Care Mental Health NP Visits Partial Hospitalization Psychiatric Visits Psychosocial Rehabilitation and Autism Services Residential Treatment Therapist Visits (after 24 sessions) MD Visits
Obtain prior authorization by calling HBI: (800) 441-4483 or (702) 248-8866. Should be obtained at least 48 hours prior to service.
MEDICAL SERVICES • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •
Air Ambulance Blepharoplasty Botox Breast Surgery Continuous Glucose Monitoring Devices Cosmetic Surgery CT Scans Dialysis Durable Medical Equipment (over $500) Endoscopy Extended Network Benefit Genetic Testing Hernia Repair Home Health Care Hospice Care Hyperbaric Oxygen Therapy Inpatient Admissions IV Infusions MRI and MRA Nerve Conduction Studies/ EMG Oral Appliance for Sleep Apnea Out-of-Network Laboratory Outpatient Perinatology Pain Management (Nerve Blocks) PET Scans Sclerotherapy Skilled Nursing Facility SPECT Cardiolyte Testosterone Pellets Insertion Transplant and Follow-up Transplant Services Virtual Testing
Obtain prior authorization from TriStar Managed Care: Phone: (702) 832-4658 or Toll Free at (844) 586-2244 Fax: (702) 847-7690 or (562) 506-0340 E-mail: authorizations@wellhealthqc.com
FALL 2016 | HEALTH TRAXX TEACHERSHEALTHTRUST.ORG
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FEATURES
understanding
AUTISM SPECTRUM DISORDER In the United States
1 in 50
kids have ASD
40% BOYS ARE
4x
Autistic children have intellectual disabilities
25% MORE LIKELY TO HAVE ASD
Autistic children have communication disabilities
20%
Autism recurrence rates in families
15%
DIAGNOSIS & EARLY SIGNS
Autism cases caused by genetic disorder
It is not possible for children to outgrow autism; however, early diagnosis can improve quality of life. Here’s what to look for:
Lack of or delay in speech
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Little or no eye contact
FALL 2016 | HEALTH TRAXX TEACHERSHEALTHTRUST.ORG
Doesn’t respond emotionally
Lack of pretend play
Fixation on parts of objects
Lack of interest in friendships
Discover
THE VALLEY HEALTH SYSTEM
Wherever you are in Las Vegas Quality care you can count on
Our integrated network of hospitals serves residents of Las Vegas and southern Nevada. Centennial Hills Hospital • Desert Springs Hospital • Spring Valley Hospital • Summerlin Hospital • Valley Hospital Our newest facility – Henderson Hospital – will open this Fall. Watch for details.
Close to home when you need us. Learn more at
valleyhealthsystemlv.com
Centennial Hills Hospital • Desert Springs Hospital • Henderson Hospital (Fall 2016) Spring Valley Hospital • Summerlin Hospital • Valley Hospital
Physicians are independent practitioners who are not employees or agents of The Valley Health System. The system shall not be liable for actions or treatments provided by physicians. 162137
Back to School Headquarters EYE PHYSICIANS & REFRACTIVE SURGEONS Pediatric & Adult Eye Exams Cataract Surgery Laser Eye Specialists Macular Degeneration & Diabetic Evaluations Medical & Laser Treatment for Glaucoma Dry Eye Therapy LASIK & PRK Refractive Surgery Cosmetic & Oculofacial Plastic Surgery Contact Lens Exams & Dispensing
Seeing Patients at: 2598 Windmill Parkway / Henderson 9455 W. Russell Road, Ste. 100 / Southwest Las Vegas 8230 W. Sahara Avenue, Ste. 121 / Summerlin 2020 Goldring Avenue, Ste. 401 / Las Vegas Medical District 6850 N. Durango Drive, Ste. 400 / Centennial Hills 3640 S. Highway 160, Ste. 101 / Pahrump
(Formerly Nevada Eye & Ear)
For Appointments Call
702-896-6043 or Toll Free 888-425-2745 www.nevadaeyephysicians.com FALL 2016 | HEALTH TRAXX TEACHERSHEALTHTRUST.ORG
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Educating. Entertaining. Inspiring. Issue after issue. Summer 2014
WomanMagazine.Vegas | Advertising Inquiries 702.685.4673 FALL 2016 | HEALTH TRAXX TEACHERSHEALTHTRUST.ORG
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