Health Insurance

Health Insurance 101: Intro to Networks

Hey Guys! Quick recap on what you should already know before we hit the ground running on NETWORKS. 

There are three essential components you should know and feel comfortable with when selecting a health insurance plan:

Three key essentials:

  • Cost Sharing
  • Benefits/Coverage
  • Networks

The gist: you need to find a health insurance plan that includes the BENEFITS, or medical services, that you need with the NETWORK of doctors and hospitals that you want to see with a COST SHARING setup that fits your budget.

Networks: the doctors and hospitals that will be covered and will “accept” your insurance plan, or in simplified terms, who you can see for less $$$.

Like I said… it’s very important that you review the network of doctors and hospitals included in the health insurance plan to make sure it includes the doctors you want to see.

Let me give you an example that I went through when selecting my dental plan…

My dentist is Dr. Ted and I’ve been going to him for years. Dr. Ted is the BEST dentist around- he’s friendly, he’s funny, he’s motivated by helping people, and heck I’ve never gotten a cavity (knock on wood!) Now when I started a new job and had to select my dental plan I had two options- HMO or PPO. So what did I do? I checked to see if Dr. Ted was in both networks. PPO networks are typically much larger than HMO networks and it turns out that Dr. Ted is in the PPO network but not the HMO network. Conclusion made– I’m selecting the PPO because for me I would rather pay more money for the PPO and get the high-value service from my current dentist who knows my teeth well.

The same applies to any plan you select, whether health insurance, dental, or vision insurance!

Make sure your doctors are -in network-

Now, this doesn’t limit you from seeing doctors who are “out-of-network”. Most of those doctors will still see you but if you are in an HMO you typically become a cash-paying patient where you have to pay for all services by yourself (“out-of-pocket”- remember that term??) with no help from the insurance plan you are currently paying for. If you are in a PPO the insurance may still cover some of it but it will be much more expensive than seeing an “in-network” provider.

Any questions on NETWORKS? Feel free to comment below and I look forward to seeing you next time when we chat about BENEFITS!

Cheers to Health and Happiness!

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Primary Care

Who is your PCP? Part 2- The Primary Care Medical Home

Hi Everyone,

Welcome back to Health Care For the People for today’s post called Who is your PCP Part 2- The Primary Care Medical Home. In part 1 we talked about the importance of having a PCP and now we are going to talk about the Primary Care Medical Home, or what we call in the industry, PCMH.

The Primary Care Medical Home (PCMH) is a model whereby your PCP is the quarterback of your care for the rest of your care team.

What is a care team you ask?

Well for starters your care team is not going to look the same as someone else’s care team.

Depending on your current health state you might have only one doctor, your PCP, or you might have multiple doctors treating different diseases. You might have a mental health provider or a social worker.

If your care is very complex you might also have a care coordinator, which is an individual who is not a clinician but who works very closely with your PCP to coordinate your care between the different providers on your care team.

Potential Members of the Care Team:

  • PCP
  • Specialists
  • Care Coordinator
  • Mental Health Provider
  • Social Worker
  • Pharmacist
  • Hospital-based providers in the event of hospitalization
  • Community providers such as home health or skilled nursing facility staff

As you can see, depending on the complexity of your health situation, it can be really complex and just like anything else in this world Communication is Key! So it’s really important that your PCP (and potentially Care Coordinator) are working to optimally communicate and collaborate on improving your health outcomes.

That’s why we call the PCP your quarterback in the PCMH model. Your PCP is at the center of your healthcare world, looking at you holistically as a patient and serving as your quarterback who is fully knowledgeable in the care you are receiving from all your providers.

If you’re interested in learning more, here is a great link from the Patient-Centered Primary Care Collaborative that has some really helpful graphics:

https://www.pcpcc.org/about/medical-home 

Have any questions about the PCMH model? Feel free to write any comments or questions below and be sure to subscribe to the newsletter!

Cheers to Health and Happiness! 

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Primary Care

Who is Your PCP? Part 1

Hi Everyone! Welcome to Health Care For the People! Now that we have been introduced let’s get started!

Today we are going to talk about a very important relationship that you should have in your life– not your wife or boyfriend or grandma or dog– but your Primary Care Provider, otherwise known as your PCP.

If you want to stay as healthy as possible, having a PCP is so vital because they get to know you very well in your current state– your body, your physical health, your mental health- and by continuing to see them every year and building that relationship they also track your health over time. This allows the PCP to manage your health in the best way possible!  

That being said, it’s very important that you get a PCP who is not only in your network (we will address this in the future Health Insurance 101 series) but also someone that you like and look forward to seeing on an annual basis, just like anyone else that you have a significant relationship with!

So now what does the PCP do??

The Role of the PCP:

  • Makes sure you get your preventive health screenings– this means annual check-ups, vaccinations, cancer screenings, and flu shots
  • Health coaching- helping you to quit smoking, eat more vegetables, exercise more, and drink less alcohol
  • Focuses on slowing any progression of disease– the first two above focus on preventing disease but for folks who have already been diagnosed with a disease, this means you and your PCP must focus on slowing the progression of disease through medication management and more. Oftentimes we can prevent or slow disease by taking better care of ourselves with our PCP’s help.
  • Addresses your urgent health needs (if it doesn’t need to be addressed by a specialist)
  • Addresses your needs holistically as a person– this means supporting you in achieving a positive mental state and referring you to community support and specialists as need be

What specialization of PCP should I see?

You might have noticed that there are different types of PCP “specializations”. Here are the breakdowns so you understand your options:

  • Pediatrics– specialize in managing the health of children (depending on the doctor they may continue seeing the patient until about 21 years old/college graduation)
  • General Internal Medicine– specialize in managing the health of adults
  • Family Medicine- specialize in managing the health of any-aged individual, i.e. the family
  • Geriatrics– specialize in managing the health of the elderly (typically greater than 80 years old)

If you are a young adult female you might think about using your gynecologist as your PCP. Most sources recommend against it because your PCP can do pap smears and again, this is an individual who looks at you holistically and will continue to know and support you over time.

What type of PCP should I see?

Nowadays your PCP could have different types of degrees. This is why we use the term “provider” instead of “physician”. They are all competent clinicians but here I will simplify the differences:

  • Physician– this is the typical M.D. or D.O. doctor that we know and love who went to medical school for four years after undergrad and then did a three-year residency in one of the above specializations.
  • Nurse Practitioner (N.P.)– this is a nurse who goes on to get a master’s or doctorate in nursing.
  • Physician’s Assistant (P.A.)– this is an individual with three years of P.A. school after undergrad and more than 2,000 hours of clinical rotations.

Obviously it depends on the individual person and the bond you make but my absolute favorite PCP I’ve ever had was a P.A. out in Washington, D.C. She was a rockstar PCP so just know that they don’t necessarily have to be a doctor.

How often should you see your PCP?

Physicians recommend that adults see their PCP at least once a year and more often as recommended! Your health insurance should cover a free annual preventive visit with your PCP. It’s free! So get out of work for an hour and go use it!

Treat yo self

It’s also important to note that if you ever go to another clinic or the hospital that you let them know who your PCP is. You want this outside clinic or hospital to interact with your PCP since your PCP knows you best. Encourage them to either give you the medical records to give to your PCP or for them to directly e-communicate with the PCP and send the medical records that way. 

Let me know if you have any questions about getting a PCP. In our next post we will discuss the Care Team- all the people that the PCP supports as the quarterback of your care. Be sure to subscribe! Chat soon!  

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Health Care Transformation

Welcome to Health Care Transformation- For the People!

Hey everyone, I’m Meghan Nechrebecki and I’m the founder of Health Care Transformation. This is me: (It’s such a pleasure to meet you!)

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I earned my Master’s in Public Health from Johns Hopkins and for the past seven years I’ve been working with doctors, hospitals, and health insurance companies to improve the health outcomes of patients. And today, it is my great pleasure to welcome you to (drumroll please…

Health Care Transformation- For the People!

This blog will educate, engage, and empower you to better understand the health care system and to take control over your health- both for yourself and for your loved ones.

And why is this so important?

Because, as you probably know by now, we as a country have really high healthcare costs, which unfortunately most of us have experienced. And sadly, we don’t have that great of health outcomes either! 

In a report by the Commonwealth Fund that compares the U.S. to other high-income countries, the U.S. ranked last on performance overall and ranked last or near last on the Access, Administrative Efficiency, Equity, and Health Care Outcomes categories. We have a lot of work to do here guys and gals!

We all know there are a lot of issues with our U.S. health care system but I actually believe that there is at least one powerful solution in front of us and that’s YOU! That’s everyone that ever has been or will be a patient.

 I firmly believe that by engaging and empowering patients to understand and navigate the healthcare system, you will actually make more informed and better decisions for you and your loved ones, which believe it or not will have a large impact on reducing health care costs and improving your health

So let’s get started! What can you expect from Health Care for the People?

Every week there will be new material to support and empower you! You can access them here on our website, follow us on Instagram, or subscribe to our YouTube channel. 

There will be VIDEOS, like this:

 

There will be INSPIRATION, like this:

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There will be EDUCATIONAL TIPS, like this:

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So head to www.caretransformation.net every week for new posts on what you need to know about taking control over your health. I’m looking forward to this journey together- Cheers to Health and Happiness!  

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