Health Education

Quality health care requires education, participation

Even with great coverage from Rocky Mountain Health Plans, your health care decisions affect both the quality of care you receive and the amount you pay out of your own pocket. Being a wise health care consumer gets you the best quality care at the lowest cost.

Keeping care affordable

We all know the cost of quality medical care continues to rise, but many of us don't understand why controlling costs is so important. The main concern is that escalating costs will put quality care out of the reach of most people. High costs affect everyone. As medical care becomes more costly, the premiums you or your employer pay and your co-payment or coinsurance amounts must also increase. One of the main objectives of managed care plans, like Rocky Mountain Health Plans, is to keep quality care affordable. Everyone who uses, delivers, and pays for health care plays a role in controlling costs.

Being a wise consumer of health care services will not only help slow escalating health care costs in the long run, it can mean less money out of your pocket right now.

Why a PCP?

In the past, the family doctor was a trusted advisor. But as specialty medical fields developed, we lost an important connection to the physician trained to oversee our total health. When you joined Rocky Mountain Health Plans you picked a primary care physician (PCP), usually a family practice physician, internist, or pediatrician. Developing a comfortable, ongoing relationship with a PCP who knows your complete health picture has many advantages. The more your doctor knows about you, the better he or she can act as your "medical manager," referring you to a specialist if necessary. Your PCP can keep all your records together and monitor tests, treatments, inoculations, and medications to avoid time-consuming and costly duplication and conflicting therapies. And, your PCP is the expert on you and your family you can call in case of emergency or sudden illness.

Without a "regular" doctor to call, many people either don't get the care they need or they seek care in an inappropriate setting. They may go to the emergency room, for example, when an office visit would be more appropriate and certainly more cost-effective.

Getting the best from your doctor

The care you receive from your doctor depends to some extent on the information you provide. Clear, open communication between you and your doctor is important. When you visit your doctor for a specific problem:

• Clearly describe your present condition or complaint.
• Tell your doctor when and how your problem began and what has happened since.
• Tell your doctor what medications you are taking, even if you got them without a prescription. Also, let the doctor know if you are allergic to any medications you are aware of.
• Know your medical history, past illnesses, and hospitalizations. The first time you visit a new doctor they will ask you to complete a health history that will become part of your file. Fill out this form thoughtfully and completely.

Is this an emergency?

The emergency room is no substitute for a doctor who knows you and your medical history. Unless your medical problem is a true life-threatening emergency, the emergency room is not the right place for medical care. Here's why:

• In the emergency room the most seriously ill and injured get care first, so you could be in for a long wait.
• The emergency room doctor doesn't know you or your medical history.
• Emergency rooms provide little or no follow-up care and your PCP may not be informed of the treatment you receive there.
• Emergency room care is very expensive - often double the cost of a visit to your doctor's office. Your emergency room co-payment (the amount you are responsible for) is usually substantially higher than your co-payment for an office visit.

When your doctor says "surgery"

A good doctor has your best interests in mind when suggesting elective (non-emergency) surgery. But the final decision to have surgery is always yours, so it's important to have as much information as possible. There is risk involved in any surgery, so learn as much as you need to make an informed decision.

• How will this surgery help?
• What are the risks of having the surgery?
• What is likely to happen if I don't have the surgery?
• Are there other ways to treat my condition without surgery?

Most health plans, including Rocky Mountain Health Plans, require you and your doctor to preauthorize many elective surgical procedures, that is, let us know you intend to have the surgery. When you and your doctor tell us you're planning surgery, we help arrange your care before and after the procedure. If your surgery is a procedure our members have had many times before, we may want you to work with a specific facility or provider because they are experienced in the procedure and have provided quality care to our members in the past. We also plan ahead to follow your progress in the hospital and arrange for follow-up care after you leave. Maybe you'll need home health care services, for example.

Before going to the hospital

No one wants to spend time in the hospital, but chances are you will some time in your life. To be sure your hospitalization is necessary and cost-effective, ask the following.

• If you're being hospitalized for surgery, could you have the procedure done as an outpatient or in a surgery facility other than a hospital?
• If hospitalization is necessary for your surgery, can it be done the same day you're admitted?
• Can tests be done before you're admitted?
• What will the total cost be? How much will you be responsible for?

What the hospital is not for

Hospitals are designed to provide short-term care. Hospitalization is expensive, and many hospital stays are unnecessary. These guidelines will help you use hospital services most effectively.

• Don't use the hospital if the same services are available elsewhere. Ask your doctor about your options. Even if there are no alternative facilities in your immediate area, there may be an appropriate option elsewhere in Rocky Mountain Health Plans's statewide network.
• Hospitals are not the place to go for a rest. They are busy, noisy places.
• Hospitals shouldn't be used for the "convenience" of having a number of tests done at the same time. In most cases, the same tests can be done as an outpatient more efficiently and for lower cost.
• Avoid weekend admissions except in emergencies. It's usually not necessary to spend extra days in the hospital before surgery. Often you can go into the hospital the day of your procedure.

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Appropriate ER use has significant impact on rising health care costs

As health care costs continue to rise, health plans are challenged to find ways to save their members money in premiums and co-payments. One area in which significant savings can be achieved is in emergency room use.

"We need to be more diligent in explaining emergency room procedures, when and how to use emergency services, to our members, but also the financial ramifications of using emergency rooms for non-emergency care," stated Dr. David Herr, medical director for Rocky Mountain Health Plans.

ER care is expensive care

The New York Times reported hospitals typically charge double for treatment received in the emergency room compared to the same treatment received in a non-urgent care setting. Emergency room services cost more because an estimated 50 percent of all emergency room patients never pay. Simply put, those who pay subsidize those who do not.

It is also estimated that 30 percent of the patients seen in emergency rooms are seen for non-emergency care that could be received in more cost-effective settings.

"When you start with the high cost of emergency room care and combine that with the member having to pay a higher emergency room co-payment, it's to everyone's benefit to use the emergency room services wisely," said Dr. Herr. "Also, if the member uses the emergency room for something that is not a true emergency, they may have to pay the entire cost themselves. Health plans, providers, and members must work together to be sure everyone knows the most cost-effective means of getting quality, urgent care."

When your child or loved one is sick or injured it can be difficult to determine the best course of action to get the care they need. The following outlines when and where to seek emergency care.

ER care

True emergencies require immediate medical care to prevent death or serious damage to one's health. The most common examples of injury and illness requiring emergency room attention include:

• spinal injuries
• poisoning
• strokes
• serious breathing difficulties
• severe bleeding
• bleeding that will not stop
• heart attacks
• loss of consciousness

In a life- or limb-threatening emergency, Rocky Mountain Health Plans members should dial 911 or the local emergency number and go directly to the nearest hospital emergency room. Once the situation is under control, your primary care physician should be contacted to provide or direct follow-up care.

Non-life-threatening emergencies

Some illnesses and injuries may not be life-threatening, but may require immediate care. They include:

• broken bones
• high fever
• serious cuts
• ear infections

In these situations, call your primary care physician immediately. Your doctor will tell you if you should go to the hospital emergency room, to their office, or to another facility.

Urgent care

An urgent care situation is one that does not pose an immediate, serious health threat but does require prompt medical attention. Conditions considered urgent include:

• ear infections in children
• minor burns
• sprains
• respiratory infections
• stomach or abdominal pain
• minor cuts that may require stitches
• urinary tract infections

For urgent care, members should call their primary care physician. The member should describe the illness or injury and follow the doctor's instruction on where to go for care.

Alternatives to emergency room care

The health care community is constantly working to find alternatives to the emergency room for non-life-threatening situations. Free-standing urgent care centers are found in many urban communities. Some medical centers offer urgent care services on evenings and weekends. There are also 24-hour nurse advice lines where members can discuss their symptoms and medical history with a registered nurse, who uses a clinical protocol to evaluate the condition and gives advice on what to do.

Make sure you know your options locally and discuss them with your primary care physician. And keep those vital telephone numbers handy, including your primary care physician, emergency services, and the local hospital or urgent care facility.

Rocky Mountain Health Plans executive director Mike Weber summarizes, "In the process of delivering quality health care, we want our members to be educated consumers. We also want to protect them from unnecessary medical care costs. To this effort, we are working everyday to make this information available, and we ask each of our members to do their part in the medical decision-making process."

After-hours alternative opens in Grand Junction

It's eight o'clock Friday night and your daughter has an earache and slight fever. It's not an emergency, but it can't wait till Monday when your doctor's office opens. But what choice do you have but to sit and wait in the noisy chaos of the hospital emergency room?

In Mesa County you have a great new alternative - Docs On Call - a new after hours medical care facility sponsored by Primary Care Partners, comprised of the doctors in Family Physicians of Western Colorado, Western Colorado Pediatric Associates, and Western Colorado Physicians Group.

Docs on Call is designed to handle injuries such as lacerations, broken bones, fever, etc. The facility is staffed by a physician and has x-ray and laboratory services.

The new Docs On Call facility can be used by Rocky Mountain Health Plans members in several ways:

• If your PCP belongs to Family Physicians of Western Colorado, Western Colorado Pediatric Associates, or Western Colorado Physicians Group and you need urgent (but not emergency) care after your doctor's office is closed, call the Docs On Call facility at 255-1576. The staff will assess your situation and fit you in as quickly as possible.
• If your PCP is not part of Primary Care Partners, the Docs On Call facility may still be available to you. If you need urgent (but not emergency) care after hours, call your doctor's on-call or answering service phone number. Your doctor may direct you to Docs On Call for treatment or may want to meet you at the Docs On Call facility.

The hospital emergency room is the place to go for life-threatening emergencies, but no one wants to be there unnecessarily. Docs On Call is a great after-hours alternative for Rocky Mountain Health Plans members in Mesa County.

DOCS ON CALL

2323 North Seventh Street, Grand Junction
255-1576
Open 365 days a year
Monday - Friday 5:00 - 10:00 PM
Saturday & Sunday 8:00 AM - 10:00 PM