Returning onsite case management to an electronic world

There’s a lot to be said for the assurance that can come with face-to-face interaction — or, rather, that once came with that kind of communication. Commuters bury their heads in smartphones, oblivious to the people and happenings around them. Meeting rooms sit empty as busy employees collaborate through instant messaging and conference calls. And merchandise previously available only at a retail store is now just a couple computer clicks and an overnight delivery away.

USA Today declared 2010, thanks to our ever-available technology, as the year we stopped talking to each other. Once upon a time not too long ago, there was a comfort in the personal attention that came with our daily interactions. This proved especially true during times of great stress or discomfort, when a friendly face delivers much more than a phone call or email ever could. When a family member is facing a devastating injury or catastrophic illness, having someone there to help manage his or her care and develop a long-term plan is not just comforting; I would argue that it’s essential.

Telephonic care that coordinates a patient’s case management works just fine in routine hospitalizations, those relatively minor instances that typically result in quick remediation and don’t require post-discharge care and supervision. But care for catastrophic illnesses can be extremely complex and is accompanied by the need for a balance of urgency, attentiveness, and, most of all, a clear understanding of what comes next.

Also see: "Stop-loss coalition development."

As self-funding health care plans continue to become a more attractive and popular option, there needs to be more effective solutions available to help manage sky-rocketing stop-loss claims, of which the size and frequency continue to increase with the further proliferation of specialized drugs, treatments and expensive testing options. Formularies provide only a certain amount of financial protection, protection that is continually compromised by the increased pressure on employers to explore additional prescription options. The implementation of the Affordable Care Act threw the health care world into chaos. While providing new coverage opportunities to millions of previously un-insured Americans, this legislation also quickly rewrote the rulebook that caregivers, payers, third-party administrators and stop-loss providers depended on.

Catastrophic conditions costlier than ever

One of those changes was the removal of lifetime maximum caps — which ranged from $1 million to as much as $2 million — from health care plans. Complex conditions are accompanied by costly claims, and that requires greater attention to help ensure the patient receives effective care immediately, with a clear path that details those factors necessary to ensure a faster recovery as well as a long-term plan.

The lifetime cap removal did its job in satisfying the needs of those individuals with expensive, long-term care needs. However, it also created a new world of financial challenges that exposed the industry to a potentially limitless system and the possibilities of blank-check treatments, with no maximum threshold. These financial limitations had fostered practical decision-making and care plans, and with their removal came the need to recreate a managed care system that maintains this sensibility without compromising patient care. 

The proliferation of expensive, specialty drugs used to treat life-threatening conditions such as cancer and hepatitis can often cost more than $100,000 each year. Additional pressure from the individual, their family and the treating doctor can help drive up costs on catastrophic claims — 5% of claims drive more than 50% of plan costs. But there are alternatives available, including generic medications that satisfy formularies without compromising what’s most important — patient care.

Also see: "FMLA extension could be 'stepping stone' to more DOL benefits involvement."

That’s why a new alternative is to deploy an on-site registered nurse who is also a Certified Case Manager who can serve as a case manager immediately following a catastrophic health care event. These experienced and Certified Case Managers (CCM) credentialed health care professionals can assist families and in collaboration with the treatment team, advocate an effective plan that ensures proper care is provided through proven and reliable channels. The patient continues to receive the best care available and stop-loss costs are managed more effectively and efficiently through this independent analysis.

That’s why it’s time to bring clarity to the chaos. Personal care in times of great distress not only delivers more effective care, but it also does it more efficiently.

Fleet is president of AmWINS Group Benefits, a wholesale broker of comprehensive group insurance programs and administrative services. He can be reached at asksam@amwins.com.