Making the Case
I was recently watching reruns of a classic western, and it got me thinking...gone are the days of doctors riding mules with black bags to do house calls. Have we become so enamored with technology, and all the great modern medical advancements, that we've lost sight of the personal touch? Don't get me wrong. I love technology, but no longer do doctors intimately know their patients' families, socio-economic situation, religion, goals, dreams and aspirations. Is that even a problem? If so, who’s going to fill the gap?
Case managers could be the answer. No one has a more vested interest in your health plan members getting the right care, at the right time, in the right place and for the right price than you, the employer.
Imagine your employee needs knee replacement surgery in both knees.
What an orthopedic surgeon sees: 64-year-old male, privately-insured patient needing bilateral knee replacement surgery. Oh, and he has diabetes.
What a savvy orthopedic surgeon sees: 64-year-old, privately-insured patient needing bilateral knee replacement surgery, who also has diabetes, who’s likely to retire and go on Medicare soon.
What a case manager sees: 64-year-old, actively at work male, Jehovah’s Witness patient, originally from Brazil, who works in maintenance and lives alone on the third floor of an apartment building with no elevator and has had problems with diabetic foot ulcers, who needs total knee replacement surgery on both knees and was referred by his primary care doctor to an orthopedic surgeon.
Now, let’s take this a step further and explore a few of the thousands of things bouncing around in that case manager’s head:
- Should this patient get surgery right now?
- Is his diabetes well controlled?
- Would it be cheaper for him to wait until he retires and goes on Medicare (would his out-of-pocket be lower than with his private insurance)?
- Will that orthopedic surgeon even accept Medicare patients?
- How did he end up with this orthopedic surgeon anyway – is he/she in the patient’s PPO network? How experienced is this surgeon? Is he/she board certified?
- What’s the infection rate, morbidity/mortality rate at the hospital where the surgery is going to happen?
- Is this patient potentially going to need blood for this surgery? Does the doctor know he’s a Jehovah’s Witness and will refuse blood? Have they put that in his chart?
- What Spanish language patient education materials can I share with this patient?
- Who’s going to get this patient back and forth to therapy?
Now, your next question should be: Why is it my self-funded health plan’s responsibility to make sure this patient gets case management?
The answer: Because you’re paying for this employee’s total knee replacements, including his surgery, hospitalization afterward, rehabilitation, complications if things go wrong, and you want him back to work!
Did you know that according to AHRQs HCUPnet project, in 2013 a 64 year-old privately-insured patient getting one knee replacement resulted in $55,059 in hospital charges? That’s just the hospitalization. That doesn’t include rehab and post-hospitalization services. It also tells us six out of every 1,000 patients ages 45-64 who have one knee replacement die while hospitalized.
Did you know it’s very common in the medical management industry for knee replacement surgery to not prompt medical management to initiate case management services?
Thousands of dollars can be wasted without great oversight and fully engaged case management. To learn more about how case management can help your organization, contact a member of the ‘A’ Team.
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