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Look to your reinsurer for help on difficult cases
Experts can help provide cost-effective care
If you are managing the care of a catastrophically ill or injured patient who needs complex care planning, coordination of resources from many sources, and a large allocation of financial resources that could cause the patient to reach his or her maximum lifetime benefit, it could be helpful to you and the patient to find out who may be sharing the risk.
Often, that means the company that provides reinsurance for the health plan or self-insured employer. Reinsurance companies often employ nurses who can assist with the medical coordination of complex cases.
"As a case manager, it is important to note what the health plan covers and when reinsurance is available as another avenue of funding and assistance," says Barbara Tomlin, RN, MS, CCM, assistant vice president, medical management for IOA Re Inc., a reinsurance underwriting company with headquarters in East Norriton, PA.
Reinsurance is stop-loss insurance for primary insurance firms or self-insured employer groups, Tomlin explains. When individuals experience catastrophic events with significant health care expenditures, those claims may become eligible for funding under the reinsurance policy, Tomlin says.
Reinsurance helps to provide a basis for financial security within an organization by adding another layer of protection against the dollars involved in caring for patients with catastrophic illnesses or injuries.
Once a patient's medical care exceeds a predetermined deductible, the reinsurer assumes responsibility for the costs. In some cases, the deductible can be as low as $20,000, a threshold easily attained with today's health care expenses, Tomlin points out.
Since the reinsurers assume financial risk only on catastrophic cases, they are likely to know the best professional or facility to tap into to optimize the outcomes for the difficult cases the case manager is handling. A reinsurer's medical management department may have access to national resources and be able to consult with their clients as to which providers or facilities have significant experience and positive outcomes.
"Care-making decisions and utilization review, however, remain the responsibility of the primary insurer or HMO," Tomlin adds.
Often, reinsurers are willing to get involved with a complex case even before the reinsurance benefits kick in.
"Once an insurance company or self-insured employer identifies a member who has the need for ongoing catastrophic care, they can call on us to provide assistance," Tomlin says.
Reinsurers prefer to be notified as early as possible so they can get a head start on finding the best treatment options for patients, she adds.
"We are often called in to provide assistance before the member needs a transplant, is anticipating entry into dialysis, or before a high-risk delivery. Proactive management is always most effective, as assessing and planning require collaboration for optimal care coordination," she says.
In another scenario, when someone has a spinal cord injury, the reinsurer prefers to be notified as soon as the patient is admitted to the acute care hospital.
"When our notice occurs early on, we can locate a center of excellence so that as soon as the patient is medically stable, we can arrange the transfer to a facility that can provide optimum outcomes in a cost-efficient manner," she says.
Reinsurers commonly encounter cases that are complex and costly, such as traumatic brain injuries, organ transplants, spinal cord injuries, oncology treatment, and dialysis. Some of the most difficult cases are with members who are being admitted for surgery but have multiple comorbidities and who experience numerous complications, Tomlin says.
"We don't provide hands-on case management but work in an advisory capacity to help the insurer's case manager identify resources that have been utilized successfully in the past," she says.
For instance, if a member needs a transplant, IOA Re works with four networks that provide specialty care and centers of excellence for transplant surgery.
Recently, Tomlin's company received a notice from a third-party administrator with chronic kidney disease who was facing dialysis or a possible kidney transplant.
The IO Re team referred the member for individual case management by an expert on kidney disease who was located in a nearby and cost-effective dialysis facility. She also assisted with coordinating more effective pricing options while educating the member about home dialysis so the member was aware of all possible treatment options.
"When it is appropriate, home dialysis is more clinically and financially advantageous to the members because they are utilizing less of their health care allocation and dialyzing daily," Tomlin says.
Because the member might elect to have a kidney-pancreas transplant, the case manager identified centers of excellence for kidney transplant in the member's area.
The reinsurance company has the resources to identify which facilities or providers can provide the specialized care the member needs, and the medical management team regularly tries to keep abreast of additional services for clinical and financial assistance, she says.
"When a case manager at an insurance company is having difficulty in locating a specialist or a center of excellence, we will help identify the best source of care for the member," she says.
Often this involves calling in case managers who specialize in one particular area and who can give expert advice about the best avenues of treatment for the patient.
In the case of a patient with metastatic cancer, the company can contact an oncology management company and contract with a case manager who specializes in oncology treatment and who has researched the standard of care treatment options and appropriate clinical pathways.
"Today, there are so many clinical trial and research discoveries that it's difficult to keep up with the most appropriate types of treatment for a particular cancer. Our case managers and medical advisors assist us in researching and determining the best cancer treatment centers of excellence and protocols for the members' medical care," she says.
If an insurer has a member who requires complex care and is admitted to a medical center in a distant state, IOA Re may employ a case manager to go to the site and meet with the treatment team to make recommendations for a specialist consultation or continuing care in a long-term care facility or rehab facility.
Tomlin has been called in to assist an insurer early in a member's high-risk pregnancy.
"We know that there are conditions that put the expectant mother at risk or diagnostic testing that might confirm that the child has a potential congenital anomaly. We will employ a company that can provide medical advice to help the mother carry the child as close to term as possible," she says.
If the fetus is determined to have a congenital defect, such as a heart defect that might require a procedure within a week of birth, the case manager hired by IOA Re might recommend that the baby be delivered at a center of excellence that can perform the surgery in a timely manner.
Calling on the reinsurer for expert help can assist case managers in finding the best medical care and the best medical resources to manage the member's treatment in a way that makes the best of his or her health care maximum benefit, Tomlin points out.
Most health insurance policies have a $1 million to $3 million lifetime maximum, Tomlin says. Case managers need to know what the member's lifetime medical benefit is to assist the member in managing the cost of care to maximize that benefit, she says.
Some dialysis providers may charge up to $500,000 in one year for dialysis care, making it likely that an individual on dialysis could exceed his or her maximum benefit before becoming eligible for Medicare, she adds.
"To be an effective case manager and create the most desirable impact, it's just as important to understand the financial aspects as well as the clinical aspects of managing a complex case," she says.
When a patient's case is complicated, it may be more cost-effective and result in better outcomes if he or she goes out of town to a center of excellence rather than receiving treatment on the local level, she says.
In these cases, insurance case managers can work with their reinsurer to determine the most cost-effective treatment options, to identify centers of excellence, and to help the member understand the options that can optimize his or her medical benefits.
"Centers of excellence have demonstrated that they provide first-rate treatment, and they often can provide care for complex conditions at a contracted price and with better outcomes than a local contractor can provide," she says.