Care Management

Care Management is the global term for a three pronged approach to providing employers and employees better healthcare outcomes and greater savings over the long term.  Most health insurance companies do an awful job of communicating the benefits of these services, let alone providing the service itself.  This leads confusion, misconceptions and disenchantment among employers about just what these plans are supposed to provide. 

Common criticisms of care management programs are that; “a wellness program is not likely to make a sick person healthy” and “disease management initiatives are not useful because they will not prevent someone from contracting a disease.”  Both criticisms are true and also acceptable because doing so is not the purpose of either program. 

We help plan sponsors understand the intended purpose of each type of care management program and work with them to design the best program for their unique group of employees.  Our approach results in greater control for the employer, better services available to employees and overall plan savings in the long term. 

The primary components of Care Management are:

Large Case Management

We partner our plan sponsors with the most effective Medical Case Management nurses who know that managing for a quality will result in the most effective care and cost control. Quality nurses address patient needs, diagnosis and prognosis, care environment and available alternatives. A multi-tiered approach is used to identify potential cases for case management. As a result, our ability to properly identify case management situations is greatly enhanced. This translates into greater savings for our clients. When executed properly large case management should provide business’s with savings of $5.40 per employee, per month.

See RMA Case Study:  How Much Does a New Pancreas Cost?

Disease Management

The effectiveness of your disease management program could be the most single important factor in determining the long term success of your healthcare plan.  What is the status of your current program?

Through strategies of education and compliance management Disease Management addresses the following chronic illnesses:

  • Diabetes
  • Coronary Artery Disease
  • Asthma
  • High Blood Pressure
  • High Cholesterol
  • Depression / Mental Health

Chronic conditions are the leading drivers of rising healthcare costs. Studies have indicated that typically 15% of members with chronic diseases drive 50% of claims costs.

The goal is to prevent a condition that when controlled, is relatively inexpensive, from spiraling out of control into a high frequency, high cost treatment.  For example, when treated, controlled and maintained diabetes costs only a few thousand dollars per year to manage.  However, with gaps in care of left untreated the dollars amounts spent by both an employer and employee are staggering. 

Disease Management programs must encourage members with chronic diseases to actively manage their health, which helps reduce lost work time and hospitalizations while promoting a better quality of life.

Wellness Program

Wellness Services are designed to target the needs of the healthy or potentially at risk population. At risk members are those who are not currently ill, but if not carefully guided and encouraged to improve health and lifestyle habits, can quickly increase healthcare costs. We work together with the employer to provide the employees with one of the most interactive personal wellness experiences available. Our goal is to deliver health and wellness information in a format that is accurate, meaningful and easy to use.

A personal Wellness Coach guides a member through an individualized plan related to specific needs. A Wellness Coach can help members establish personal health goals, provide educational information and counsel members on moving toward positive behavioral change. Wellness Coaches collaborate with the participant to discover interest areas and any recurrent issues that need to be addressed or challenged in a way to create positive change. Participants’ thinking and belief systems are examined from a broad, healthy perspective and the work begins toward specific, measurable goals.

The goals of the programs are to motivate and support those who wish to take charge of their wellness by providing them with weekly topics, instructions, worksheets and assignments that help build a foundation for better health and help avoid the clinical and financial impact of chronic disease.