Putting It Into Practice: Real World Examples Of Where A Medical Director On Staff Made All The Difference
After we published our last blog on the importance of choosing a employee benefits broker with a Medical Director on staff, several readers asked for some specific examples of how skilled Medical Directors like ours can improve patient care outcomes while still reducing costs. So, we thought we would share a few real life examples with you to illustrate the point.
Lowering Expenses, One Member at a Time
An expensive diagnostic procedure was ordered for “Member A” during a follow-up visit with her physician for a potential thyroid condition. Her insurance plan required a pre-authorization for the procedure, which was flagged for review by our Medical Director.
The physician had ordered the procedure to be done at the hospital with which he was affiliated. Member A participated in a high-deductible plan. The particular test to be administered came with a hefty out-of-pocket expense of $2,500, if the procedure was performed in a hospital setting.
With a little research, our Medical Director found an outpatient diagnostic center within five miles of the hospital that could perform the procedure for a $50 co-pay. Coordinating with the diagnostic center and the physician's office, the Medical Director saved Member A $2,450 in out-of-pocket expenses and saved the employer-funded plan the cost of an overnight hospital stay for Member A.
Savings like this can add up quickly over the course of a standard plan year. Member A not only was appreciative of the savings, but also found the outpatient center to be far more convenient.
Mitigating the Cost of High-Dollar Claims
“Member B” received a diagnosis of Chronic Inflammatory Demyelinating Polyneuritis, an autoimmune disease which requires ongoing IVIG therapy. Reviewing the case, our Medical Director found that a 30 percent savings could be generated by moving the therapy from a hospital outpatient facility to an infusion therapy center and using a specialty drug vendor.
This resulted in significant savings for Member B, as there was a deductible reimbursement program offered by the drug company for patients outside a hospital setting.
Member B wasn’t the only one that benefited from the inventive approach of our Medical Director. In this case, the JP Griffin Group's self-funded partner saved over $200,000 per year on Member B's healthcare costs.
Improving Patient Care By Identifying Potential Problems
“Member C”, a pregnant woman, came to the attention of our Medical Director through routine monitoring of pharmaceutical claims. Member C was receiving Progestin therapy. This fact had escaped the notice of the carrier's surveillance team because, as it was a drug claim only, there was no diagnostic code associated with it.
With extensive clinical experience, our Medical Director was aware that Progestin is often indicated for the treatment of premature labor. Armed with this knowledge, we were able to reach out to the carrier's care management nurses to alert them of the need to contact Member C and provide appropriate coordination, education, and pre-term labor support.
Member C benefited from the best available standard of care, and our Medical Director's actions also mitigated a potential catastrophic high-claim exposure for the carrier in excess of $1,000,000.
Coordination with Disparate Agencies
In yet another case, “Member D” and spouse were traveling together in the Southwest. Unfortunately, the spouse fell ill during their trip and had to be admitted to the hospital with acute bronchitis/pneumonia. After a 10-day hospital stay, two weeks of occupational therapy were ordered by the hospitalist in order to strengthen the spouse before the trip home.
Here’s where the trouble began. Because the spouse did not have a primary care physician licensed in the state where the illness occurred, the home health agency providing the occupational therapy would not accept the referral from the hospitalist. Member D and spouse were caught in the middle of a red-tape nightmare, far away from home and in a weakened condition.
Our Medical Director acted quickly to coordinate with the case manager, home health agency, Member D, and spouse to facilitate discharge from the hospital and arrange appropriate occupational therapy.
The Proof Is In The Pudding
These are just a few examples that illustrate the tremendous benefit of partnering with a benefits broker with a Medical Director on staff. We are proud to tell these stories, and proud of the effort our Medical Director and support staff put forth every day on behalf of our employer partners and members.
If you would like more information about how we can help you develop an effective and impactful employee benefits program, please contact us. As leaders in the field of benefits consultancy, we welcome the opportunity to share with you our best-in-class approach to this complicated field.