Advocacy Powers a
Successful Consumer
Health Plan Strategy
Problem
Achieve Sustainable Cost Reductions
A large financial services company needed to achieve sustainable
reductions in health care costs and trends. The company has a long tradition of
disciplined change and had at will and union employee groups. Top management set
the following key change parameters:
- Employee cost share needed to be inline with the company’s competitive set
- Improve member, provider and vendor accountability by continuously analyzing and
benchmarking all health data
- All health management and wellness strategies had to be tailored to the company’s
specific information
- Reduce fiduciary risks associated with health plan administration.
Approach
Actionable Information
- Benchmarked and profiled plan, network and population disease prevalence, cost and
risk drivers. This required obtaining and integrating the employer’s data
from multiple medical and drug carriers to nationally recognized norms which were
customized for the employer’s plans & demographics.
- Established pre-implementation metrics with relevant benchmarks for actions suggested
by an external consultant and approved by management.
Action
Proactive Help & Management
- Consumer Plan: Customer implemented their consumer plan benefits
using HP Tools® benchmarking, modeling and disease
prevalence tools; the information tool was used to price & evaluate consumer
driven medical and drug plan options as well as network alternatives and disease
management initiatives.
- Advocacy with Independent Review – Conduent Care and Quality Solutions
and the company used Advocacy as the employee gateway
service into more aggressive management with Conduent Care and Quality Solutions’
Case & Condition (Disease) Management services
as well as Independent Appeals – here’s
how they did it.
- Step 1: Bond with the Employee –
Advocacy helped employees navigate the ever-changing health care landscape
and independently handle all network, plan and administrative voluntary appeals.
This enabled Conduent Care and Quality Solutions to really help health plan members with
an independent professional voice and review actions taken by the customer’s
carriers and treating providers.
- Step 2: Drive Participation in Management Programs – With
the trust built by the Advocacy program, employees
& their dependents were more receptive when Conduent Care and Quality Solutions’
Registered Nurses called them for Case and Condition (Disease)
Management. By achieving high participation in these programs, Conduent Care
and Quality Solutions was in a much better position to impact the plan’s costs
while providing added value to the members with a one-on-one approach.
- Step 3: Integrated Coordinated Care – Nursing services were
targeted at all stages of the health care continuum:
- Stage I – if patients’ health risk and utilization were increasing,
Conduent Care and Quality Solutions implemented the initial stages of Conduent Care and Quality
Solutions’ Case Management program - reviewing
and establishing a plan of care and benefits available for services. If signs or
leading indicators for chronic conditions were present, Conduent Care and Quality Solutions’
Registered Nurses also invited members into the Condition (Disease)
Management program to dampen future health care spikes.
- Stage II – if patients’ health status became high risk, Case Managers actively assist with referrals, reviewed
services, and coordinated discharge planning with providers – on average,
spending over 5 hours per case!
- Stage III – to manage continuing chronic disease costs, Conduent Care
and Quality Solutions’ Condition (Disease) Management
services focus on self-care and taking the necessary steps to prevent or mitigate
future heath care crises and costs.
- Step 4: Independent Appeals – in the event that a member
did not agree with the results of their claim appeal from the plan administrators,
the member could appeal to Conduent Care and Quality Solutions. Conduent Care and Quality
Solutions’ makes all determinations relative to medical necessity and either
upholds or reverses the claim while assuming fiduciary risk for the company.
Result
Flat Trends, Strong Buy-In
- Flat Trends – Medical and drug costs
(gross of member cost sharing) have remained flat for 2 years. This was during
a period when other employers experienced double digit trends.
- Back to Benchmark – Costs have been brought in line with
regional benchmarks. 5 years of historical monthly information from multiple plans,
medical carriers, provider networks, and pharmacy benefit managers is available
to company through HP Tools® over the web 24/7
and data is refreshed on a monthly basis. Automatic and fully benchmarked rolling
three year Key Indicator report actively used in the plan’s performance management
system.
- Improved Productivity – HR staff workload has decreased because
they can immediately refer clinical, review and/or administrative problems to Conduent
Care and Quality Solutions’ Advocacy, Coordinated Care,
& Independent Appeals programs.
- Better Plan Risk Management – Independent
Appeals has also minimized the plan’s “benefit appeal”
legal risks.
- Employee Buy-In is very good due to the communications, wellness,
Advocacy and Independent Appeals
process along with Conduent Care and Quality Solutions being a completely independent
party.