Jim’s Take

The “Little Stuff” Matters

Ever heard the statement from your broker that “the claims are what the claims are?”

Brokers mouth those words all the time. Carriers say the same thing — except they all add the additional phrase, “that’s why you should be with us, because our discounts are better than the other guy’s discounts.”

What both are saying is that when trying to get the lowest price for your health care, the claims are incidental. What controls the price isn’t the claims themselves … it’s the processing system that handles the claims.

It’s a complete lie!

And if you believe it, you’re going to pay a never-ending series of increases going as far out as the eye can see.

But, Jim, Can You Prove What You Say?

But of course. Let me tell you about one such “little thing” and tell you the difference it made.

Our Utilization Management partner (yes, utilization management, not utilization review, which is what you get from unimaginative brokers and run of the mill TPAs and carriers) recently proved it with a tiny little thing.

Surgical errors are a leading cause of medical injuries (the 3rd leading cause of adult fatalities, according to a Johns Hopkins study). Our Utilization Management partner believed that perioperative teaching of patients could significantly reduce surgical errors and post-operative complications.
Are you kidding? Perioperative, according to Wikipedia refers to “… the time period of a patient’s surgical procedure. It commonly includes ward admission, anesthesia, surgery, and recovery.”

What in Heaven’s Name does the patient – your employee – have to do with ward admission, anesthesia, surgery and recovery? She’s just there to get the treatment, do what she’s told and shut up, right?

Wrong, Bucky! At least that’s what our Utilization Management partner thought. And they tested their hypothesis in conjunction with a cooperative employer and its large employee base. Here’s how their test went.

Here’s How It Was Tested

The Utilization Management partner’s theory was that a patient-centric model of treatment was the best course, and they felt that could be accomplished by better patient education.

Patients/employees were contacted both prior to elective surgical procedures and soon after discharge from surgical procedures. The Utilization Management partner discussed with them topics like

  • whether all their durable medical equipment had arrived
  • what to expect in the upcoming procedure and the recovery period
  • what questions patients typically had about medications
  • a review of warning signs that would warrant communication with their doctors

Some calls from the Utilization Management partner resulted in the discovery of potentially serious complications which were given the medical attention they required before another hospitalization occurred.

One Year Results

Surgical admissions dropped from 19.7/1000 employees to 10.8. That’s a 45% reduction in admissions – which of course included re-admissions after surgery.

Average length of stay in hospital was reduced by 44% in the first year, and it dropped another 16% in year #2. Think about that fact and then combine it with the fact that the average cost of a hospital (just for room and board) is $5,500/day.

The number of people who had more than one hospital admission in a 12-month period dropped by 30%.

Why did it happen? First, patients were more aware of what was going on and were more involved in their entire treatment process. Second, part of the training taught the patients to insist that their doctors justify WHY they were doing what they were doing and to demand that their doctors practice evidence-based medicine.

Other good stuff happened because of the Utilization Management partner’s involvement in patients’ medical treatment plan. Two cases demonstrate that impact.

Case #1 – Our Utilization Management partner got a request from a hospital to pre-authorize a cancer surgery. They called the patient and discovered that she didn’t have throat cancer — she had breast cancer and was scheduled for surgery at the same hospital.

Her identity had been stolen. Our Utilization Management partner worked with the hospital to assure that the medical records of the patient and the thief weren’t compromised, and then the hospital arranged for the police to be there when the ID thief showed up for her next appointment!

Case #2 – A 39-year-old man was going in for routine surgery. Our Utilization Management partner went through the standard pre-operative discussions. When they followed up after the operation they discovered that – thanks to their training – the patient had gone to the emergency room when he suffered red, painful swelling around the knee.

He discovered he had Deep Vein Thrombosis, i.e. a blood clot. He told the nurse that had he not had the pre-treatment training he would probably have thought it was normal and would have not gone to the ER.
U Mass Medical Center for Outcomes Research says that 50,000 knee surgery patients die from Deep Vein Thrombosis EVERY YEAR!

So how do you put such a program into effect at YOUR health plan? Simple, you call BBI. Or click this link and ask for more information: jedholm@bbibenefits.com