The Medical Savings Account Program Model For Employers
V. Active Clinical Case Management

Review of claims experience confirms 1% of the population accounts for up to 30% of medical spending. 5% of the population accounts for 50% of consumption of all medical expenditures.50Claims management can effect savings in these cases. Intensive oversight, review, and adjudication of large numbers of small claims produces some benefits but is as expensive as the process is extensive. Measurable value results when strategies are developed that focus both on early identification of large case expenditures and enabling informed consumers.

Active Case Management

Active management, coordination of services and, avoidance of inappropriate procedures contribute to improved use of medical resources. Large case claims management processes can be purchased as stand-alone services, separate from the health insurance policy; or they can be bundled with high deductible insurance. Most insurers provide large case management within their risk packages.

Applied with sensitivity and judgment, managed care can be an effective cost-control technique. The question remains how and from whom to purchase those managed care services that will best balance the interests of the patient with those of the organization.

"Some MSA programs include provisions for the company to pay for preventive medical examinations, immunizations, and diagnostic tests."

Effective managed care services may be prenegotiated and included in risk sharing agreements made with provider organizations, networks, or health plans. For insured plans, these arrangements are almost always factored into the premium for the catastrophic health policies. The added price of the premium correlates directly with the degree and intensity of included managed care services.

Self-insured companies can arrange to procure similar services in contracts with selected provider organizations and health plans. Arrangements for risk sharing may also apply. In any arrangement where large claims management is not specifically included in the contract, separate procurement of large claims management is essential to lower the attendant risks.

The employee ombudsman

Additional support may be provided through an ombudsman. The ombudsman acts specifically as employee advocate when modified work, child care, or family emergencies become an issue. If these problems are not addressed with sensitivity and empathy, employee attitudes can deteriorate, productivity suffers, conflicts arise and costs go up. The employee may turn to legal recourse with all its attendant costs and consequences.

Early intervention and satisfactory resolution can prevent these losses. A sincere effort applied in a timely manner often turns the situation from an employee seeking redress as a victim to an advocate for a caring company that goes the extra mile for its employees.

Some employers may retain a physician to act as a medical advisor on complex and more costly healthcare problems. This might include consultative services, independent medical examination, and use of additional specialists. Trained medical advisors can often mediate unresolved disputes between health care providers, third party administrators, and insurers. Additional responsibilities might include review and coordination of services between workmen's compensation programs and the employee health plan. The medical advisor can assess medical claims, utilization of services and tests, and verify the necessity and appropriateness of services.

Effective medical advisory functions often begin prior to major injury or illness. Prevention can include employee education, advice, and training at the frontline and production levels. Informed employees make better choices that impact not only their lives but the mood and morale of the company.

Other medical advisory functions may involve company focus meetings with selected "informal leaders." Such meetings last about two hours each. Topics can cover many areas of interest including uses, advantages, and abuses of the MSA and the excess risk coverage plan. Health problems affecting either individuals or the group can be explored and employee questions answered on the spot. The information gathered at these meetings is invaluable and can assist the employer to tailor a program that will be accepted by frontline staff and supervisors, while satisfying the interests of unions, governmental regulators, and the medical community.

"Additional support may be provided through an ombudsman. The ombudsman acts specifically as employee advocate when modified work, child care, or family emergencies become an issue."

"A sincere effort applied in a timely manner often turns the situation from an employee seeking redress as a victim to an advocate for a caring company that goes the extra mile for its employees."

Using competent medical advice enhances employer control over the cost of care. It also enhances the employer's relationship with employees because the employer is pro-active in assisting employees through difficult health issues. Employers need to determine the roles and relationships intended for this level of medical advice at the worksite. Important questions include:

• Is the physician the agent of the company?
• Is the physician acting as the agent of employees?
• How are matters of personal privacy to be handled?
• Who will have a right to access to medical information provided to the physician advisor?

Failure to address these questions and establish reasonable policies in advance can produce very unsatisfactory situations for employees, providers, and employer.

Evergreen Freedom Foundation P.O. Box 552, Olympia, WA 98507 Phone: (360) 956-3482, Fax: (360) 352-1874 Email: effwa@effwa.org