MEDICAL MANAGEMENT MATTERS
Medical Management Matters
BY: DEBORAH AULT, RN, CCM, CCP, AATMC, MBA PRESIDENT – AIMM( AULT INTERNATIONAL
MEDICAL MANAGEMENT)“ NURSE DEB”
There are numerous significant benefits for employers to move their health benefit offerings into the self-funded arena, and the fine folks at Qandun are well-versed to go through those with you. However, the move is not entirely without challenges. As business owners, C-suite executives, and others with a vested interest in the overall well-being of a company begin to look at self-funding as an option, they often begin to ask some very pertinent questions: Are we healthy enough to consider self-funding? Is the timing right to make the move to self-funding? Can we get stop-loss coverage that is fairly priced?
These are absolutely the right considerations to have. The problem, however, is that fully insured health plans— and the carriers that you purchase them from— are extremely protective of the data you would need to be able to answer those questions. In the past, what happened was that decision makers had to take a bit of a“ leap of faith” in order to jump from fully insured to self-funded. Fortunately, the typical outcome was a positive one, but as with anything, there was the occasional bad experience. Let’ s face it— nobody wants to be“ that guy” who took the leap to self-funding only to be hit two or three months in with the delivery of premature triplets! It is especially frustrating when that catastrophic event was absolutely foreseeable.
Another“ old fashioned” approach was to have employees complete health questionnaires. It does get some data, but it’ s all self-reported data, and you get everything on the spectrum from the hypochondriac who takes this as an opportunity to tell you about every minuscule cough / cold / sniffle to someone newly diagnosed with cancer who doesn’ t want anybody to know so the employee fails to complete the form( or to complete it accurately).
Now there is a solution for employers who are poised to consider self-funding as an option and who are asking the right questions but are having difficulty getting the information. We developed a product called the Bridge Program. It is an adjunct employee benefit offering. It absolutely does not interfere with or disrupt your current fully insured plan at all. In fact, it enhances your members’ experience with their health plan. Let me explain.
First, this product gives your health plan members 24 / 7 access to a professional nurse who has advanced expertise at helping them to navigate both the health care delivery system and their health plan. They now have a concierge to hold their hand through a health event. Someone to help them be as healthy as possible, as quickly, efficiently, and effectively as possible.
Secondly, it provides an online Health Risk Assessment survey that looks both at current conditions and future health risks. It gives the patient a meaningful and insightful report to take back to his or her doctor as a health conversation starter and health risk mitigation stimulator.
Third, it ensures, via the“ Happy Birthday Health Drive,” that outreach to every member of your plan occurs. There’ s no better time to tell your employees that you care about them, and you want them to be healthy, than around their birthday. It’ s also a great time for people to take stock of their overall health and to ensure that they are doing their part to stay healthy for the future years to come. We engage the members of the plan conversationally, making sure they have an appropriate primary care physician relationship; informing them of what a good head-to-toe annual physical should include for someone of their age, gender, and lifestyle; and assessing their current health issues or concerns.
All of these interactions give us a large data set from which we can then answer the following questions: Are we healthy enough to be self-funded? Is now the right time to switch to self-funded? And it also gives us the clinical information needed for solid clinical underwriting of the plan— helping you get that fair and reasonably priced stop-loss or join that captive you really want to be in. It’ s no longer a mostly blind leap of faith. Now you’ ve got actual clinical underwriting— all handled by an independent, outside clinical agency— protecting you from HIPAA risk!
Once a group becomes self-funded, its opportunities explode! As fun as that can be, it also brings its own unique set of challenges. It’ s imperative that these first tender years of being self-funded get handled with special loving care! Often I see groups make the conversion to self-funded in an unmeasured and haphazard way, and they ultimately suffer the consequences for that.
Here’ s what I mean: a self-funded group has a great deal of autonomy in terms of coverages, premiums, specialty products, and the like that did not exist when it was fully insured. One potential weak point creeps in when the group fails to engage the right advisor to assist them during these important formative years. The right advisor will get to intimately know the self-funded health plan sponsor— its culture, its motivation behind offering health benefits, its population, and the things that are unique to the group. That advisor will then take responsibility for identifying which vendors the group should consider to deliver the critical elements of its health plan.
This is crucial. If the advisor does not take the time to truly understand the goals, objectives, and tolerances of the group, then it’ s unlikely that the advisor will select the
6