Vendor Management

Getting the best results from your Disease and Large Case Management Programs:

You depend on your insurance carrier or disease management vendor to improve the health and medical outcomes of your plan beneficiaries. You know that effective case management and disease management will reduce catastrophic events and control claims costs, but how can you tell whether your vendor is delivering the results you need? Most of their reports and presentations are just numbers and activities, so how do you tell whether they are really controlling your costs?

That's were Precept comes in. Using our proprietary Health Management Audit metrics, we can measure their performance accurately and consistently. Referencing best-in-class program results and national benchmarks, we determine whether your vendor falls short, and where room for improvement lies. Working with your vendor, we can improve the services your plan beneficiaries receive, make sure more care is delivered, and improve the financial and service results for your plan. Where your vendor is unwilling or unable to deliver best-in-class results, we can find a vendor who will.

Vendor Accountability for your Disease Management Program:

Your health plan beneficiaries with chronic illness drive the majority of your health plan costs, and their medical claims are often determined by how well they take care of themselves.

Disease management services reach out to those with diabetes, heart disease, lung disease, and other medical conditions to make sure their care is optimal. They review medications, the physician’s treatment plan, the beneficiary’s understanding of their condition and how to care for themselves, and compliance with recommended care. Through a long-term process of coaching and support, disease management nurses help beneficiaries to better care for themselves and incur fewer medical claims.

How can Precept help you get the best Disease Management Results?

Disease management programs are effective only if your beneficiaries receive high quality, consistent and cost-effective education and coaching on their medical conditions. This requires identification, assessment, and ongoing telephonic contacts which are best measured against best-in-class results across the disease management industry. Helping to identify the number of eligible’s who should be part of disease management programs and assuring that these individuals are assessed and that meaningful clinical services are provided are critical first steps. When results are reported, making sure the numbers are real and that they translate into real cost savings and improvement in health status can be challenging.

Precept can help you every step along the way, from evaluating potential vendors and specific disease state programs, to overseeing the identification and assessment of your beneficiaries, to assessing the quality and impact of the services delivered, to measuring the real impact of the program on health plan costs.

Is Disease Management right for your company?

Many health insurers offer disease management programs as part of their insured health benefit products. While there may be some value to these programs, they often enroll only a small number of an employer’s beneficiaries, and provide limited service. Many rely on mailing informational materials, for example, which have little impact on behavior and do not meaningfully reduce medical claims costs. Effective programs include ongoing telephonic coaching between the disease management nurse and the program participant.

Disease management is most cost effective for companies that are self-funded for two reasons. First, only self-funded companies have access to the detailed medical claims that are necessary to identify individuals with eligible medical conditions like diabetes and asthma. While fully insured employers may receive disease management services from their health plan carrier, these programs are usually of limited scope or impact, coaching very few of an employer’s beneficiaries and having little impact on medical costs. Second, self-funded companies will be able to measure the impact of the disease management program on their medical claims costs. By measuring the claims savings delivered through these programs, and by holding disease management vendors accountable for delivering promised results, employers realize the maximum possible return on their investment.

Vendor Accountability for your large case management program

Your plan members who suffer from a catastrophic illness will generate large medical claims, often in excess of $50,000 annually.

The care of these individuals is usually complex, long-term, involving multiple physicians, support services, hospitals and other institutions. It is in these settings where medical errors are most often made, where communications between providers fails and where individuals impaired by serious illness find themselves unable to cope with the emotional burden, complex medical instructions, and an overwhelming number of treatments and medications. In essence, a case manager is a nurse who, though frequent contact and in-depth knowledge of the patient and their care, supports the member in understanding their illness and how to care for it, makes sure that essential care is delivered, avoids expensive treatment alternatives from which the patient will not benefit, and involves a medical director to deal directly with treating physicians when care is substandard or ineffective.

How your company can benefit from Large Case Management

Your company’s health plan will have a small number of catastrophically ill beneficiaries every year, generally less than 1% of your plan’s enrollment. Yet this small number will account for 25% or more of your total claims costs, making this an ideal focus for controlling cost. Intensive oversight and support of these individuals will reduce large claims costs up to 20%.

How can Precept help you get the best results?

A great case management program will identify these catastrophic cases early in the course of their illness. In fact, with predictive modeling some individuals at high risk can be identified and entered into case management even before large claims develop. Once in a program, great case management will include a thorough evaluation and intensive ongoing contact. Evidence-based care protocols, access to information on the best physicians and hospitals available and contracting information to determine the best treatment alternatives will produce the best results. Assuring that a case management vendor is delivering on this promise means making sure that these results are delivered at every step of the way, and that reported savings represent a real improvement in claims dollars spent. Precept has industry-leading expertise in helping employers make sure that these are the results they get from their case management vendors.