In 2019 when Flume Health stepped in to replace Blue Cross Blue Shield with our transparent self-funded model, we found a problem even worse than out-of-control premiums: member health was being neglected.
The patient in question had been suffering from lung problems for six years, but the incumbent had never actively managed his care. A few months into the Flume Health plan, he ended up in the ER with severe chest pain, and the ER doctor called for a full lung transplant.
Left on his own, statistics show the patient would have gone straight to the referred hospital to join the waitlist, without realizing he had other options. The plan sponsor would have paid the bill regardless of whether it was overpriced, and the status quo would have rolled on...
Instead, Flume Health was able to step in at the pivotal moments of his care journey with a mix of high-tech, high-touch processes to steer the outcome toward a win-win for the patient and the plan.
Here are the steps taken whenever a client receives referral for a high intensity item:
As part of every Flume Health plan, pre-certification is conducted on major procedures during concurrent review. This is a built-in feature that swiftly analyzes high-volume claims for fraud, waste, and abuse, while picking out the big ticket items for personal review by our experts. In this case, the surgical recommendation triggered Flume Health's integrated medical management partner, AIMM, to look into the case. AIMM focuses on identifying providers with the best outcomes and preventing overtreatment. The question here was: was their local hospital the best place to have the procedure?
Overnight, Flume and AIMM's integrated systems searched for all available providers of the lung transplant surgery. Using the patient's current specialist as the geographic benchmark, six (6) other hospitals were identified within a similar distance that classified as Centers of Excellence (COEs). Each of these COE's were scored based on 5 key clinical data metrics in order to create a ranking for each facility: 1- and 3-year survival rates, readmission rates, waitlist length, the facility’s willingness to share data, and the bundled rate for the procedure.
The highest scoring hospital was not the same hospital the patient's ER doctor had recommended, but an internationally accredited research hospital within driving distance of the patient. It had better survival rates for this particular surgery, lower readmission rates after 3 and 6 months, and a shorter waitlist for lung transplant. Not to mention the price for the surgery was $150,000 cheaper than at the incumbent hospital.
⬆️In the optimization phase, providers are scored on clinical rankings such as
waitlist time, survival rate, readmission rate, and whether or not the facility has an open data sharing policy
Once they had these results, Flume's account management team arranged a call with the Advisor and the Plan Sponsor to explain that they had found a higher value alternative that the patient should be aware of before signing to go in for surgery.
The three of them called the patient and walked him through their process. If the patient chose the higher-value option, not only could they get a better surgical outcome, but the cost savings to the plan could be passed through to them: the surgery would be free. The difference in price at this better hospital was so large, in fact, the plan sponsor even agreed to pay for transportation to and from the hospital, their overnight stays, and full paid leave during their recovery period, along with the cost of the procedure.
Meanwhile, Nurse Deb from AIMM had already contacted the hospital to get them to pre-approve the patient for surgery if they decided to come there. She even put the patient's name on their waitlist in order to get him into the O.R. as quickly as possible.
At the end of the day, it was the patient's decision where to do the surgery. Many plan members love and trust their current doctors, and the patient did ultimately decide to stay at his current care provider. The plan still covered the surgery, as well as several follow-up appointments. Regardless of where a patient ends up getting care, it’s a health plan’s responsibility to make sure they’re empowered to make an informed decision.
In the final installment of our recurring series on healthcare arbitrage, we round up a few other tactics which don't require as much ongoing involvement, but which can still provide important savings opportunities.
In the latest installment of our recurring series on healthcare arbitrage, we break down how plans can use disease management programs to reduce costs associated with chronic diseases.