Specialty products may save you money
Companies offer niche services
New health care companies are springing up that promise to save managed care organizations money while increasing member satisfaction, and they deliver on that promise in many cases. In addition, many times these companies achieve better clinical outcomes by focusing on small components of patient care rather than on care across the continuum.
"We've developed a service we call PathWorks Episodes of Care," explains Vi Karr, CCM, CVE, MBA, chief operations officer for MedSmart International in Costa Mesa, CA.
"We start by evaluating the patient before the medical event, such as a surgery, and put together an entire package of services that includes case management."
MedSmart's PathWorks Episodes of Care focuses on high-volume cases that are usually resolved within 30 days, such as joint replacement, Karr says.
"We begin by assessing medical necessity. Then we evaluate the home prior to surgery. We train local home health agencies to do home evaluations. We often uncover comorbidities or psychosocial problems the surgeon is unaware of. Addressing these issues before surgery can reduce complications and costs."
In addition, MedSmart unbundles hospital bills by developing direct relationships with manufacturers of surgical hardware and other equipment.
"Payers don't always realize that items like joints and implantables used in the operating room and included in hospital bills are marked up an average of 50%," Karr says.
MedSmart also offers another service, Buy-Smart, which is available as a component of its PathWorks packages or as a stand-alone prod-uct. BuySmart provides case managers with cost comparisons for a range of product brands at wholesale cost without provider markup. Items such as bone stimulators, high-tech prosthetics, and custom wheelchairs also are available at substantial savings through the Buy- Smart service.
Network facilitates provider choice
A Florida company saves money for managed care organizations by focusing on the home care aspects of the patient care continuum. "We use an independent home care network. We are not a provider, but a home care network management company," says Richard J. Harris, senior vice president of CHCS in Sunrise, FL.
"We have proprietary case management and information systems that result in reduced cost and increased member satisfaction in virtually every case we handle. And, because we are not a provider, we can select the most appropriate provider in the network for each patient," he explains.
CHCS doesn't replace the managed care case manager, but simply manages the home care component of the patient's care. "We micromanage the home care aspect of the case. It gives the managed care case manager an opportunity to look at the patient globally and holistically," explains Susan Zimmerman, RN, CCM, ABQUAR, chief operating officer of CHCS.
One contract, not 15 or 20
"We also [give] feedback to the managed care case manager - lots of information they never had access to before. We simplify their job. In the past, the payer may have had to contract with 15 or 20 providers of home care services. Now, they simply contract with us," she says.
CHCS manages home care services for a capitated fee. "If we assume risk, then we need to put our money where our mouth is," Zimmer-man says. "We put together a case management level within our structure to protect ourselves and the quality of our services."
Case management delays skilled nursing
Recently CHCS developed a long-term capitated custodial care product, Harris says. "It's a new benefit that provides non-skilled care to Medicare risk plans. It's the first step in bringing long-term care to managed care plans and their members."
The long-term care product also uses case management, Harris explains. "Our case managers access alternative service providers such as Meals-on-Wheels programs whenever possible. They facilitate member access to community services and delay the need for skilled nursing."
Of course, when it comes to unskilled care, the question of reimbursement arises. "Medicare doesn't pay for these services. Medicaid often does pay. CHCS is positioning itself to facilitate between long-term care and managed care," he says.
[Editor's note: For additional information on PathWorks or BuySmart, contact: MedSmart, 1675 Scenic Ave., Costa Mesa, CA 92626. Telephone: (800) 652-1134. For more information about CHCS products, contact: CHCS, 2770 46th St. NW, Boca Raton, FL 33434.]
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