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Look Who's Watching Your Health Expenses
by M.P. McQueen
Monday, October 1, 2007
provided by

In a bid to control spiraling health-care costs, a growing number of employers and health insurers are turning to services that essentially audit an employee's health care and look for ways to both improve outcomes and save money.

But critics contend that some of these programs intrude into the private relationship between patients and their doctors, and that they add yet another layer of bureaucracy, while saving money mostly by denying or switching specific drugs and procedures.

The services are provided by companies known as care managers or integrated-health managers. Healthways Inc., ParadigmHealth Inc. and others in the business often review doctors' treatment plans to make sure they conform to evidence-based practices established by medical standard-setting bodies. Based on the results of these reviews, the companies then may nix certain drugs or procedures. Some services also help coordinate care for seriously ill people, including finding appropriate hospitals and therapies, and helping them deal with the tangle of health-care red tape.

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Some care managers also provide medical second opinions, with the idea that an incorrect diagnosis can waste money. J.B. Hunt Transport Inc. and ConAgra Foods Inc., for instance, offer their employees the second-opinion services of Best Doctors Inc. as a free, voluntary benefit: Workers and their families aren't required to use the service and don't have to take the advice.

Care-management companies have been around for years, offering various services mainly to hospitals. Recently, though, these companies have begun marketing to large employers, including PepsiCo Inc., Principal Financial Group Inc. and EMC Corp. Today, there are more than 200 care managers providing programs designed to save employers and health plans money by reviewing employees' health-care claims and targeting high-cost cases for special management, according to research by consulting firm Deloitte & Touche LLP.

But as the use of care-management providers has spread, so has a backlash from some patients, especially when the services aren't optional.

Edite Donatelle, a 46-year-old physical therapist in Park Rapids, Minn., says she found care-management services provided by her insurer, Blue Cross-Blue Shield of Minnesota, to be intrusive. She says she received repeated phone calls about her asthma and her husband's multiple medical issues, even when she asked them to stop.

"I don't want to talk to a stranger on the phone about my health care when it is being controlled very well by my doctor," Ms. Donatelle says. "I don't see the need for another stranger in the mix."

A spokeswoman for Blue Cross-Blue Shield of Minnesota declined to comment on Ms. Donatelle's case, but said: "Our research shows that over 90% of members who participate with our care-management programs say they are satisfied or very satisfied with their interactions in the programs."

Other critics say care managers can be rigid, not taking into account differences among individual patients, and the judgment of doctors and nurses on the scene.

"The patient's physician should ultimately be the one in charge," says Cecil Wilson, immediate past chairman of the American Medical Association. He says care-management programs can be helpful in delivering quality health care so long as cost reduction isn't the primary consideration.

But care managers don't always steer patients to the least-expensive drugs and procedures. Jamie Rochowiak, a 31-year-old mail handler at Hess Print Solutions Inc. in Brimfield, Ohio, says she had suffered several ministrokes but still couldn't quit smoking. She says a care coordinator from Quantum Health Inc. intervened to get her employer's health plan to cover an antismoking drug after her claim initially was denied. "They got me approved for a prescription that I really needed that wasn't covered by my insurance. They have helped me out tremendously," she says.

Stacey Irvin, vice president of human resourceat Hess, says employees were initially reluctant to participate in the Quantum optional care-management program, even though workers get a discount on their health-care copayments if they do. Ms. Irvin says Hess has also introduced on-site wellness and other programs that together have helped to reduce the company's current health-care expenditures to about half of their historical trend. That, in turn, has helped Hess keep employees' share of health-plan premiums level for the past three years, she says.

Other care-management firms provide second opinions. Best Doctors says it has a network of 50,000 medical specialists around the world who review case files looking for wrong diagnoses and ineffective treatments, particularly for life-threatening illnesses and injuries, at an average cost to large employers of $2 to $3 a month per employee.

Gail Corbett, a 45-year-old executive assistant in Medway, Mass., says her employer, EMC, contacted Best Doctors after she was admitted to a community hospital last month with a severe headache that a magnetic-resonance imaging test indicated was a benign brain tumor. Best Doctors had Ms. Corbett transferred to Brigham and Women's Hospital in Boston, which the firm said was the best facility for her condition.

Ms. Corbett says her case manager cut through red tape to schedule her surgery immediately rather than having to wait another week, as she was previously told. Later, when a complication arose during postsurgical recovery at home -- blood clots in her lungs -- the same case manager saw that she was readmitted to Brigham for treatment by the same surgeon who performed the initial operation.

Ms. Corbett, who recently returned to work, says the additional service meant that "my husband and I could focus on the situation and what we were going to do." She says she didn't have to pay any additional fees. "I think it is one of the best benefits they [EMC] have implemented."

Delia Vetter, senior director of benefits at EMC, says that since the company started offering Best Doctors services to its 20,000 North American employees and their dependents in January, EMC has saved an estimated $100,000 or more, mostly by avoiding inappropriate medical procedures. She says of the 37 cases at EMC that Best Doctors has reviewed, 14% of them have had a change of diagnosis, and 89% a change of treatment. Best Doctors also has provided EMC employees with 107 referrals to specialists and hospitals so far this year, she says.

Best Doctors president Evan Falchuk says the company typically saves money for employers by recommending less invasive procedures that require fewer days of hospitalization and less recuperation, and by avoiding serious medical mistakes.

PepsiCo and Principal Financial say they contract with ParadigmHealth to coordinate care for some of their sickest employees and dependents, including those suffering from rare cancers, complex neonatal problems and severe injuries including paralysis. ParadigmHealth says it refers these patients for support services such as long-term rehabilitation. Other cases are referred to programs for management of chronic diseases such as diabetes and asthma.

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Posts: 3875 | From: ca. | Registered: Jul 2005  |  IP: Logged | Report this post to a Moderator

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Unfortunately, another thing that i think will happen is that some employee's with larger medical problems will get replaced on the job with an indivual that has less medical problems and expenses.

These care managers seem to already have access to our medical records without our direct consent.

There might be clauses in the medical forms we sign that allows these care managers access to our medical records in roundabout wording?

Posts: 3875 | From: ca. | Registered: Jul 2005  |  IP: Logged | Report this post to a Moderator

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