Quadruple bypass surgery: the story of a persistent case manager

Not too long ago, a 65-year-old man from the UK was admitted to an Illinois hospital for quadruple bypass heart surgery.

We believe a full-service risk management approach includes both containing and avoiding costs.

The charges for his treatment were quoted anywhere between US$250,000 and $300,000, and possibly even more. The treating facility did not have a contractual relationship with Global Excel but offered an average discount of around 30%.

We believe a full-service risk management approach includes both containing and avoiding costs.

Through aggressive case management and persistence, we were able to have this patient transferred to a high-quality, Global Excel-contracted facility about 29 kms (around 18 miles) away for his required treatment, avoiding $165,750 in excess charges – a net 65% in savings on his initial medical bills.

Our patient underwent a successful, clinically necessary, quadruple bypass heart surgery

The clinical situation

Medical staff at the original facility had insisted that a transfer could place undue stress upon our patient, but our medically trained case manager and our medical advisor persisted, underlining that our patient’s state, though urgent, was not emergent, and was currently stable enough for a transfer.

After speaking with our Medical Director, the initial facility approved the transfer to the contracted facility, where our patient stayed for six days (the average stay is over nine and a half days for this type of surgery).

Our patient underwent a successful, clinically necessary, quadruple bypass heart surgery that met Milliman guidelines. Home health was also required and was arranged through a contracted provider.

Originally, he presented with multiple comorbidities, chest pressure, and dyspnea. He was found to have an N STEMI (non-STelevation myocardial infarction) with diffuse 3-vessel coronary artery disease on the left heart catheterisation, requiring a coronary bypass without catheterisation.

In Global Excel’s view, orchestrating the member journey means doing what is best for the member, within their policy benefits. Getting involved early in the process of determining a patient’s healthcare needs is essential for steering them to the right type of care. Member safety is always top of mind, ensuring the receiving facility’s quality of care is equal or superior to that of the previous one, and that all stakeholders (the member, their family, and our client) agree that a transfer is the best option.

Getting involved early in the process of determining a patient’s healthcare needs is essential for steering them to the right type of care

The financial results

Our case management team proactively identified a costly case early on and maximised savings opportunities by steering our patient to a high-quality, cost-effective facility. By liaising with the inpatient negotiation team during medical rounds for the charge estimate and average savings, they successfully avoided about $85,000 in facilities fees alone.

Medical rounds can include regular, interdisciplinary reviews of high-risk cases or destination medicine around the world: patients in facilities not suited to their illness, or abusive, over-charging facilities. This involves financial, client-facing and coverage teams, medical staff and, if necessary, our legal expertise.

A direct contract resulted in a deep discount and significant savings at the receiving facility where the coronary bypass surgery was performed

A direct contract resulted in a deep discount and significant savings at the receiving facility where the coronary bypass surgery was performed. After successful cost avoidance and containment, the final payable amount to the hospital was $89,700; the equivalent of 1.7 times cost and a significant value to our client.

Our conclusion

Persistence is key!