A businessman travels from India to Mexico. His plans call for a two-week stay in several cities, some more cosmopolitan than others. During the second week of the trip, he develops acute abdominal pain. The treating doctor at a local clinic thinks it is a simple digestive disorder.
However, when the businessman contacts doctors through his insurance company’s assistance line, they are able to establish that his appendix is about to rupture. “He ended up being sent to the US for emergency treatment,” said John Spears, VP for Business Development and Marketing at cost containment firm Global Excel, whose company was contacted by the businessman. “The initial surgery went well, and he was repatriated.”
The patient received the correct treatment because he was assessed by one of Global Excel’s doctors and an accompanying nurse, who are on call 24 hours a day. They form part of the company’s Essential Care Team, staffed with 16 full-time registered nurses, 13 case managers, one in-house medical director, four full-time doctors and two supporting part-time physicians. “In many instances, our doctors are directly involved in reviewing treatments and in validating the appropriateness of admissions and interventions,” said Spears. “Our doctors will leverage their expertise and knowledge of procedures when there is a need to validate and review the treating medical officer’s and primary care physician’s diagnostics.”
Case managers typically lead communications with the hospital to obtain medical updates, and monitor patients’ ongoing emergency care. “Together with our medical director or one of our in-house doctors, they’ll intervene at different levels,” said Spears. Members of the team update family members and regularly meet in order to share best practice on individual cases too.
Traditionally, companies have largely concentrated on ‘containing’ costs after a healthcare event has occurred. But intervening while a patient is being treated, or case management, is becoming more prevalent said Spears. “Healthcare inflation rates average over six per cent worldwide, costs continue to rise dramatically, and this traditional way of thinking needs to change,” he said. “We are convinced that the only way to truly manage healthcare risk is to intervene much earlier in the process.” The idea is to avoid incurring unnecessary costs up front, he added.
The complete package
Cost containment and assistance company MDabroad uses doctors widely. “We think that this is the way the industry handles cost containment now, but its evolution over the years has been relatively slow,” said Max Luvecce, Business and Product Development Manager at MDabroad. “We would not conceive our business activity without a doctor or a medical team.”
Cost containment is more passive an intervention because it involves analysing costs and treatments after the event. The medical team can have a role here too, but it’s limited to analysing a procedure, medication or lab test in relation to the diagnosis declared in the medical records. “However, in case management, intervention is active and aimed at the patient’s wellbeing, as well as analysing the options in real time,” he said. “For example, if a patient should be evacuated, our medical team will intervene and propose it as an option.”
Christian Deloughery, Head of International Business Development at cost containment firm Penfield Care, which has been using doctors since its inception in 2012, said cost containment and proper medical treatment go hand in hand. “Practice has shown that their all-round expertise at the end of the day saves the payer, i.e. the insurance company, a lot of money,” he said. “They prevent overtreatment, incorrect or insufficient treatment, [and] decide on whether or not to medevac/ repatriate.”
Traditionally, companies have largely concentrated on ‘containing’ costs after a healthcare event has occurred. But intervening while a patient is being treated, or case management, is becoming more prevalent
Deloughery said he has seen the unnecessary use of MRI scans or high-level expertise at many hospitals, particularly in the MENA region. “We had one case where the receiving ER staff seemed to escalate as much as possible, not following a ‘normal’ triage procedure – in this case we were even looking at a Joint Commission International (JCI) accredited hospital,” he said. “Through negotiation [with] the hospital, the invoice was limited only to a basic ER visit.”
A thorough service
Healthwatch, an assistance company that provides support in Greece and the Balkans, said its doctors receive medical reports for inpatient cases day by day and update insurance companies. “We are one of the very few companies worldwide that use doctors to control costs. Usually doctors are just used for inpatient cases and for repatriations,” said Healthwatch’s CEO Dimitrios Papapavlou. “We use doctors for every single case, even cases worth €10.” In some more problematic countries, it’s necessary to have two doctors to sign off cases, he added.
Papapavlou said doctors help control costs by investigating the need for long or short stays, IV treatment and observations. They double-check lab tests and scans. He said that his staff check every single file, even simple outpatient procedures, for that reason. “This is done before any guarantee is sent,” he explained. They even perform virtual exams and help patients buy over-the-counter medication over the phone.
Dynamic case management
Savings provided by using doctors in case management vary according to company and region. MDabroad’s Luvecce said 20 per cent can be saved on average. Global Excel measures costs avoided by proactive assistance and case management, and says these vary between 15 and 40 per cent. “We even have clients who have seen a 50-per-cent reduction in outpatient claims costs through very proactive cost avoidance initiatives,” said Spears. Healthwatch’s Papapavlou said the average saving is between 12 and 19 per cent, but rises to 45 per cent in some countries. “Egypt and Turkey are countries we must have an eye on, as well as some new travel destinations like Albania and Kosovo,” he said. The US, too, is a particular case by itself, he added.
Ian Jones, Global Head of Cost Containment at AXA Travel Insurance, said the company’s medical teams around the world are required to demonstrate that cost is considered when evaluating a customer’s needs. “The medical teams are excellent at what we call dynamic case management,” he said. This includes preventing unnecessary treatment, stopping overstays in ICU, appropriate repatriation or moving a customer to a more suitable step-down facility. “The doctors manage the inpatient cases along with teams of nurses and highly skilled claims agents. They determine the treatment plan and try to work hand in glove with the treating doctor in the hospital,” he said. “Having cost-conscious medical staff ultimately reduces claims costs, but without reduction in treatment or care. The customers’ needs are always first and foremost.”
Cost savings are embedded all the way through the claims and assistance process, said Jones. “We consider red flags for fraud, recovery opportunities, overcharging or overtreatment, as well as securing all discount opportunities,” he said. “But I think the key is not to look at cost containment as a separate process. If cost awareness is baked into everyday decision making then it just becomes habit forming.”
“With doctors and the other medical staff being so busy, then it is not productive or practical to have cost containment as a separate process,” he added. “Entwining it into daily activity takes time and effort but ultimately achieves the best outcome in my opinion.”
Jones agrees that certain locations around the world require more oversight of the treating doctor. “But this is of course a generalisation. Not all Mexican hospitals overtreat and overcharge, for example,” he said. “We are all aware of hot spots where customers have been told they have broken legs which aren’t broken or where pacemakers were fitted unnecessarily.”
Having cost-conscious medical staff ultimately reduces claims costs, but without reduction in treatment or care
The biggest problem with some treating doctors, however, is lack of knowledge, especially related to aeromedicine. “Customers can be unnecessarily detained in a foreign hospital because the treating doctor does not think they are fit to fly,” he said. “This is perhaps due to lack of awareness or simply an excuse to charge for additional days hospital stay.”
Healthwatch’s Papapavlou said there are several financial incentives driving hospitals to overcharge, including fierce competition between different insurance companies for lower prices, as well as the seasonal nature of income. “In travel hotspots, doctors work for a period of six to seven months and they have to make up all their expenses for 12 months. This forces them to try and charge high prices,” he said.
It’s both who you know and what you know
Importantly, however, using doctors and medical staff in case management is not just about preventing fraud. In some countries, for example, hospital staff rarely speak over the phone or are bound by privacy regulations and, in such situations, doctors can also help to get information. Some health systems are so complex patients find them difficult to navigate, particularly in the US. “Understanding how the US system works is essential for timely intervention,” said Global Excel’s Spears, whose team is led by a US-trained physician. “Just trying to find the right person to talk to can be incredibly difficult.”
Because so many professionals can have an impact on a case, it’s often not easy to know who to call. “Getting that person on the phone can be a very daunting task for organisations outside the US. It’s incredible how many times we hear from our clients, ‘we called and left a message, but no one called us back’,” he said.
Of course, having a good working relationship with the treating hospital, from admission to discharge, is essential for effective cost avoidance and containment – a point that all the companies contacted by IHHR agreed upon. Immediate updates on the patient’s condition are more likely and can help avoid unnecessary treatments and costs in general.
“Cost containment starts before the case, with agreements, local experience and knowledge. You should know each provider, the license they have, medical laws and local medical council regulations,” said Healthwatch’s Papapavlou. This has an immediate impact on cost containment, he said. “There should not be a TPA or cost containment company without a 24/7 doctor available in 2020.”
Axa’s Jones said good relationships are key to informing future contact with providers. “We develop clear evidence of certain providers who never overcharge.” he said. “They are rare, but when we find them, we cherish them, and we are able to fast track their payments.”
MDabroad’s Luvecce warns that good relationships with any hospital depend on the volume of cases handled with a specific hospital and how fast bills are paid. “If none of those conditions are fulfilled, it will have an impact on your leverage when trying to contain costs,” he explained. “One should be wary of unjustified medical procedures whenever an unknown provider has cared for the patient.”
The key is not to look at cost containment as a separate process. If cost awareness is baked into everyday decision-making then it just becomes habit-forming
The best solution to avoid unnecessary payouts is to use a well-known providers network, said Luvecce. “For example, never use hotel doctors, and have a case management team get involved as soon as possible. We know of many cases where rapid intervention has avoided such abuse,” he said. A recent case was brought to his attention where a hotel clinic charged over US$5,000 for a sprained knee (no X-rays, just medication and a brace).
Integrating technology into the mix
And when it comes to creating a network of well-known and trusted advisors, that’s where technology can be masterfully put to good use. Penfield reckons its dedicated software, named Care Finder and Veritas Claims Management System, helps achieve average savings of over 50 per cent by encouraging patients to use better providers. This eliminates costly issues associated with low-quality, ineffective care, said Deloughery. “The software allows patients to select teams of top-quality doctors and facilities. They can also engage their doctors in using quality and cost information in order to facilitate their referrals to specialty care,” he explained. “Doctors contribute best to cost [containment] when they deliver high-quality care, reducing complications, readmissions and mortality and when they refer to high-quality peers and colleagues and high-quality facilities.”
Technology is vital in helping doctors with case management too. Teleconsultations, as well as peer-to-peer conversations with treating physicians, urgent care clinic referrals and emergency room visits, are all possible remotely.
The importance of having reliably informed medical decision makers is perhaps even more important than ever, given the current Covid-19 pandemic. Assistance providers are among those offering early physician intervention such as telehealth services, pre-visit consultations and digital symptom checkers, which are not only reducing the strain on their local healthcare facility, they are reducing the associated costs of large numbers of inpatient and outpatient visits.
Ultimately, although doctors are vital to contain costs, these trained medical professionals are not auditors. Cost-containment audits and analysis must be carried out by other professionals – so say the companies who employ doctors as part of the case management and cost containment group. “Doctors are an important part of the team, but it is crucial to remember that they will intervene when called on and the rest of claim or case will be dealt with, in its smallest details, by an experienced team member,” concluded MDabroad’s Luvecce.