| Utilization Review Management makes $8 million | | | | self-funded health plan's claims costs. The usage |
| difference for JCWS Health Plan | | | | of evidence-based clinical care guidelines was |
| Utilization Review Management Situation | | | | executed in a step-wise approach allowing the |
| Like several American businesses, ever rising | | | | health plan to realize opportunities for immediate |
| expense of healthcare has been drastically | | | | impact and reinvestment of saved resources into |
| impacting on Johnson Controls World Services | | | | additional services. This new approach yielded |
| (JCWS). Their particular self-funded health plan | | | | steady progress toward meeting JCWS's goal: a |
| trust encompassed 14,000 personnel who're | | | | population that is well-educated, and empowered |
| spread out over more than seventy US locations | | | | to utilize preventative health strategies, early |
| and a minimum of ten international cities. The | | | | intervention for health issues, and best-in-class |
| populace had been separated in half with | | | | medical care. Resources were able to allocated to |
| approximately fifty percent of the associates | | | | areas of highest need through the specific, |
| assigned to government contracts and fifty | | | | actionable results of data mining. Outbound calls |
| percent to private. The health plan had been | | | | started with the top 1% of claimants in cost and |
| facing DCAA direction to be able to segregate | | | | or risk. |
| the trust funds into independent government and | | | | Once the 1% was completed, the top 5% were |
| private accounts, had simply no trustworthy | | | | addressed. Additional condition specific areas |
| claims experience, has been encountering | | | | where JCWS's occurrences and or spending were |
| astonishing substantial claim costs, and had been | | | | out of proportion to national averages |
| predicting a 2.1 million dollar deficiency on 12 million | | | | benchmarks were addressed. The group's |
| dollars in claims. | | | | covered members were provided with |
| Once the resources were segregated the total | | | | one-on-one interactions with RNs. Members asked |
| amount within the federal government part of the | | | | questions and offered informative details that RNs |
| trust began to diminish at an alarming rate. | | | | used to further assist them in becoming |
| Exploration of the cause concluded in various | | | | educated, empowered consumers. Consistent, |
| areas of concern. To begin with, the commercial | | | | dedicated communication between THE ANCHOR |
| side of the trust had seemingly been subsidizing | | | | GROUP and members developed a relationship |
| the federal and the federal populace seemed to | | | | and trust in the plan that was rare in previous |
| possess a higher risk profile. Secondly, 31 individual | | | | years. The use of the PC3M® model also |
| claimants accounted for 39.4% of the annual claim | | | | provided the ability to measure the impact of |
| experience in 2003. Two individual claimants | | | | interventions from a clinical quality stand-point, a |
| accounted for 8% of the plan's total claims | | | | patient satisfaction stand-point, and from a |
| increase. Over the same time frame, individual | | | | financial stand-point. |
| claims in the $20-49K range had elevated by | | | | Results |
| 61%. Every one of these issues ran JCWS's | | | | JCWS was grossly aware of the deficits in their |
| average claims charges 24% higher than their | | | | health plan. The first step to securing their future |
| TPA's book of business. This was a unacceptable | | | | was initiation of Utilization Management, Case |
| rate for just about any group to face. | | | | Management, and Maternity Management. Not until |
| To address the problem, the Company instituted | | | | results of this first claims analysis were they able |
| weekly supervising along with reporting of trust | | | | to visualize the depths of the previous deficits. |
| assets, monthly executive reviews, innovative | | | | This inaugural step was able to decrease the |
| trust payments, and made mid-year adjustments | | | | projected claims by $54.11 PMPM. The number of |
| to the plan. The erosion of benefits and also | | | | hospitalizations per 1000 members was down, as |
| growing payments were not well accepted with | | | | well as the length of stay for each of those |
| this populace who had bathed within the ease and | | | | admissions. The second step was to identify and |
| comfort regarding stable premiums for 2 years. | | | | rank the plan's issues with a now-solid database. |
| Despite these kinds of significant efforts in place, | | | | Individual members and general trends were |
| JCWS nevertheless suffered double-digit inflation, | | | | identified and interventions were put in place to |
| an expected $3.6 million dollar short-fall, and 40% | | | | evaluate and alleviate projected costs. Step three |
| Collective\Bargaining Agreements, along with | | | | of the Step-Wise Method of Implementation of |
| increasing workforce dissatisfaction inside a highly | | | | PC3M® was to sit down and do something with |
| aggressive marketplace. | | | | the facts on hand. Registered Nurses start |
| Answer Description | | | | touching individual patients through outbound |
| In an effort to uncover some method of | | | | phone calls and mailings. These nurses have been |
| reversing the increasing costs that up to now had | | | | trained to not only educate the member on the |
| merely been slowed, the plan chose to refocus | | | | condition that identified them but also on any |
| by realizing along with adopting a few fundamental | | | | other facts that present themselves through |
| health plan and health care concepts. The plan | | | | thorough evaluation. |
| recognized what they referred to as "basic truths | | | | Risk Indicators and overall claims dollars spent |
| about health care": | | | | were used as "triggers", not just the top |
| Quality Treatment Costs Much less | | | | conditions as in older medical management models. |
| Most Participants Don't Have a clue on | | | | Population Management Initiatives were developed |
| Selecting Top quality Providers | | | | based on data mining results. These included a |
| Patients with Advocates within the | | | | six-month drive on key issues identified in this |
| HealthCare System Get Much better Outcomes | | | | population as well as direct mailings to high-risk |
| Non-Compliance is actually Harmful as well as | | | | members. The next step was to identify risk |
| Pricey | | | | using data and surveys. This simple and relatively |
| A Small Portion within the Populace Accounts | | | | inexpensive step had several unexpected results. |
| for a large percentage of the entire Cost | | | | Members actually reported making lifestyle and |
| (Beginning/End State) | | | | health behavior changes based solely on the |
| Most Diagnoses is done via Laboratory Work | | | | survey. A better understanding of lifestyle |
| The Initial Part of Medical Information is by | | | | behavior issues that were driving the health |
| way of Laboratory Work or Rx | | | | conditions in the population was revealed through |
| Prevention Costs Less When compared with | | | | claims mining as well as the ability to begin |
| Treating Disease | | | | predicting the next year's issues and proactively |
| Most Long-term Conditions Possess Expected | | | | address them in hopes of averting them. This |
| Patterns | | | | self-assessment also brought to light the impact |
| People Will Take the road of Least | | | | corporate culture had on health care costs. |
| Resistance, Including the Path regarding Lowest | | | | At the end of year one of these interventions, |
| Charge | | | | the self-funded health plan had gone from a 3.5 |
| The plan set out on a mission to choose a | | | | million dollar deficit to a 4.5 million dollar surplus! ER |
| partner who could address these issues. The | | | | visits almost disappeared, and premature babies |
| fundamental premise was to follow the data to | | | | virtually disappeared. The savings were used to |
| identify the specific areas that required attention. | | | | enhance benefits, and the plan now offers |
| The objectives included improved employee | | | | preventative health services at NO COST to |
| satisfaction, improved healthcare quality, | | | | members. The financial results from year 2 |
| decreased absenteeism, increased productivity, | | | | interventions will soon be through the auditing |
| and finally overall control of health care costs. Ault | | | | process. In year 3 the plan will continue their |
| International Medical Management (A.I.M.M.) was | | | | current services with A.I.M.M. and will enhance |
| selected to partner with the health plan to provide | | | | those services to take an even more assertive |
| PC3M®, a unique Patient-Centric Comprehensive | | | | stance on preventative health initiatives. Medical |
| Care Management model of medical management | | | | claims costs for the self-funded health plan |
| services. | | | | continue to decrease and the plan has completed |
| The PC3M® service focuses on improving health | | | | avoided all cost escalation for 3 years, even with |
| care quality through patient education and | | | | increased coverage and benefits, and no increase |
| empowerment as a means of decreasing the | | | | in employee cost-sharing. |