Integrating Medical Solutions

How communication can improve both quality of care and your bottom line

Your employees go to the dentist and to the doctor. They call nurse help lines and visit the eye doctor. They use employee assistance programs and go on disability.

But in many, if not most, cases, those individual silos of health care are not communicating with one another.

Now imagine a system in which all facets of the health care system work together to offer integrated care and lower costs, and you've got an integrated medical solution, says Mark Haegele, director, sales and account management, at HealthLink. "Under a truly integrated medical solution, all of those components talk to each other," says Haegele. "They have a continuous feedback loop, with medical talking to dental and a nurse line talking to disease management."

Why are integrated medical solutions important?

There are multiple components of a traditional benefit plan, including medical, dental, disability, vision, life, employee assistance programs, disease management, lifestyle management, medical management, case management, nurse lines and other things. And the industry is just beginning to recognize the importance and value of the information associated with each of the components and their implications for other components.

It is just now understanding that information obtained through an eye exam has a direct implication on the identification of heart failure, diabetes and other diseases as it relates to the medical plan. It is just starting to utilize the fact that the identification of gum disease has a direct correlation to and implication on premature birth.

How does integration work?

As an employer, you have to be aware that a vendor is not related to other vendors and ask, 'What data elements, what information is important for other vendors to have?' Then ask whether those different parties are conversing and whether they're sharing information to try to create the best solution for the employer. Ninety percent of the time the answer is no, as even large carriers have silos within the organization that can preclude an integrated solution.

What are simple steps an employer can take today to get started?

Basic things include working with your pharmacy benefit manager and those running your disease management program to ensure there is compliance among employees with certain disease cases.

Work with your third-party administrator, carrier or broker to identify members who have hypertension and diabetes, based on claims experience, and provide it to the pharmacy benefit manager (PBM) to make sure that someone - whether it's the PBM, broker or those running disease management - is reaching out to members to create awareness among those who are not in compliance with their treatment plan.

For example, those in your disease management program probably don't know if people are taking their prescribed hypertension drug. They don't have that information because there is no integration. But if you take that information from the PBM and make sure that gap is being bridged and that someone's reaching out to members who have diagnoses of hypertension, but who aren't taking medication, you're creating awareness and integrating those components to create compliance.

Employers start asking, via their brokers or their health plan, 'How are you helping my members stay compliant with their medication, and how are you pulling information from the health plan database to identify opportunities for health improvement within the plan?'

What other questions should employers be asking?

Ask how disease management is integrated with your claims operation. How does your case manager integrate with your disease manager? How does vision integrate with the medical plan? How does dental integrate with the vision and medical plan? How does your disease management program interface with pharmacy benefit management?

How does your health plan attempt, through integration, to ensure prescription compliance? Does your employee assistance program integrate with your pharmacy benefit management program as it relates to antidepressants? If you have a third-party administrator, what is it doing to feed information back to health coaches or to those in a disease management role?

What is your health plan doing to incentivize members to help prevent fraud and abuse? For example, some plans encourage members to closely review hospital bills for errors, and if the bill is adjusted as a result, return some of that savings to the member.

From claims data on the medical side, you can identify and assess the risk probability associated with your disability insurance, so you can oftentimes get a disability insurance quote that's much more attractive than the norm because of information you've identified from the medical plan. If you integrate case management and disease management with disability, so your disability team has more information on the front end, it affords it the ability to better manage members, get them back to work more quickly and ultimately lower disability costs.

Finally, take a hard look at your vendor management and work with your broker about overall vendor integration strategy so that vendors become aligned over time. You're not going to go from a completely disjointed operation in your benefit plan to having something that's integrated overnight. But if you start asking questions, you can begin to create some level of integration within your plan.

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