Unmonitored Service Vendors Characterize Health Plans
city government with almost 27,000 healthcare plan beneficiaries
had been paying provider bills through its TPA, which among
other problems, failed to monitor submitted claims properly
and received kickbacks from the PBM on a per RX basis. The
MCO was raising premiums double digits annually and would
not disclose critical cost and provider contract information
to our client. It was apparent that relationships among the
various service vendors were so rife with conflicts-of-interest
that controlling costs and monitoring the quality of services
were secondary considerations.
provided our client with more than 50 substantive recommendations
for changing the infrastructure of its healthcare benefits
plan and ensuring optimum control and accountability. Realistic
savings will accrue in the 18-21% range of its healthcare
expenditures, which exceed $50 million annually.
Employee Benefits Costs and Low Morale
A national communications company with 4,000 employees was experiencing
rapid annual increases in health care benefits costs. All of the
traditional methods of suppressing costs had been implemented.
The labor unions, which represented over 80% of their hourly employees,
were threatening a strike over the increases in costs and reduction
in benefits of the health care plans. Labor-management tensions
mounted and employee morale and productivity were severely strained.
HCI designed and implemented an Employee-Employer Partnership®,
which provided our client and their employees with the vehicle
for changing to a more rational, cost-effective and qualitative
self-insured health care plan. An on-site primary care clinic
and Micro-PPO specialty care delivery system were created for
our client. Within one year, health care benefits costs were reduced
23%. Employees were provided with easy access to objective, state-of-the-art
medical information on demand. Incentives were created to reward
beneficiaries who utilized the highest quality health care providers
in the region.
Long-Term Care Insurance Company Denies Legitimate Claims
HCI was contacted by the daughter of a Senior, who required home care aide assistance following hospital discharge and sub-acute nursing home care. She was insured by a national company, which arbitrarily decided to deny reimbursement for her care. After reviewing the long-term coverage policy, which was in force for more than a decade, HCI provided the impetus for the insurance company to reverse its denial and pay the claims retroactively and going forward.
Government Health Care
Program for Medically Indigent Population is Improved
A Midwestern County government was mandated to fund health care
for a medically indigent population of 20,000 people. Poor eligibility
verification, a non-competitive preferred provider network, ill-conceived
utilization review practices, and several other deficiencies caused
the program to have a budget deficit of over $11 million.
HCI designed and implemented cost control mechanisms which closed
loopholes and established an efficient and high quality managed
care system. Per case contracts for hospitals and physician providers
were designed and successfully negotiated. Capitation contracts
for 73 other health care providers were implemented. A new system
for processing and monitoring claims was designed and implemented;
we retained a Third Party Administrator to operate it. Within
the first 11 months, our client saved $10 million and reduced
patient complaints by 34% because both preventive care and the
quality of care had been improved. Preventive care, previously
given short shrift, became the top priority.
The Medicare Enrollee's Annual Challenge
HCI was contacted by the family of a Senior, who had enrolled in Medicare several years ago. They asked us to provide them with an analysis of current Medicare plan options: Medicare, Medicare Advantage, Medicare Part D Prescription Programs, and Medicare Supplemental Plans (aka MediGap) offered in the client's zip code area.
Our analysis revealed that the client could save at least $3500 annually by making other choices among the myriad of options, especially his Medicare Part D and Supplemental plans. This client realized a significant cost savings and much greater freedom-of-choice in his selection of healthcare providers.
Three Employers: A Common
Hemorrhage is Stopped
Obtain Assistance to Pursue Litigation
Three employers with a common Third Party Administrator and a
combined 19,300 covered lives believed that certain health care
providers were billing for excessive care in specific specialty
areas on a consistent basis.
HCI organized a network of physicians with the most successful
medical outcomes and hospitals with the best quality indicators.
We designed a per case payment formula. Our clients were able
to realize $3.1 million in savings and an 18% reduction in the
mortality rate for their employees and dependents within two years.
A wrongful death lawsuit was filed against a hospital. The case
involved a young man who sustained injuries in an industrial accident.
HCI was retained to evaluate the evidence and to assist in discovery.
We found that the facility was seriously understaffed and inexperienced
physicians and nursing staff had treated the patient in the first
critical hours following his injuries. Several personnel attempted
to cover-up the incident and failed to report significant details
to hospital administration. An out-of-court settlement was reached
and several hospital staff were terminated.
Creating Change in Rural
Excessive Mental Health
A major employer in a rural area was totally dependent upon one
hospital for most health care services for employees and their
dependents. Excessive utilization was evident in all but two diagnostic
areas. Our client was experiencing excessive costs of $4 million
HCI established a Consumer Information System, hired a vendor
to staff and administer a primary care clinic, and created a targeted
specialty care Micro-PPO which included physicians from the nearest
large city. Our client has experienced an average of 28.6% savings
from the base year's healthcare costs over the initial 4 years
of these changes.
Oregon Tort Reform 2004 ---
Capping Liability Damages, Punishing Consumers
The Oregon Trial Lawyers retained HCI to help
defeat Ballot Measure 35, which would have amended the constitution to establish a $500,000 cap on non-economic damages in medical liability cases. The ballot measure lost by 50.53% to 49.47%.
The failed effort to pass the ballot measure was funded by healthcare providers within and outside of Oregon. HCI has long been committed to enhancing quality of care and patient safety as the solution to curbing preventable plaintiffs' injuries, deaths, and subsequent litigation. Our independent analysis of medical malpractice insurance premium increases links them to cyclical and erratic investment returns and poor portfolio management, not frivolous lawsuits.
HCI's role in the successful effort to preserve unconstrained patients' jury awards was to provide consultation, information, and research input to trial lawyers campaign management.
A Northeast services company was experiencing high costs for mental
health care and out-patient primary care services. Somatizing
and chronically ill patients were driving these costs.
HCI developed a customized managed mental health care program
linked to primary care networks and the Employee Assistance Program.
Our client reduced mental health care costs by 32% and overall
health care costs by 17.5%.