When Flume Health stepped in to replace Blue Cross Blue Shield for one client’s health benefits, we found a problem even worse than their out-of-control premiums: member health was being neglected.
The patient in question had been suffering from lung problems for six years, but the incumbent's TPA was not actively managing his care. Now he had ended up in the ER, and the doctor was recommending a full lung transplant!
Left on his own, the patient likely would have gone straight to the nearest hospital to get on the waitlist, without even realizing that he had other options. The employer would have paid the bill regardless of whether it was overpriced, and the status quo would have rolled on...
Instead, Flume Health delivered a win-win-win for the patient, CEO, and provider by providing an opportunity to:
- get the patient better care with no out-of-pocket cost
- save the employer a ton of money
- give the provider a clear and easy path to billing
Here's how we did it:
ER initiates pre-certification request
As part of every Flume Health plan, pre-certification is conducted on major procedures during concurrent review. In this case, the surgical recommendation triggered Flume Health's medical management partner, AIMM, to look into the case. AIMM focuses on identifying providers with the best outcomes and preventing overtreatment. The question here was: was their local hospital the best place to have the procedure?
Flume Health performs provider optimization
Overnight, Flume and AIMM's integrated systems performed a comprehensive search for all available providers of the lung transplant surgery. Using the patient's current specialist as the geographic benchmark, six other hospitals were identified within a similar distance that classified as Centers of Excellence (COEs). Then, each of these COE's were scored based on key clinical data metrics in order to create a ranking for each facility. The metrics included 1- and 3-year survival rates, readmission rates, waitlist length, and the bundled rate for the procedure.
⬆️Flume and AIMM's integrated systems searched for alternative hospitals first based on geography
to the patient. The above is an example, using the Flume Health offices as home base- no PHI is included here.
Clinical team recommends a better hospital
The highest scoring hospital was not the same hospital the patient's ER doctor had recommended, but an internationally accredited research hospital within driving distance of the patient. It had better survival rates for this particular surgery, lower readmission rates after 3 and 6 months, and a shorter waitlist for lung transplant. Not to mention the price for the surgery was $150,000 cheaper than at the incumbent hospital.
⬆️In the optimization phase, providers are scored on clinical rankings such as
waitlist time, survival rate, readmission rate, and whether or not the facility has an open data sharing policy
The Flume team in action
Once they had these results, Flume's account management team arranged a call with the Advisor and the Plan Sponsor to explain their findings: they had found a higher value alternative that the patient should be aware of before signing to go in for surgery.
The three of them called the patient and walked him through their process. If the patient chose the higher-value option, not only could they get a better surgical outcome, but the cost savings to the plan could be passed through to them: the surgery would be free. The difference in price at this better hospital was so large, in fact, the plan sponsor even agreed to pay for transportation to and from the hospital, their overnight stays, and full paid leave during their recovery period, along with the cost of the procedure.
Meanwhile, Nurse Deb from AIMM had already contacted the hospital to get them to pre-approve the patient for surgery if they decided to come there. She even put the patient's name on their waitlist in order to get him into the O.R. as quickly as possible.
Allowing the patient to make their own choice
At the end of the day, it was the patient's decision where to do the surgery. Many plan members love and trust their current doctors, and the patient did ultimately decide to stay at his current care provider. The plan still covered the surgery, as well as several follow-up appointments. Regardless of where a patient ends up getting care, it’s a health plan’s responsibility to make sure they’re empowered to make an informed decision.
Flume Health helps employers make their health plans more affordable and easier to use. We work with self-insured companies as their health administrator (TPA), replacing the incumbent insurance carrier. In doing so, we are reinventing what it means to have “health insurance”.