Employee health challenges come in many shapes and forms. Some may require acute care for only a short period of time. Others may have ongoing health concerns that stretch out for longer periods, or even a lifetime. Each situation comes with its unique set of complexities and cost challenges. That’s why it’s so important to have programs to guide patients no matter their need, while also keeping costs under control. In this product spotlight, we’ll highlight how our Medical Management programs make a difference for patients, leading with empathy, knowledge and experience. Plus, we’ll uncover innovative ways our programs are addressing some of the industry’s leading concerns.
Looking closer at our core programs
Our Medical Management portfolio supports everything from precertification and medical necessity review to coaching members through specific health concerns. Here’s a birds-eye view of our mainstay programs and what they aim to do:
-
- Utilization Management. Ensures patients receive medically necessary care in the most appropriate setting for an appropriate length of time. Our recommended precertification list is based on medical guidelines and our experience with maximizing savings and reducing barriers to care.
- Case Management. Offers personalized support for patients and caregivers to navigate serious (and often high cost) health conditions. Clinical experts support patients in taking an active role in their health care to improve health outcomes and enhance quality of life, while trying to reduce health care costs. Additional specialized solutions offered are: chronic kidney disease (CKD), pain management injections, High-Cost Drug Management, Maternity Management, and pre-admission and post-discharge counseling.
- Disease Management. The Nurse Health Coaching Program utilizes claims data to identify members with nine chronic conditions for which evidence-based guidelines are established. Dedicated nurse health coaches provide participant-centric coaching tailored to participants. Clinical assessments identify gaps in care, so nurses can provide education to help close those gaps and improve clinical outcomes.
Targeted solutions for high-cost situations
Our capabilities run even deeper to address many key cost drivers and industry trends. For instance, our claims-based Maternity Management Program supports every pregnancy for education and counseling. Individualized assessments identify high-risk and potentially premature pregnancies, focusing on improving health outcomes and lessening costs. In addition, we have a program dedicated to effectively lowering costs for members who are prescribed high-cost specialty medications. Our High Cost Drug Management Program extends support to patients needing injectables or infusions costing over $2,000 per dose per month. It works alongside pharmacy strategies and includes case management and steerage for better patient intervention and cost containment.
Understanding every angle of health
One way we stay current is by understanding how other factors can impact the health of our members. We’re proud of recent innovations and enhancements that allow us to help patients in new ways. Here are some ways we’re approaching health from other angles:
-
- Adding a behavioral health component to oncology care. Oncology treatment can often go beyond the physical aspect affecting mental well-being. We recognize this and want to make sure members, along with their families, have full support as they battle cancer. Our oncology case managers provided the member the opportunity to work with a dedicated behavioral health specialist in addition to their primary case manager.
- Acknowledging sleep and its relationship to healthier outcomes. Our Case Management Program now features a sleep assessment. Members identified as being open to receiving help with their sleep will be referred to a certified sleep health coach to work through issues sleeping as they heal and recover from illness or injury. Additional benefits include improvements in mood, heart health, brain function and increased immune health.
- Offering counseling for before and after hospital stays. Special programs help to prepare members before admission and after discharge, as they transition to home care following treatments or surgeries. The extra education and support at these critical times reduces readmission rates and chances of complications.
Leading with empathy, knowledge and experience
Our Medical Management programs are designed to consistently connect members with highly qualified health care professionals, including registered nurses (RNs), and licensed social workers. Many of our clinical team members bring 10 to 20 years of specialized experience across diverse areas of care. What truly sets them apart is their unwavering commitment to supporting each patient with empathy, deep clinical knowledge and a wealth of experience.
Contact us if you’d like more information on the suite of URAC-accredited services available to members.
Check with your Meritain Health representative for more information.
This material is for information only and is not an offer or invitation to contract or meant as medical advice. Health benefits and health insurance plans contain exclusions and limitations. See plan documents for complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary and are subject to change.
