Transplant Insurance Program Cuts Catastrophic Medical Costs

Such exploration is drawing many corporate managers to a unique catastrophic medical risk management program that can manage the entire transplant process.

Ensuring optimal medical care and emotional support for a transplant patient from day-one of diagnosis through surgery and post-operative care is critical. Experience has shown that it is the best way, perhaps the only way, to achieve a positive outcome for both the employee, who must endure a transplant, and for the employer, who must finance it.

For many companies, however, providing this support is far easier said than done. It is simply beyond the means and expertise of the vast majority of corporations and health care administrators.

A managed transplant program puts this goal within reach. It balances the needs of employers and employees, allowing employers to protect their balance sheet, and employees to secure world-class medical care and the support system they need to manage the emotional and clinical aspects of these procedures.

Corporations are first and foremost attracted to managed transplant programs because it makes good financial sense.

By creating coverage for a transplant, these programs allow a company to fund catastrophic medical costs without exposing health plan deductibles and health and stop-loss premiums to these high-severity losses.

When an employer self-insures medical benefits, this unique coverage allows the employer to keep the program stable and shielded from catastrophic loss. It also keeps transplant claims from impacting the medical stop-loss cover self-insuring companies typically carry as a reinsurance layer.

A well-structured program can provide fully-insured coverage for a range of procedures, including heart, heart-lung, lung, liver, kidney, pancreas after kidney and bone marrow transplants.

Coverage offers access to leading academic medical facilities, as well as including reimbursement for costly immunosuppressant drugs that are vital to the ultimate success of a transplant procedure.

Beyond protecting against catastrophic medical costs, a managed transplant program can mitigate an employers liability on several fronts.

Because these programs allow a company to give all employees access to treatment at superior medical facilitiesand to equivalent levels of benefitsexposure to discrimination claims is mitigated. This is a paramount consideration when a companys workforce spans multiple locations and partakes in many different health plans.

Moreover, since transplant specialists are performing the transplant, there is a high degree of credibility, further reducing employer liability. Also, by separating out the transplant exposure to a fully insured plan, the program can help mitigate fiduciary risk.

Few HR managers are equipped to address the administrative issues associated with the transplant process and to support an employee through the maze of decisions they must navigate along the wayfrom selecting the best facility for a kidney match to choosing the best-qualified, Medicare-certified hospital.

These programs can relieve employers of the burdens by delegating day-to-day management of the transplant case to specialists, including nurse case managers. These nurse case managers help employers control transplant costs and relieve the employer of the responsibility of assisting the employee through the transplant process.

The participation of the nurse case manager is pivotal to managing costs and care before a transplant operation, and arguably even more vital post-operation, when patients must comply with an often-complicated immunosuppressant regimen.

Without proper adherence to such a regimen, the transplanted organ may be rejectedand the employer and employee would be left to confront a repeat operation, incurring all over again the medical costs and productivity loss that goes with it.

For every advantage a managed transplant program offers employers, there is an advantage for the employees as well. Employees gain access to lifesaving treatment and to the nations leading transplant facilities, including Baltimore-based Johns Hopkins University Hospital and hospitals affiliated with the Mayo Clinic in Rochester, Minn.

Moreover, the same nurse case manager that helps employers manage costs helps patients and their families shoulder the enormous physical and emotional burdens of the transplant process. Acting as the patients advocate, the nurse case manager counsels employees on critical care choices, strategies to enhance compliance, and other clinical aspects of the process.

The nurse case manager is easily accessible to the patient and his or her family virtually anytime to clarify benefits concerns, set expectations for the transplant process, and keep all parties "in step" through a difficult journey.

Case managers often coordinate travel and hotel accommodations for those accompanying the patientand insurance covers many of the travel expenses associated with the transplant process.

After the transplant procedure is completed, when the health of a patient is particularly fragile, nurse case managers remain actively involved, managing post-operative treatment.

Employers that have been through the ordeal of an employee transplant know the financial and emotional turmoil that comes with it. They have learned from experience the importance of managing all aspects of a transplant case.

Stephen Mueller is senior vice president for the Accident & Health division of Zurich North America, New York. He can be reached at info.source@zurichna.com.

Reproduced from National Underwriter Edition, April 7, 2003. Copyright 2003 by The National Underwriter Company in the serial publication. All rights reserved.Copyright in this article as an independent work may be held by the author.