Aid From Unlikely Sources

When a serious medical crisis occurs, your insurance company may provide more than hospital coverage.

A growing number of plans offer specially trained case managers to help patients during a major illness.

Different from disease-management programs, which focus on patients with a chronic condition such as asthma or diabetes, the case-management services are for patients with costly and complex medical conditions such as cancer or an organ transplant. These managers -- typically nurses -- help patients with everything from avoiding duplicated tests to finding the best-priced prescriptions and other services.

Complex-Case Monitors

"They take our very fragmented health-care system and put some glue on it to ensure that a patient with a complex condition does not fall through the cracks," says Alwyn Cassil, a spokeswoman for the Center for Studying Health System Change. "The case manager's job is to pull these pieces together."

Intensive case-management programs typically are individualized and for patients with multiple physicians and drug regimens. In 2007, about 23% of employers offered catastrophic case-management programs, up from 16% in 2005, according the National Survey of Employer-Sponsored Health Plans by Mercer.

It's not unusual for the case managers to help coordinate patients' care, often finding needed equipment and prescriptions, and diagnosing depression.

"Patients are not only overwhelmed by their personal health challenges and fate, but the challenges of the [health care] system," says Richard Migliori, executive vice president, Medical Affairs, UnitedHealthGroup.

Early Warnings

He says one of the biggest cost savings is that these case managers are trained to recognize potential problems earlier. For example, if the transplant patient spikes a fever, the case manager would know whether it's just a cold or something serious and needs immediate attention.

Dr. Migliori says the case managers also are crucial because they're in constant contact with the patient and see their medical records. They know whether that person is taking the meds and following the doctor's directions. If not, they could find out why and help that person before something more serious occurs. Today, big savings for the insurer also mean big savings for the consumer, who is paying more and more out-of-pocket expenses for care.

When necessary, they help get the patient help assistance from social-service agencies for transportation, home care and housekeeping, says John Heraty, a case manager for Aetna, who also is a social worker.

Patients often are automatically contacted by a case manager because a hospital visit will bring the situation to the insurance company's attention. Alternatively, the patient or a family member could check the insurer's Web site or contact the employee's human-resources department or the insurance company.

"It is cost effective for employers to do because even in a recession we're in a war for talent so we want our talent to come back to work," says Helen Darling, president of the National Business Group on Health.

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