WPS Medical Management

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1 Medical Management WPS Medical Management Controlling Costs through Compassionate Support

2 Managing Costs. Improving Outcomes. Just one employee with catastrophic medical claims can send your health insurance premium through the roof. For some conditions, pharmacy claims alone can top five figures in a single week. Proactive measures are needed to monitor care and keep costs in check. At the same time, employees and their families dealing with serious health conditions need a compassionate advocate to help them navigate the health care system and make sure they get the right treatment. That s where WPS Medical Management can help. WPS Medical Management monitors patient care, from hospital to home. Our services include: Case Management, targeting the one-percent of members with catastrophic, complex, or long-term conditions who generate 22 percent of health care costs.* Medical Review, a review process that monitors treatment plans and medication usage to assure appropriate care. Utilization Management services that help members maximize their health care benefits and achieve proper utilization of services. All of these highly effective support programs are designed to optimize patient outcomes while ensuring cost-effective, appropriate care. Enhancing Service with Advanced Technology. In today s health care environment, effective medical management requires rigorous data analysis. We ve invested in a powerful collaborative care management platform that streamlines data collection, applies clinical rules, automates workflows, and electronically connects patients with their providers. This system allows us to more intelligently administer medical management services, improving health care quality and reducing costs. *Agency for Healthcare Research and Quality, Research in Action, Issue 19, June 2006

3 Serious Help for Serious Conditions. Our Case Management program helps employees, family members, and providers take action as a team to manage catastrophic health conditions. Our dedicated staff of physicians, nurses, and social workers act as patient advocates to optimize available benefits, coordinate care, reinforce treatment plans and medication usage, and plan for short- and long-term needs. At the same time, we work to identify cost-saving opportunities and ways to provide care more effectively and efficiently. Participant Identification Early identification is key to effective case management. Our staff uses a variety of methods to identify members who may benefit from our services and support. Data-Driven Referrals: Most case management referrals are generated by an advanced care management platform, fed by our claims system. We use this platform to monitor patient care and flag cases that may benefit from intervention. Internal Referrals: Many cases are referred by WPS Member Services, and by other internal staff who have regular contact with members, employers, and providers. External Referrals: We also encourage self-referrals from members, as well as from families and providers. Members referred to Case Management receive a personal phone call and/or letter from a member of our staff encouraging participation. Risk Stratification Members identified for intervention are separated into health condition categories based on the severity of their case. This stratification process allows our staff to personalize interactions and more quickly determine support services needed. We specialize in working with members with conditions such as: Behavioral health issues Cancer Catastrophic or long-term illnesses and injuries End-stage renal disease High-risk pregnancy Organ and tissue transplants Situations requiring rehabilitation, hospice, or nursing home care We also work extensively with members who require specialty medications, complex treatment in international settings, and end-of-life care.

4 Member Engagement Case managers work with members, families, and providers to develop and implement a progressive care plan. Throughout the duration of their treatment, members can expect to receive: Ongoing coaching Condition-specific educational materials Coordination of care and discharge planning services Our Case Management program helps ensure members get appropriate care right from the start. Through consistent attention to detail, we help limit the potential for major complications and costly expenditures down the road. Over a Half-Million Dollars Saved. A WPS member was being treated for Fabry s disease (a genetic condition) and was receiving weekly infusions of a specialty drug at a local clinic. Initially, the clinic was ordering the drug through an out-of-network supplier. A WPS Case Management nurse discovered the error and intervened, putting the clinic in contact with an in-network supplier who offered the drug at a special discounted rate. This was a routine intervention. Our program saved the member s health plan $592,514 in pharmacy expenses over a one-year period, while reducing the member s out-of-pocket costs and preventing a major hit to their lifetime maximum. The Right Care, at the Right Time, at the Right Cost The WPS Medical Management program focuses on improving patient outcomes while managing costs. In addition to Case Management services, we offer the following specialized programs, designed to ensure appropriate care and proper utilization of services. Utilization Management: Our URAC-accredited Utilization Management program helps eliminate health care costs associated with unnecessary or inappropriate health care use. This includes everything from review of planned care before a patient receives services (preadmission cert-ification and URAC ACCREDITED HEALTH UTILIZATION MANAGEMENT preauthorization) to post-discharge services review, after a patient has left the hospital. Medical Review: Our team of experienced nurses and physicians review treatment plans and medication usage to help ensure that members receive care that adheres to established clinical guidelines. This critical practice not only contains costs, but enhances patient safety and improves outcomes. Together with our Case Management program, these services help make sure that members receive the right care, at the right time, at the right cost.

5 Medical Management Achieves Real Results. The goal of medical management is to monitor treatment plans and medication usage, and to coordinate care to improve outcomes and reduce costs. Medical management interventions often result in: Shorter hospital stays Fewer emergency claims Reduced hospital readmissions More appropriate care In the U.S., we spend more than $2 trillion a year on health care.* And nearly one-quarter of that is generated by the 1 percent of the population with catastrophic health conditions. WPS Medical Management is committed to tackling this problem head-on, one member at a time, providing a better health care experience for you and your employees. * Source: Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group Agency for Healthcare Research and Quality, Research in Action, Issue 19, June 2006 The Right Medical Management Program. Right Here for You. Since 1946, WPS mission has been to provide affordable, comprehensive health coverage for our friends and neighbors right here in Wisconsin. In today s health insurance marketplace, WPS Medical Management delivers needed solutions to help employees improve their health, while lowering health care costs for employers. Contact your local agent to learn more about WPS Medical Management. Or, call WPS at

6 1717 W. Broadway P.O. Box 8190 Madison, WI Wisconsin Physicians Service Insurance Corporation. All rights reserved

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