Disease Management & Maternity Management | BENEFIT CARVE OUTS

Disease Management
Traditionally, medical expense plans have focused on the treatment of sickness rather than prevention and education. Even though this philosophy changed with managed care, there has often been less-than-complete attention paid to controlling chronic conditions that can lead to frequent and often expensive medical intervention. The list of chronic conditions is lengthy; a few of the conditions on this list are asthma, diabetes, heart disease, high blood pressure, arthritis, allergies, back pain, and multiple sclerosis. Many chronic conditions are high maintenance, and most are not curable. However, with proper control, hospitalization for the condition and related complications can be reduced. In addition, the patient's longevity and quality of life can be increased. As managed care has evolved, the concept of disease management has taken on increasing importance, sometimes through the use of carve-outs for certain chronic conditions. The two most commonly carved-out chronic conditions are probably diabetes and asthma.

Traditional case management begins with an episode of illness, whereas disease management begins prior to it. Disease management programs attempt to identify persons with chronic conditions as early as possible so that proper treatment can minimize future spells of illness. In this regard, it is important to work with primary care physicians so that they can steer patients toward the disease management program.

Disease management programs have a network of providers who deliver the needed care and prevention. These include physicians as well as nurses who provide patient counseling and education and who may even make home visits. Education about a chronic condition is crucial in that a disease management program is much more effective if a patient understands how to manage his or her lifestyle in light of the condition. It is also important for a disease management program to involve pharmacists, because patients with chronic diseases are often on maintenance drugs, the effectiveness of which can be influenced by prescription drugs that might be prescribed for other illnesses. A disease management program also has procedures for reacting to emergencies and providing ambulatory care following a hospitalization.

Maternity Management
The identification of high-risk pregnancies and proper medical treatment can result in significant cost savings to a benefit plan. For example, the expenses associated with premature birth can amount to several hundred thousand dollars. As a result, many plans have begun to incorporate maternity management, which focuses on low-frequency, high-cost claims, in contrast to many cost-containment efforts. Although there is a cost in providing this coverage, this cost will usually be more than offset if only one large claim is avoided. Some providers of medical expense plans provide maternity management with their own staff, while others carve out the benefit.

A maternity-management provision requires a patient or her primary care physician to notify the maternity management program within some prescribed time period after confirmation of pregnancy. Failure to obtain this precertification may result in a reduction of benefits. A case manager, usually a registered nurse, works closely with the expectant mother and her physician throughout the pregnancy to see that a complete assessment of the mother's health is made so that unfavorable risk factors can be monitored. Individualized maternity education is provided through brochures and telephone contact. This education focuses on such aspects of prenatal care as nutrition, alcohol use, and smoking.