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Why
Coordinate Care?
Many people
receive health care benefits through their employer. In years past,
employers paid most (if not all) of the health insurance premium.
Employees went to the doctor or hospital and paid only a small portion
of the total bill, if anything at all.
As times changed,
however, health care costs increased in response to inflation, advanced
medical technology, changing government mandates, an aging population
with longer life expectancy, physician and nursing shortages, reduced
Medicare and Medicaid reimbursements, costly prescription drugs,
and increases in the premium for malpractice insurance.
Along with
this came increasing concern over unnecessary or duplicative treatments
as well as ever-rising consumer demands for access to high quality
care at affordable prices, all at the expense of someone else. In
addition, the health insurance system had an inherent flaw—the
more services provided by physicians and hospitals, the more the
system paid them, even if services were duplicative or felt to be
unnecessary.
To continue
to provide effective health care benefits, employers were forced
to examine the ways in which they financed medical care for their
employees. In addition to the use of deductibles and coinsurance,
employers turned to managed care companies to help coordinate medical
care and reduce cost, rather than just shift cost from the employer
to the employee. In response, managed care organizations like Medical
Associates Health Plans have been instrumental in developing and
implementing strategies to assure that care is provided in the most
appropriate setting, while preserving quality and affordability.
At Medical
Associates Health Plans, we take a collaborative approach to managing
quality, cost-effective care by working closely with members, physicians,
hospitals, outpatient facilities, skilled facilities, and pharmacies
to individualize your plan of care:
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Case Management
Our Medical Review team follows the daily progress
of all hospitalized members to assure the efficient delivery of
care. Patients with chronic diseases are offered personalized education
to help them manage symptoms and prevent complications.
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Utilization Review
Our Quality Improvement Committee examines members’
utilization of medical services and physicians’ practice patterns,
developing measures to continuously improve on quality and cost
efficiency. Our Registered Nurses review over 3,700 medical records
a year, evaluating adherence to the high standards of care set forth
by the National Committee for Quality Assurance, through whom Medical
Associates has received Excellent Accreditation.
•
Wellness/Preventive Benefits
A significant area of cost-reduction has grown in recent years in
the area of wellness and preventive care. Most managed care organizations
including Medical Associates Health Plans provide coverage for annual
physical exams, immunizations and vaccinations, routine screenings
such as pap tests, mammograms, hemoccult testing (blood in stool),
cholesterol levels, blood pressures checkups, and prostate cancer
testing, to name a few. These benefits contrast greatly from traditional
indemnity policies in which coverage is generally limited to treatment
of illness and disease. Wellness services that promote early detection
of disease are standard benchmarks in the managed care industry
and viewed as crucial in the cost containment of medical care. Wellness
services keep employees healthier in the long run and increase the
chances of successful treatment when a disease does occur. Please
consult with your physician regarding these preventive services.
•
24-Hour Patient Services HELP Nurses
Medical Associates Health Plans offers a dedicated
telephone line staffed by Registered Nurses around the clock as
a ready source for any health related question or need. The HELP
Nurses are a direct link to our network of participating physicians
and providers, through whom members may obtain medical advice or
assistance in reaching their doctor. There is no fee for the service,
and it is available 24 hours per day, 7 days per week. The HELP
Nurses are located in Dubuque, and may be reached at the following
phone numbers: 563-556-4357 or 1-800-325-7442, toll free.
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Drug Formulary
Medical Associates Health Plans uses a defined
list of covered drugs known as a formulary. This process has been
adopted by hospitals, employers, and managed care organizations
across the country as a successful method of managing prescription
drug costs. Our formulary is frequently reviewed and updated by
a committee of local physicians, pharmacists, and administrators.
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Pre-Admission Testing
This is a coordinated effort between physician’s offices,
hospitals, and ancillary services like laboratory and radiology
to deliver all necessary pre-surgical tests in one central outpatient
location. Cost and time spent in the hospital are reduced, as well
as time taken off work by the member/employee.
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Outpatient Surgery
Today’s
advanced medical technology enables surgeons to perform many procedures
on an outpatient basis, thereby reducing costs previously associated
with overnight hospital stays. At Medical Associates Health Plans,
our Registered Nurses help coordinate after-discharge needs when
necessary, further assuring that services are cost effective and
authorized for coverage.
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