Health Insurance Case Management of NO USE in Acute Care Cardiovascular High Cost Claimant

This video, presented by Dr. Eric Bricker of AHealthcareZ, offers a critical perspective on the efficacy of health insurance case management and utilization management during acute care episodes, specifically for cardiovascular high-cost claimants. Dr. Bricker introduces the concept by categorizing high-cost claimants into three major diagnostic areas: orthopedic, cardiovascular, and cancer, then focuses on cardiovascular cases. He uses a compelling real-life patient story to illustrate his points, detailing the journey of a middle-aged woman born with a bicuspid aortic valve who, five years after a mechanical valve replacement, developed a severe peri-valvular abscess.

The patient's case study unfolds from an initial fever and a visit to her primary care physician (PCP) to a subsequent hospital admission due to positive blood cultures indicating a serious bacterial infection. A CT scan revealed a peri-valvular abscess around her mechanical aortic valve, a condition untreatable by antibiotics alone and requiring immediate, complex cardiothoracic surgery. The surgery, lasting over six hours, involved replacing the infected valve and draining the abscess. Complicating matters, the patient developed a heart block during the procedure, necessitating the insertion of temporary electrical leads and later a permanent pacemaker. This extensive medical intervention led to an almost month-long hospitalization, including an ICU stay, and a six-figure medical bill.

Dr. Bricker's central argument, derived from this case, is that during such acute, life-threatening medical crises, external utilization or case management from insurance carriers provides virtually no value. He asserts that once a patient is in the operating room or ICU with a critical condition, clinical decisions are solely based on immediate medical necessity and the expertise of the specialized medical team, rendering outside intervention irrelevant. Instead, he proposes a "bookends" framework for effective management of high-cost claimants, particularly for employers who often bear the financial risk through self-funded plans. He posits that the truly impactful intervention points are before the acute episode, through high-quality primary care and proactive identification of risks, and after the episode, by ensuring robust, high-skilled post-hospitalization follow-up care, ideally at a center of excellence.

The speaker emphasizes that earlier, more astute PCP intervention (e.g., checking blood cultures for a patient with a mechanical valve and fever) could potentially mitigate the severity of such an event. He also highlights the critical role of specialized facilities and highly skilled surgeons in achieving positive outcomes for complex cases, noting that the patient was fortunate to be at a hospital associated with a dedicated cardiothoracic surgery center. The video concludes by advocating for a strategic shift in how healthcare costs for complex conditions are managed, moving away from reactive, in-episode interventions by carriers towards proactive, preventative, and post-acute care optimization, especially for conditions like heart attacks and atherosclerosis where prior events are strong indicators of future risk.

Detailed Key Takeaways:

• Acute Care Case Management is Ineffective: For cardiovascular high-cost claimants undergoing acute, critical care (e.g., major surgery, ICU stays), external utilization management and case management by insurance carriers offer minimal to no value. Clinical decisions are driven by immediate medical necessity and specialized medical expertise.
• "Bookends" Intervention Strategy: The most effective approach for managing high-cost claimants involves interventions at the "bookends" of the care continuum: before the acute episode through high-quality primary care, and after the episode with robust, high-skilled post-hospitalization follow-up.
• Proactive Primary Care is Crucial: High-quality primary care physician (PCP) engagement is vital for early detection and prevention. In the case study, a more vigilant PCP checking blood cultures for a patient with a mechanical heart valve and fever could have potentially prevented a severe, life-threatening infection.
• Importance of Post-Hospitalization Follow-up: Ensuring patients receive the best possible follow-up care, ideally at a center of excellence, is critical for long-term outcomes, preventing recurrence, and managing chronic conditions after a major acute event.
• Major High-Cost Claimant Categories: The three primary diagnostic categories contributing to high-cost claimants are orthopedic, cardiovascular, and cancer. This categorization helps in focusing targeted intervention strategies.
• Identifying High-Risk Individuals: For conditions like heart attacks or atherosclerosis, leveraging claims data to identify individuals who have already experienced an event is key to proactive management and enrollment in high-quality preventative and follow-up care.
• Life-Threatening Nature of Cardiovascular Events: The case study underscores how rapidly a seemingly simple symptom like a fever can escalate into a life-threatening cardiovascular crisis requiring extensive, highly specialized, and immediate intervention.
• Significant Financial Burden: A single, complex cardiovascular hospitalization, especially with an ICU stay and major surgery, can easily result in a six-figure medical bill, highlighting the substantial financial impact on self-funded employers and the broader healthcare system.
• Value of Specialized Medical Facilities: Access to specialized hospitals and highly skilled medical professionals (e.g., cardiothoracic surgeons, dedicated nursing units) is paramount for achieving positive outcomes in complex, high-risk cases. Lack of such resources can have dire consequences.
• Leveraging Data for Proactive Management: Employers and healthcare stakeholders should utilize claims data and business intelligence to identify high-risk individuals and patterns related to high-cost claimants, enabling more targeted and effective pre- and post-episode interventions.
• Shift Towards Proactive Healthcare Management: The overarching recommendation is a strategic shift from reactive, in-episode management by insurance carriers to a more proactive, value-based approach centered on preventative care and comprehensive post-acute support.

Examples/Case Studies:

• Bicuspid Aortic Valve Patient: The video features a detailed case study of a middle-aged woman born with a bicuspid aortic valve who previously had a mechanical valve replacement. She developed a high fever, which, after initial dismissal, led to the diagnosis of a peri-valvular abscess around her mechanical aortic valve. This required a six-hour cardiothoracic surgery for valve replacement and abscess drainage. During surgery, she developed a heart block, necessitating an external pacemaker and a subsequent procedure for a permanent pacemaker. Her hospitalization lasted nearly a month, including an ICU stay, and resulted in a six-figure medical bill. This case serves as a prime example of a cardiovascular high-cost claimant where acute care was critical, but external case management had no discernible impact.