Applying life care planning principles in acute situations

Area of Science:

• Healthcare Management
• Insurance Operations
• Employee Benefits

Background:

• A US stop-loss carrier sought guidance on their in-house catastrophic case-management program in 2004.
• The target market comprised self-funded Employee Retirement Income Security Act (ERISA) plans with under 10,000 lives.
• The carrier faced data gathering and communication issues with third-party administrators (TPAs).

Purpose of the Study:

• To assess the viability of case management services provided by a stop-loss carrier.
• To identify challenges in implementing such programs for smaller ERISA plans.
• To explore solutions for improving data flow and communication among stakeholders.

Main Methods:

• Consultation request initiated by a stop-loss carrier.
• Analysis of the operational challenges within their catastrophic case-management program.
• Focus on self-funded ERISA plans with fewer than 10,000 lives.

Main Results:

• The core issue identified was inconsistent work and communication flow between the carrier and TPAs.
• Data gathering presented a significant obstacle to program effectiveness.
• The viability of carrier-provided case management was questioned due to these systemic issues.

Conclusions:

• Carrier-provided catastrophic case management faces significant hurdles in smaller self-funded ERISA plans.
• Effective data sharing and communication protocols are crucial for program success.
• Addressing TPA coordination is essential for viable stop-loss carrier case management.