4 Best Practices for Balancing Costs and Care When Employees Are Hospitalized
3 minute read•Navigation Insider
Inpatient hospital expenses are the third largest claims category for commercial health insurers, based on a recent study by America’s Health Insurance Plans. Average daily hospital charges in the U.S. hover above $2,000, according to data from the Kaiser Family Foundation.
This means inpatient care is a cost concern for self-insured employers, whether they have several hundred or tens of thousands of health plan members. To ensure members get the care they need — while also seeking ways to control hospital costs — most employers and benefits consultants build “concurrent review” into their benefits programs.
Concurrent review involves monitoring the status and progress of hospitalized members to ensure they receive high-quality care in the most clinically appropriate setting. An effective review process also can identify ways to avoid unnecessary costs, help members make steady progress toward a safe discharge, even reduce the risk of readmission.
For most employers, an insurance carrier conducts the concurrent review. In a typical approach, the carrier preapproves a set number of hospital days, based on the diagnosis. Beyond that, the employer may have little to no engagement with the member or the care team unless a hospital stay extends beyond the approved length.
This hands-off approach can miss opportunities to avoid unnecessary tests or services, to “step down” care to a less costly but still clinically appropriate level, or to arrange home-based services that can prevent an extended hospitalization.
Quantum Health’s daily concurrent review process is integrated into our core consumer healthcare navigation and care coordination solution. We assign a nurse who engages one-on-one with the member before, during and well after a hospital stay. Our nurses and medical directors collaborate with hospital care teams as often as daily (depending on the member’s condition and prognosis) to ensure treatment is meeting national criteria for appropriate care. They also support a member’s family and providers in planning for the member’s needs upon discharge.
This integrated, proactive approach yields results. Our analysis shows that members hospitalized for COVID-19 treatment were discharged a day sooner than a national benchmark. Another study found positive results with the youngest members we serve — newborns treated in neonatal intensive care units (NICUs). Our average length of NICU stay was three days shorter than a national benchmark and on par with results published by a leading specialized maternity point solution. That means the members’ employers saw similar savings on NICU cases, without the cost and complexity of adding another partner’s services.
Not all concurrent review approaches are equally effective. Quantum Health clinical leaders point to at least four key elements that contribute to high-performing concurrent review:
Hospital costs are an inevitable expense. When a concurrent review partner proactively engages with members and providers in an effective way, the inevitable becomes more manageable.
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