Meritain Health's approach to Medical Management is about finding balance. The balance between providing quality care and managing total cost of care, all while staying focused on the member experience at center of it all.
We engage with members to provide support for a reason, a season or lifetime.
In our latest In the Booth podcast, we are pleased to have Bridgette Cassety from broker engagement and Tina Etzler, a senior strategic consultant from the product team discussing our Medical Management Programs.
Welcome to another edition of in the booth. My name is Bridgette Cassety, and I'm the head of broker engagement here at Meritain health. And I'm so excited to have another session with Tina Etzler, who is one of our senior consultants on our product team here at Meritain health. And Tina it's always great to have you with us. You bring so much passion with you around the topic of medical management, and there's always so much to cover and so much to talk about. And I think the last time that we were together, that we really focused and chatted around the value proposition and the approach for medical management here at Meritain health. So I thought today that what we could maybe dive into a little bit deeper is how Meritain can really help our members with intervention and other approaches that really impact the total cost of care. And of course the member experience, and these are two things that certainly when we go out and talk to our customers in the field are top of mind, which is understanding how we can enhance member experience and also manage quality and total cost of care at the same time. So with that, do you wanna spend a few minutes and really talk about our approach when it comes to those types of interventions with medical management?
Sure. Thanks, Bridgette. So I think about it as being that we have to think strategically in intervening in ways that can make a difference in that member's health and to do that, we intervene programatically. So by that, I mean, we have some traditional approaches, things that are historically tried and true in managing costs for plan sponsors, but those have been around a long time. And although our results are historically better than external benchmarks that are around our industry, we really try to take a perspective that targets things at a deeper level with our programs. So, you know, we look at specific clinical areas of focus where we can reduce cost by really actively engaging those members with case management. And then at a broader level there's things we can do to support big picture thinking. And that really includes, you know, chronic disease management and wellness and the truth of it all is that health is so personal because it changes over time and is often just based on that member's circumstances, you know, as advocates for healthier living, we just wanna be there for members meeting them wherever they are at in their health journey and providing support.
That's really what we're here to do.
And I think Tina you're right. You know, when you use the word it's personal you're right. Healthcare is personal, right. And it changes, it changes as we, as we journey through life. And, you know, you have to have a strategy, right? You have to have a strategy to approach it. So can you talk a little bit more about how we actually engage with members on this strategic journey?
Yeah. I like to think about it and explain it as we engage with members for a reason, a season or lifetime, you know, really we're helping them reach towards the highest level of health available to them at any given time. So a reason we might engage with members is triggered by a specific event at a single point in time. And it's something that's within the scope of our program. So, you know, managing utilization of clinical services is the most common opportunity we have to, you know, kind of manage costs. So we make sure that there's proof in the pudding. And by that, I mean that this action provides previously demonstrated success according to approved guidelines. And as the member provider of exhausted all the other avenues for effective treatment prior to them reaching this point and that they've tried everything they can, that bleeds them to this course of action and makes it medically necessary.
We're asking basically, does this work according to the collective experience of experts and does this make sense based on what's already been done. And as a side note about that process, we've really done our homework. You know, we know what services we can impact and which ones have proven out over time that don't work. So this means that we don't put any extra hoops in for providers or members for things that we already know. We can't impact our providers and network members, you know, our provider networks and our members really, really appreciate that. You know, and then we also ask, okay, what's the most appropriate amount of time in the hospital for this specific member and under these specific circumstances. So we make sure that members are being treated in appropriate length of time in various settings, use our nursing and physician expertise to determine what's best for the plan's cost and the member's health. We also need quality requirements for the program where UAC accredited and we're showing our plan sponsors an average return on investment program about six to eight to one.
And Tina, I think that when you talk about quality, that's still important, right? We wanna make sure that what we're doing is not just providing a savings, but also delivering on quality and making sure that that we're accountable to our customers for that. You know, you talked about sort of that season, that, that space around a season. So can you maybe give our listeners some examples about cases where folks do have those ongoing health conditions that we can get engaged with? Can you talk a little bit more about that? Cause I think that encompasses a whole big bucket for a lot of our listeners.
Oh, absolutely. So that leads right into kind of that season part. So a season is when a member might have something impacting their health going on for a while. So we're gonna intervene with that member and provide our support for a period of time until they're doing better. You know, some of the most common topics that I hear regularly are around readmissions, right? So you don't want people going back into the hospital. So we have a pre-admission and post-discharge program where, you know, we're gonna engage members before they leave the hospital. We're gonna be a resource for education. We're gonna do care coordination, and we're gonna help head off any reasons that are gonna send him back at the hospital for readmission. You know, really we can typically provide a reduction that impacts, you know, the potential for readmissions by either 65% on the front end or 35% on the back end.
So we really do a good job at, at keeping people from having to go back into the hospital. Another one that's really kind of top of mind is, you know, maternity and NICU. Again, those admissions are very expensive. So members having babies that's really common and a NICU admission is a head price tag. So, you know, we support pregnancies to avoid trouble down the line. We support pregnant members with our maternity management program and encourage, you know, healthy pregnancy and avoid that readmission that might have otherwise been preventable. You know, right now we're seeing a return of about eight to nine 8.9 to one on this program. It's, it's going really well. Another area of course, hot topic, oncology and oncology is just evolving every minute. So, you know, how do we figure out how to apply the latest approved methods to managing our, you know, current cases?
Well, we use the NCCN guidelines and really a process for additional reviews of what's experimental investigational. We do a good job at that with involvement of, you know, physician leadership. And we have an ROI that's pretty good on our oncology cases too. And last really something that is on everybody's mind is the increasing cost of gene therapy, drugs. So drugs are being approved by the FDA continuously and you know, some of them are just outrageous. So we manage injectables and infusions over $2,000 per dose per month. And that would include those really what I call ultra high cost gene therapies, which can be over a million dollars. That's a lot. So we're gonna determine medical necessity. We're gonna steer to the most cost effective resource for dispensing and administration. And, you know, we're really gonna make sure that this drug is working as intended in that member's overall plan of treatment.
So we're seeing a great ROI on that program as well. It fits currently in about six to one. So, and just one last topic, just to throw it in there. It's one of those things that like, you never think about it until you need it. I love this one. So what if your member needs a medical transport be a helicopter, right? Or what if they fall ill and they're in a foreign country stuff that you just don't think about? Cuz it doesn't happen that often, but when it does, oh man. So yep. We have that covered too. You can just call us and we'll proactively manage and agree to cost in advance, you know, when we can and that will help save money as well. And our clients in Alaska really appreciate that.
Oh Tina, I think you're right. It's, that's the best part about talking to you? There's so many things and so many facets to medical management, some of them are obvious and some of them aren't like with the example you just gave with you know, the medical transport, but it all happens. And it's all in that bucket of, of how to provide quality and, and to manage costs both at the same time. And you know, I think that you talked about sort of that season that goes on and, and we're there to support that, but can you talk a little bit more about those chronic conditions? Right. So there's always the extremes of the chronic conditions that go on with folks. So can you maybe describe a little bit more deeply about how we support that, which I think you would put the lifetime bucket?
Yeah, so I, so I started with that reason season. Now we're a lifetime. So, you know, a lifetime can be for members who are already living their life at their most optimal health, or it might be someone who is managing a chronic condition that isn't gonna go away. So we manage nine chronic conditions in our disease management program where we educate, support those members, various stages that they're, you know, managing their condition and we really wanna get to them before things get worse and more costly. And we have a dedicated team that's gonna support customizing the approach for each plan, which takes into account whether they, whether or not they wanna consider incentives or benefits. And, you know, we really give them a good guideline for communication that is really gonna help make the program successful. You know, we can also then take another step into that and dive deeper into wellness, which is really under our population health umbrella.
We have tons of resources, both an overall population, health strategy, including disease management and a whole host of other wellness opportunities and options. So, you know, we can do a lot of what specialized vendor programs do, but really we offer it all in one place within the same organization, which allows really for a more easily coordinated member experience and reporting for clients. So it's a lot easier for us to show activities and outcomes and just cover a breadth of clinical things. So if there's truly something that we just don't do, you know, we know there's things and we really are really new and are just beyond our current program capabilities. So for our plan sponsors, if you wanted to include an out outside resource, you know, we can add them in seamlessly. A good example is, you know, recommending getting second opinions on cancer diagnosis before heading down a plan of treatment, you know, a lot of cancer diagnosis are wrong first out of the gate. So having a second opinion really helps target and cut down additional costs in oncology. So we could connect second opinion services from our portfolio and add that into the member experience or another area that's really a, a topic right now is family building and being able to offer, you know, infertility support and put that into the, the benefit offering and, you know, connect members with ability to support fertility. It's really exciting, the new things that we're learning to do and be able to pull together. I love it.
And Tina, you know, you've provided a lot of good information. I mean, there's so much there's so much that we have packed in here and lots of great information, but if you could summarize, always like to leave our listeners with a couple of good nuggets to take away from a conversation, you know, how would you summarize that we're lowering the total cost of care while driving the engagement that you're talking about. Could you maybe just give us a quick summary of what that looks like from your perspective?
Sure. So we know what drives health plan costs. It's, it's clear utilization, length of day readmissions, high cost, drugs, pregnancies, cancer transplants, head pressure, chronic pain, kidney disease. I mean, we've got it. We understand all of those. So from my perspective, the bottom line is that we have an extensive variety of ways to drive down those total cost of care. And really just like I started with, it's all about being able to have a programmatic intervention with those members. You know, we really wanna share our passion for supporting members and living their best health available to them, but also managing costs at the same time. So, you know, we would love to offer our flexibility and expertise to help our plan sponsors and brokers find the right balance that's program interventions that best serves membership and also their bank account.
You're right. Tina, it's it, it is finding that balance. I think that's really well said that the success to, to medical management is discovering that balance together, right? And it's that balance that provides quality and managing total cost of care and keeping that member experience in the center of all of it. I wanna thank you, Tina, for joining me again today. There's always so much. I take away from our conversations around medical management. It's such an important topic as we talk about being advocates for healthier living and helping our plan sponsors and brokers and consultants out there manage total cost of care. So I really appreciate our listeners for joining us for another edition of in the booth. And we look forward for you to join us again on future podcasts, where we strive to bring you informational educational material on relevant topics. Thank you.