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The Road of Complex Care

Mayo Clinic Is Helping Employers Cap Costs and Improve Care

The cost of health care keeps rising and employers and employees alike face the challenge of finding the best care for the best value. One of the costliest areas of health-care spending is the evaluation and treatment of patients with serious medical illnesses and/or complex medical problems. These patients may have rare diseases, require complex procedures or have multiple medical conditions that lead to higher risks of complications or death — all of which are associated with higher costs of care.

These patients’ illnesses and complex medical needs require specialized care that is often not available locally or at regional referral centers. Physicians and surgeons may not have a great deal of experience with the diagnosis and treatment of patients with certain serious illnesses and complex conditions. Patients may seek multiple consultations, searching for a diagnosis or treatment from an experienced provider. They may even receive wrong diagnoses, resulting in costly, ineffective treatments. In addition, they may suffer side effects and complications from ineffective or unnecessary treatments that are expensive and potentially avoidable.

“Mayo Clinic is world renowned for its treatment of patients with serious illnesses and those requiring complex care,” said Charles Rosen, M.D., medical director in the Mayo Clinic’s department of contracting and payer relations. “With expertise across virtually every medical specialty, we have created a program that allows employers to access high quality specialty care and manage their health-care costs. Employees are able to get the care they need at one of our three campuses in Arizona, Florida and Minnesota.”

Establishing its first specialty care program in 1997, Mayo Clinic partnered with Walmart Inc. to provide care for their associates and health-care beneficiaries in need of organ and bone marrow transplants. Since that time, Mayo has expanded this relationship to include a cancer program and participation in Walmart’s spine and joint replacement Centers of Excellence networks.

The Mayo Clinic Complex Care Program was developed as more employers recognized the need to partner with specialty care centers to provide excellent, cost-effective care for patients with a wide variety of serious illnesses and complex medical conditions.

Mayo Clinic physicians are salaried and do not have any volume-related incentives. Their only interest is their principle value, to do what is in the best interest of the patient. William J. Mayo, M.D., one of the two founding brothers of Mayo Clinic, believed in this approach, too, stating, “The best interest of the patient is the only interest to be considered.”

Complex Care Program Provides Value to Employers, Patients

Mayo Clinic staff work closely with employers to design a program that augments their company’s health care benefits and meets their employees’ needs. The plan involves collaboration between an employer, a trusted payer partner and Mayo Clinic.

Some employers require employees to use the care program, while others offer it as an optional benefit. Many employers engage with a payer partner to provide a travel and lodging benefit to cover costs for patients and their caregivers who travel to one of Mayo’s three campuses.

Through the care program, employees from participating companies receive coordination of care across medical specialties. Teams of experts work together to identify what screening tests and clinical examinations are needed to meet each patient’s medical needs. What might take months elsewhere is often done in days at Mayo, reducing time away from work and eliminating unnecessary costs to patients and their employers.

With this approach, Mayo Clinic experts are able to deliver the right care by correcting any misdiagnosis, adjusting treatment plans and removing duplication of care.

Mayo Clinic staff work closely with employers to design a program that augments their health-care benefits and meets their employees needs.

The program is divided into two offerings: 1) The Complex and Serious Illness offering provides access to subspecialized expertise for individuals with high-cost or high-risk diagnoses; and 2) Care Pathways for well-defined conditions or procedures.

Examples of complex and serious illness medical conditions in this plan include:

  • Diseases with simultaneous, complex medical conditions like organ failure;
  • Diseases with high rates of misdiagnosis, such as multiple sclerosis, autoimmune disorders and rheumatoid arthritis;
  • High-cost treatments like spinal fusion surgery, dialysis, implantable devices for heart conditions and joint replacement;
  • Rare and unique cancers;
  • Heart conditions such as adult and pediatric congenital heart disease, dysrhymias and valvular disorders; and/or
  • Unknown diagnoses for gastroenterological and neurological disorders.

Mayo Clinic specialists may provide an eReview, or virtual travel review, to determine if an individual would benefit from traveling to Mayo Clinic for an evaluation. This screening process helps to control costs, avoid unnecessary travel and provide the most appropriate care for every patient.

The second part of the program involves Care Pathways, which are well-defined episodes of care for specific conditions or procedures. These pathways include organ transplants, specific cancer surgical procedures, spine care and joint replacement. Bundled pricing may be available for some Care Pathways to offer employers predictable health-care costs.

“We have high volumes and special expertise in these areas that has enabled us to determine the best approaches to diagnosing and treating these patients,” Rosen said. “Our aim is to restore health and quality of life. We want patients to be able to return to work as quickly as possible. These pathways help avoid unnecessary tests and procedures. Our expertise helps avoid complications, prolonged hospitalizations and hospital readmissions — ultimately lowering the total cost of care.”

Both components of Mayo Clinic’s Complex Care Program were created to achieve these goals:

  • Provide an accurate diagnosis;
  • Recommend appropriate treatment; and
  • Deliver specialized care and procedural excellence.

What follows is a closer look at the plan in action.

Diagnostic Accuracy

The first step in treating patients with complex medical problems is an accurate diagnosis. A misdiagnosis could lead to a patient receiving the wrong therapy, resulting in wasted health care dollars and potentially harmful side effects from ineffective treatment.

For example, each year Mayo evaluates thousands of patients for multiple sclerosis (MS) and for presumed idiopathic transverse myelitis, disabling conditions affecting the brain and spinal cord. The diseases can be difficult to diagnose because symptoms vary or could be caused by another condition.

“With our expertise and coordinated care, we’re able to accurately diagnose and treat patients from the start,” said Mark Keegan, M.D., a neurologist at Mayo Clinic’s campus in Rochester, Minn. “Approximately 80% of patients we see are coming for a second opinion after being diagnosed with one of these conditions. Of those, over 20% are found not to have multiple sclerosis, 70% did not have transverse myelitis and more than 30% require a change in treatment.”

Appropriate Treatment

Once an accurate diagnosis is made, the next step is recommending the right treatment, the first time.

Most people suffer from some type of back pain during their lifetime. As Mohamad Bydon, M.D., a neurosurgeon at Mayo’s Rochester campus explains, many patients with a degenerative disk disease (a common cause of back pain) do not require surgery.

“There are now less invasive, safer procedures to treat spine problems,” Bydon said. “In some cases, for older patients or those with complex medical conditions, surgery is not a good option.”

For patients with complex medical conditions, where and from whom they receive their medical care is a crucial decision.

In fact, many Walmart associates seen through the Mayo Clinic Complex Care Program for spine problems or joint replacement avoided surgery.

“Over half of our associates referred to Mayo Clinic, one of our Centers of Excellence network health systems, have avoided spine surgery and about a fifth avoided joint replacement surgery,” said Lisa Woods, senior director of health-care benefits at Walmart. “These patients received treatment to relieve their pain without the risk of surgery. They benefited from receiving appropriate treatment at a lower cost and with better results.”

Patients with chronic kidney failure who are approaching the need for dialysis are also at risk for inappropriate treatment. In many practices across the country, patients undergo a vascular access procedure so they can begin dialysis and then only after beginning dialysis are referred for a kidney transplant.

“In these cases, the best decision would have been to proceed with a preemptive kidney transplant, avoiding the high cost and side effects of dialysis,” said Patrick Dean, M.D., surgical director of the Mayo Clinic Kidney Transplant Program in Rochester. “Often these patients can return to a normal life after transplantation, rather than enduring dialysis therapy for three to four hours, three to four times per week.”

Procedural Excellence

For patients with complex medical conditions, where and from whom they receive their medical care is a crucial decision.

“Should a patient be treated by someone who performs an operation or procedure a few times a year or one who sees patients with similar conditions almost every day?” asks Rosen. “We regularly see conditions and diseases that are rare in many other practices, and our experience allows us to provide state-of-the-art care.”

Woods echoes the benefit of Mayo Clinic’s expertise.

“Walmart’s experience is that patients that have undergone operations at Mayo Clinic and the other centers in our networks have fewer readmissions, shorter lengths of stay and return to work sooner than patients treated at other centers,” she said.

The Patient Experience

Seamless care for patients is at the center of the Mayo Clinic Complex Care Program.

To date, 85% of patients in the Mayo Clinic Complex Care Program rated their likelihood to recommend Mayo Clinic as “very good.” The remaining 15% rated the likelihood as “good.”

“Our aims are to schedule an efficient itinerary, deliver an integrated evaluation and provide a treatment recommendation during the visit, schedule surgical procedures either during the patient’s visit or at their convenience and to follow up with the patient’s local health care provider and facilitate their transition of care when they return home,” said Rosen.

“Mayo Clinic has redefined the value of complex care,” he added. “Our value is to get the diagnosis right, to do the right thing and to do it right.”

For more information on Mayo Clinic’s Complex Car Program, please contact Dana Baker, director, or Cheryl Nienhuis, director.

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