Advocates for the Critically ill
Wally Otto and LaRue McManus of ConnectCare3 are confident they can help employers hold the line on the cost of health insurance by providing extra services for people with critical or catastrophic illnesses.
"Approximately 3 percent of the insured population are responsible for over 25 percent of insurance costs," said Otto, chief operating officer for the Leola startup. "The vital few are the big cost causers."
ConnectCare3 offers an add-on to regular health insurance that helps guide those vital few through the health care system with the goal of improving the outcomes of their care. And that in turn can get those critically ill employees back to work sooner.
McManus is the nurse navigator who has been providing most of that guidance since the new company started helping clients last October.
"It's really about patients understanding that they have options," she said. "It's not our position at ConnectCare to recommend a treatment, but to listen and help them navigate through the system."
That help includes research to find the best centers for treating the illness and in some cases accompanying patients to appointments as an advocate for their care, she said.
ConnectCare3 is an offshoot of the Benecon Group, a consulting firm that specializes in setting up insurance benefit programs, including self-insured consortiums of municipalities and businesses.
"We work hand in glove with Benecon," Otto said.
ConnectCare3, a stand-alone company, provides the workplace training and patient services for the new program. Benecon provides ConnectCare3 with human resource, financial and marketing services.
Sam Lombardo, president and CEO of Benecon, is also CEO of ConnectCare3. It was Lombardo's own experience with a critical illness that was the impetus for starting the company.
He talks about his illness in some detail in a video, "How It Began," on the company's Web site, http://www.ConnectCare3.com.
In 1999, severe headaches prompted Lombardo to seek medical care.
"The MRI showed I had this small, acorn-sized tumor in my cerebellum," he said. "Fortunately, it was benign. All I had to do was survive the recovery."
That turned out to be harder and more irritating than Lombardo expected, leading him to wonder afterward whether the recovery might have been shorter had someone guided him to a more advanced center for his surgery and acted as his advocate during the process.
The goal of the new company is to provide for other critically ill people the kind of service that Lombardo lacked.
"If I'm sick, I want someone pushing the envelope to find out where I can get the very best treatment," Lombardo said.
Getting started
While Lombardo believed this kind of service would result in better outcomes for patients, Otto said, he also suspected it might offer cost savings for insurers and employers through shorter hospital stays.
To test that theory before starting a new company, he commissioned a $30,000 study by the Johns Hopkins School of Public Health in Baltimore.
The study evaluated the number of hospitalizations for a group of nearly 90 Medicaid cancer patients, comparing those who chose to participate in an existing case-management program with those who declined.
The study found that those who enrolled in the program were much less likely of being admitted to the hospital than those who declined the service.
Based on those results, Benecon started putting together a business plan for ConnectCare3 about a year and a half ago, McManus said.
Otto, who had been working as a management consultant for Benecon, took on the assignment, and in March 2008, agreed to become the new company's COO.
McManus — a registered nurse with experience in intensive care, post-anesthesia care, women's and children's health, and outpatient surgery — joined Otto in June and concentrated on preparing educational materials for the launch in October.
There are three legs to this new insurance program, Otto said. Hence the "3" in ConnectCare3's name.
The first is research to identify the best providers of treatment and the social-service resources available to support the family during the process.
The second leg, he said, is the guidance that McManus, and eventually others, can provide to help the patient navigate the system.
And the third is a medical panel that SelectCare3 has set up that can be called on in certain circumstances to provide expert medical advice about the patient's options.
The panel has four doctors who work on contract, Otto said, including one involved in the study Lombardo commissioned.
A third employee, Michelle Hemphill, who has a background in insurance at Benecon, rounds out the company's current staff.
Hemphill is the intake coordinator, responsible for the initial patient assessments and the research on the social services available to them.
About 12,500 people are now enrolled with ConnectCare3, Otto said. Most of them are the 5,200 employees and their dependents covered by the Pennsylvania Municipal Health Insurance Cooperative, a consortium of about 150 municipalities and one of Benecon's clients.
ConnectCare3 has been busy with this pilot group, traveling to far-flung rural municipalities to give educational presentations to employees and building a database of resources for each of the communities.
McManus said many of the employees she has spoken to have come up to her afterward and said, "I wish I had had this service a year ago."
One, she said, was a police officer who had lost a child. He regretted the time he had been forced to spend making arrangements for his family to stay away from home to accompany the child to the hospital, tasks ConnectCare3 could have handled while he focused on the child.
ConnectCare in action
Since last fall's launch, about 20 of the covered employees have come forward to avail themselves of the service, Otto said.
Several had cancer. One is a candidate for a liver transplant. Another needed help sorting out medication conflicts.
The program is voluntary, Otto said, and there is no set criteria for what qualifies as a critical or catastrophic illness.
"We had someone tell us, 'Anytime someone comes at me with a scalpel, it's a critical illness,' " he said. "In the beginning, we learned when there are questions that are not about serious illnesses, we could handle that."
"If employees call us," McManus added, "we have the resources available to provide them maybe not full services, but to answer their questions."
One of the clients, for instance, had been advised to have an adult tonsillectomy but had been reading horror stories about the procedure on the Internet.
"We know where the reliable information is on the Internet," McManus said. "We learned about a less invasive procedure, and that individual was able to have that type of procedure. ... The recovery was easier, and the individual was able to return to work earlier."
One of the trends in the health insurance industry is to provide this kind of coordination between patients and physicians, said Robert Zirbelbach, a spokesman for America's Health Insurance Plans, an industry advocacy group in Washington that represents 1,300 member companies.
Many insurance companies are providing such services through Web sites and 24-hour hot lines, Zirbelbach said. They pay off through reductions in hospital stays, readmissions and emergency room visits.
"It's in everyone's interest for everyone to get the right treatment at the right time," he said.
What Zirbelbach had not heard of before was a service like ConnectCare3 that makes house calls and sends someone to accompany patients on appointments.
"It really demonstrates the innovative approach to health care that people are taking," he said.
Otto and McManus said they believe that face-to-face approach is what sets ConnectCare3 apart.
"As far as we know, we're the only one that goes out and makes house calls," Otto said. "We believe that's the best way to go."
To illustrate the advantage of that approach, McManus tells of a call she received from a fairly young client who had been diagnosed with pancreatic cancer and wanted to go to the best place for treatment.
McManus said she was ready to recommend a facility in New York that was renowned in the field until she met the patient in the waiting room before an appointment with an oncologist.
When she saw that the patient was already exhibiting signs of the end stages of pancreatic cancer, she realized there would be no advantage to making the complicated arrangements for treatment at an advanced center.
"The treatment plan we needed to develop was an end-of-life plan," she said, concentrating on support services for the family, which included a 5-year-old survivor.
"That unfortunate individual ... passed away," she said, "and the family had very little time to deal with it."
Casting a wider net
Now that ConnectCare3 has had several months to work out the details of the new service, it is preparing to ramp up its client load.
"We have prospects that will be coming online in a few months," Otto said. "We believe this business is going to grow very rapidly."
That will require more staffing.
"We are committed to next-business-day response," he said. "We are right now looking for an expansion of our work force, particularly in the area of professionals like LaRue."
Although Benecon's insurance clients are being approached about signing up for ConnectCare3, employers with any kind of current health insurance can sign up for the additional coverage, Otto said, as can individuals.
The cost for group coverage can range up to $6 a month per employee, but can be less than half that depending on how much a company's own human resource department can help with the training and administrative tasks, he said, particularly when the company has a fairly large group of employees who are all under one roof.
"Progressive employers are saying, 'We're ready to make a short-term investment for a long-term return," Otto said.
