Discover the advantages of a TPA with integrated medical management services

In a world where the cost of just about everything seems to be rising, health benefits are no exception. Most employers are likely familiar with the option of self-funding their health plan as a cost-containment strategy. When it comes to self-funding (also called self-insuring) employee health benefits, a third-party administrator (TPA) is a specialized service provider that manages and administers many elements of the health plan, including claims processing, enrollment, billing, provider network and customer service.

TPAs play a crucial role in facilitating the efficient and effective delivery of employee health benefits. But in addition to streamlining various administrative processes, the right TPA can also serve as a guide and educator, particularly if they have an in-house medical management program. Taking a holistic view of the health plan can help employers control health care costs more effectively and enhance the overall quality of services for members.

Exploring the strategic advantages of TPAs with an integrated medical management team

Some employers – and many of their employees – do not realize their TPA might have an entire team of nurses working to support their health plan. While these nurses hold various roles, their goal is very much the same – improving the health of members. Speaking from the lens of a nurse on an integrated medical management team within a TPA, the biggest benefit for an employer working with a TPA is the ability to individualize your plan. Your employees’ health care needs are not cookie cutter, your plan doesn’t need to be either.

Data analytics and reporting

The integration of medical management with data analytics capabilities empowers employers with valuable insights into health care utilization patterns. Data analysis combined with clinical outreach drives health plan performance management. By understanding employee health trends, employers can work with their TPA to proactively address potential issues and optimize benefit plans.

One of my favorite examples of this was with a client whose associates participated in a biometric wellness screening program. Our case managers reached out to associates with results that were at risk of or indicative of conditions such as diabetes, hypercholesterolemia, obesity, current tobacco use, etc. For this company, it was noted by several of their associates that they were working on healthier eating and lifestyle changes, however the employer provided free lunches that featured a buffet of high-calorie, fatty, and fried foods. They did not have options such as salads or grilled chicken.

We were able to make recommendations to this client that their associates who were at highest risk for or living with chronic diseases were ready and wanting to make healthier choices. As a result, the company updated their employee buffet to include salads, fruits, vegetables, and grilled chicken options. I love this example so much because we were able to make recommendations that are outside the box to benefit both the employees’ waistline and the employer’s bottom line!

Enhancing employee wellbeing through case management

Care coordination is one of the most impactful ways an integrated medical management team at a TPA can serve employers and their employees. As a registered nurse for more than 15 years and now working in health insurance since 2018, I see firsthand how coordinated care can lead to the more efficient use of resources and improved health outcomes for employees. Within a medical management team, certified case managers, who are registered nurses, support members and help them navigate their health care in a way that aligns with their benefits.

Case managers take the time that a bustling provider’s office may not always have to coordinate care between specialists, facilities, vendors, community resources, the member, and their support system. This can be as simple as answering questions about the member’s diagnosis and setting goals to lower their risk of diabetes or more complex, such as arranging transportation to treatment; coordinating second opinions or visits with home care and a durable medical equipment (DME) vendor; providing support to the caregiver to prevent an unnecessary ER visit or hospitalization; finding an in-network facility that meets the complex needs of their child; or empowering difficult conversations with their care team about palliative care or end of life wishes.

Here are a few more examples of medical management services:

• Transition of care: Case managers support members as they undergo transitions in health care settings such as rehabilitation services or hospital changes. Follow-up care and any post-discharge needs are also organized by these professionals, which takes the burden off members to plan by themselves.
• Chronic disease management: Case managers work closely with members who have chronic health conditions. They provide education, coordinate appointments and help members adhere to treatment plans, promoting overall health and wellbeing. If depression or anxiety keep a member from taking their medications as we need to start at the root and not just lecture them on pill reminders, the cost of hospitalization, or the complications of their condition.
• Behavioral health: Beyond possessing this unique expertise to provide advice for your physical health needs, case managers will often develop a trusted relationship with patients over the course of regular conversations and coaching. Mental and behavioral health conditions are a growing concern and can be exacerbated by the stress of a chronic physical health condition or new medical diagnosis. Case managers can provide emotional support or direct members to community resources they may not otherwise realize are available.
• Health education and social barriers: Case managers engage in health education initiatives, offering guidance on preventive care, healthy lifestyle choices, and wellness programs available through the health plan. Case managers also know that health care requires a whole person approach and assess barriers to care such as financial, transportation, safety, or food and find creative ways to break down those barriers.
• Assistance with authorizations: In cases where certain medical procedures or treatments require prior authorization, utilization review nurses guide members through the process to ensure that approvals are obtained. This ensures the safety and appropriateness of care.

It can be difficult to make health care decisions at times – should I have that surgery or take that medication? Motivational interviewing along with decision support and education can help members make the best choice for themselves as they are actively participating in their own treatment plan. An informed member will make choices that are intrinsically motivated, which means they are more likely to commit to the steps needed for recovery and wellness.

The importance of member benefit education

Ultimately, the right TPA partner works to empower employers to make informed decisions about their benefits and members to make informed decisions about their health. Employees who are educated about their benefits — and can easily access resources to expand their knowledge — tend to be satisfied with their employer-sponsored health plan and more engaged at work. This includes understanding coverage options, choosing appropriate providers and selecting care that aligns with their health and financial needs. Additionally, members are more likely to use their benefits effectively when they know what they can access – leading to better preventive care, timely screenings and appropriate utilization of health care services, improving health outcomes and lowering unnecessary health care costs.

Related: Will self-funded plans get caught up in carrier and TPA legal battles?

For employers with self-funded health plans or those considering self-funding, finding a TPA partner with an integrated medical management team can be a strategic investment in the wellbeing of their workforce and the financial health of their organization. And having the right guide by your side can help employers make strategic decisions when it comes to managing risk, cost, and care outcomes.

Lorene Barulich, MSN, RN, OCN, CCM, Clinical Programs & Strategy Manager