Prevention, Screening and Wellness Programs, A Sure Thing

We are all studying Health Care Reform Legislation and how it will affect our world. Hopefully, when the dust settles we will find a way to continue making a living and do good work. Clearly there are changes in store for many of us. Let’s face it; we are all a little scared right now.

Like most of you, we have participated in a myriad of Webinars, conferences and discussions with colleagues about the health care reform bill and how it will impact us now and in the future.  It may not seem that the bill contains something we can all buy into; but that might be because you haven’t studied the law as it pertains to Prevention, Screening and Wellness Programs.

Recently there was the case of a nine month old baby whose parents agreed to take off life support after watching him lie comatose for three weeks at a large Children’s Medical Center from the effects of RSV, a sometimes fatal virus. We know that monthly Synagis injections given during the RSV season produce antibodies that fight the virus. Synagis could have prevented this tragedy. We worked with a 50 year old woman who had a family history of colon cancer, had multiple pre cancerous polyps removed at initial colonoscopy screening and was not tested again until two years later when symptoms sent her to the hospital where she was diagnosed with Stage 4 colon cancer. The disease took her life within a month. A distraught mother spent a harrowing night trying to convince her morbidly obese college age son from jumping out the window of his 5th floor dorm room some 200 miles away from home. The young man told his mother he felt isolated and different from his peers and could not fit in. These are just a few stories of life threatening health problems that might have been prevented, and there are so many more.

Today there is screening methodology to identify babies at risk for RSV. We know that colon cancer can be hereditary and that a propensity for multiple polyps can be a red flag that there is a cancer lesion threatening to develop. More frequent colonoscopies for at risk patients can save lives and claims dollars.  Obesity is a monumental public health problem here in the United States. Children can be educated to develop better eating habits, make healthy food choices, and increase their activity. Weight problems if aggressively and regularly addressed can be managed in some cases. Social anxiety is an ugly by product precipitated by feeling different and unattractive. It is hard to know who the obese college student could be if he wasn’t grossly overweight. It’s heart wrenching to think what his parents are going through. As a health care professional it is encouraging to see Michelle Obama shining a light on the childhood obesity epidemic. Aside from secondary psychiatric problems, we know that obesity can compromise an individual’s immune system and put them at risk to develop diabetes, hypertension, asthma, and even some cancers.

The Patient Protection and Affordable Care Act along with its companion legislation encourages and supports prevention, screening and wellness initiatives in many ways. Incentives are increased, selected preventative services cost to insured are eliminated, small employers are encouraged to implement programs and a significant amount of grant money is available for qualified wellness demonstration programs. The law also allows the cost of wellness programs to be considered as claims costs.

Some of us may benefit more than others by finding a place for ourselves within the parameters of the new law. There are those who will make changes in their service offerings that they never considered before. For all of us there is the real possibility that we, or a friend or loved one may be the beneficiary of an immunization program that prevents a serious illness, or a screening that detects early cancer which is subsequently treated and arrested. Easy, affordable access to lifestyle changing programs that begin the journey toward optimal weight and health is a value added component of many wellness programs. Attaining and maintaining ideal weight decreases the risk of cardiovascular diseases and other health problems. We know claims dollars will be saved by a broader effort to prevent the preventable. Prevention expenses are considerably less costly than cardiac surgery, a course of chemotherapy or lengthy stay in a hospital.

This is what I know for sure; we should all become more engaged in wellness initiatives. If promoting wellness becomes a given, some health problems will be minimized or prevented. If $250,000 is saved preventing one case of advanced colon cancer, how many colonoscopies would that saved money cover? Synagis is expensive upwards of a thousand dollars a month. It is normally given for 6 or 7 months a year for the first year or two of an at risk child’s life. The whole treatment course could cost $14,000. It can cost $20,000 a day to treat an infant with RSV in intensive care. If a baby is confined for 3 weeks that’s $420,000.

The conversation and controversy surrounding the new legislation will continue for a long time. Prevention, Screening and Wellness programs are a concept that flows from the best part of our collective selves. Promoting wellness, participating in screening to detect certain diseases, and taking advantage of preventative modalities such as immunizations are programs we can all take part in to improve the quality of our lives while containing medical claims costs.

Virginia S. Capone, RN BSN CCM

Virginia S. Capone, RN BSN CCM has 25 years of medical cost containment experience and is President of Capone & Associates, Inc. For 16 years Nightingales, a division of Capone & Associates, Inc.has provided patient advocate services to individuals and employers.

   Our experienced team of nurse case managers picks up where insurance leaves off. We negotiate reductions on uncovered medical bills, provide assistance completing insurance forms and interpreting benefit plans. We help plan participants find the best treatment options and direct them to payment resources when benefit plan does not provide coverage for medically necessary treatment. We serve to reduce phone and e mail traffic to human resource and customer service departments by working with insured to understand and use their benefits optimally. Nightingale nurses study our customer’s health benefit plans. We direct insured to prevention, screening and wellness programs available to them.

   Our mission is to be a patient advocate company that manifests our passion for helping others while saving our customers claims dollars.

   We are marketing to employer groups, union trusts and the broker community while exploring partnerships with drug assistance programs, web based physician consultants, banks and debt management assistance programs. Our clients are referred by employers, community organizations, or learn about our service via our Web site.

   Health care reform will lead to changes in benefit plan parameters for insured consumers. We know the number of insurance subscribers will increase by millions. Now more than ever; Consumers will need advocates such as Nightingales to help them navigate this complicated yet essential part of their life.

   Count on Confidentiality, Quality and Timeliness when you Ask The Nightingales.

Nightingale, 100 Springhouse Drive, Collegeville, PA 19426, Phone: 800-526-1877 ginnyc@askthenightingales.com, www.askthenightingales.com.