4 minute read
Specialty Care Management changes the conversation about catastrophic claims.
Q A&
DR. RACHELLE SCOTT
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SENIOR MEDICAL DIRECTOR OF MENTAL HEALTH, EDEN HEALTH
Tell us about Eden Health.
Eden Health is a new kind of primary care that helps simplify the complexity of today’s health care system. We unite primary care, mental health, care navigation, and more under a Collaborative Care model to simplify the complexity that patients typically face. Eden works directly with employer groups and health plans to provide this exceptional, 24/7 virtual and in-person care that builds trust, engagement, and satisfaction.
How does your service address the pain points of your customers?
Eden Health is the best at creating long-term, trusted provider relationships that have a tangible, positive impact on employee health. By ensuring employees experience consistent, positive, and meaningful interactions over time with the same care team, Eden builds trusted relationships that lead to greater engagement, increased adherence to care plans, happier employees, and improved health outcomes. This helps employers keep employees healthy while lowering health care costs.
Most peoplewould be surprised to know that my company …
Responds to every patient message in under seven minutes, 24/7.
What are the most exciting or transformational things happening in your segment of the industry right now?
I am incredibly encouraged by the increased focus on mental health. Enabling virtual mental
Contact: rscott@edenhealth.com
MAVERICKS you should know
health services has allowed more access and greater compliance with mental health services. It has also allowed us to reach typically difficultto-reach populations. At Eden Health, we take it one step further by delivering care in a Collaborative Care model. In our Collaborative Care model, the patient has a team that is made up of a PCP, a therapist, and a psychiatrist. The PCP screens the patient and refers them to a licensed therapist for talk therapy if needed, or consults with a psychiatrist for medication therapy if needed.
This is an evidence-based approach; our PCPs are trained in mental health assessment, triage, and treatment and connect patients to the resources that they need. It is also an effective use of resources. Given the nationwide shortage of mental health services, it helps increase access to mental health treatment.
What’s your favorite thing to do on weekends?
I keep it simple! I love spending time connected with loved ones and usually catching up on shows I missed during the week.
What’s the best Netflix series you’ve watched?
I absolutely love Chef’s Table. I am hooked once I hear the music, but what I love most is hearing about the chefs’ stories: their challenges and triumphs. A good story always captures my attention.
Is there a great book you’d recommend to your colleagues or customers?
A little recency bias here, but I loved the most recent book I read, which was actually recommended to me by a colleague and friend: The Forty Rules of Love by Elif Shafak. It is a story of relationships and transformation.
What are you most passionate about?
Sports! But besides that, I would say helping people feel connected and listened to.
AVERTING PRICE CATASTROPHES
BY OLIVIA DESMIT | PHOTOS BY CMJ PHOTOGRAPHY, LLC
Arisk management company in Pennsylvania is setting the standard for controlling catastrophic claims. Specialty Care Management provides an à la carte solution to self-funded health plans, with offerings ranging from outpatient dialysis to oncology.
While the company offers three different product service lines, President and CEO Craig Clemente says its bread and butter is outpatient dialysis risk management.
Within its unique approach, the company offers two options: Dialysis Plus and Prime. Plus is a full administrative and legal carveout of the benefit, allowing the plan sponsor more autonomy and freedom. Prime is a more traditional setup with a TPAbased vendor relationship. Other offerings include cancer management and transplants. But SCM’s plans don’t start and end with purely medical coverage. It also provides clinical underwriting consulting and negotiation services. Whether one or all its offerings apply is up to each plan sponsor and its risk management strategy.
As an organization, SCM’s mission is to minimize these types of claim costs.
“One of the things we look to do is identify and manage emerging risk upstream as much as possible,” Clemente says.
SCM’s various solutions, including chronic kidney disease case management, provide care and support throughout the entire process — not just at the beginning of dialysis treatment. The company takes this approach because its plans involve conditions that require treatment. Dialysis is not an elective service and typically involves a lifelong treatment plan.
“Our programs look to remove outof-pocket expenses for members, so there is no copay, coinsurance, or associated deductibles for the benefit of outpatient dialysis,” he says. “While we enhance value for members, the employers are getting charged a flat, fixed-cost rate.”
Municipalities, government agencies, and unions are some of the most common partnerships.
LAST DOLLAR DOWN
Specialty Care Management has been providing innovative catastrophic claim coverage for two decades. Its mission has stayed the same in that time: managing risk from the last dollar spent down.
What does this mean? Typical cost containment companies
Craig Clemente, president and CEO of Specialty Care Management
