Diabetes Case Study

Situation

A 36-year-old DAKOTACARE member with Type 1 diabetes wrote on the initial diabetes program questionnaire that was sent out to him, “I take care of my own diabetes.” 

By looking over his claims, Dawn Hahn, a nurse and quality care manager for DAKOTACARE, noticed that he hadn’t been in to see a physician for more than three years. 

Dawn sent him an informational packet. After he received the education packet, he called with the intent of quitting a DAKOTACARE diabetes program he was enrolled in. 

Solution

Dawn talked with him for a while about his diabetes, and he expressed some concern about numbness in his toes. It was also during the conversation that Dawn noted he was using a very old glucometer that was giving him inaccurate blood sugar levels.

Dawn sent out a new glucometer to him, and he agreed to stay in the program for a few more weeks while he monitored his blood sugars with the new glucometer. 

He noticed right away on the new glucometer that his blood sugar readings were very elevated (averaged around 300), so he made an appointment to see his physician and insulin changes were made.

The patient called back six weeks later to let Dawn know that his toes were feeling much better and his blood sugars were coming down nicely after insulin changes were made.

He praised the program for being “persistent” with him, and he has decided to remain in the program. Today, he is doing well. 

Diabetes Case Study

Situation

A 28-year-old DAKOTACARE member with Type 1 diabetes had high blood sugar levels for a year and had been hospitalized five times during that period for out-of-control diabetes.

When Dawn Hahn, a nurse and quality care manager for DAKOTACARE, learned of this patient’s condition, she made a push to have this patient on a more regimented program to better control the diabetes.

Solution

After consultations with the doctor and the local diabetes educator, DAKOTACARE approved additional diabetes care, including weekly face-to-face sessions with the local diabetes educator; weekly visits with the doctor; and a referral to an endocrinologist.

The member is now on insulin pump and blood sugar levels that are very good. Most importantly, this patient has had no hospitalizations within the past two and a half years.

Dawn and the patient continue frequent telephone contacts to keep the member’s condition in check.

Asthma Case Study

Situation

A 30-year-old DAKOTACARE member had missed a total of eight workdays within a two-month period. The member believed it was a bad cold hanging on until one day she received an initial letter announcing DAKOTACARE’s asthma program.

When she received the education packet that had information on the condition of asthma, its symptoms and triggers, she called Dawn Hahn, a nurse and quality care manger for DAKOTACARE, to say, “These conditions fit me. I may have asthma.” 

The member went on to say that her doctor had told her in the past that she had asthma and gave her a prescription for an inhaler to help control the symptoms. The patient was in denial that she might have asthma and elected not to fill the prescription. 

Solution

After having a consultation with Dawn and after looking through the asthma information, she realized the doctor was right. She immediately filled the prescription.

Since that time over four months ago, the patient has not missed a day of work and she’s feeling much better.

Large Business Case Study

Situation

One of South Dakota’s longest-standing banks has continued to enjoy tremendous growth in the Rushmore State. As they grew to 250 employees, they also wanted to control healthcare costs. They opted to look for a third party administrator that would “work to our advantage regarding cost savings, deductible choices and also a way to tailor our benefits to meet our specific health and financial needs.”

Solution

The senior vice president of human resources at the bank had the privilege of working with DAKOTACARE at a previous employer and wanted their bid for the bank’s healthcare solutions.

Through DAKOTACARE’s professionalism, responsiveness and courtesy of time, the bank named DAKOTACARE as their third party administrator. After one year, the results have been very evident.

“We can definitely identify the savings and where our costs are being funneled,” said the senior vice president of human resources. “Our account manager is wonderful and, if I have any questions, she makes me feel like the only person she has to attend to for that moment.”

In addition, the bank has the ability to proactively monitor activity because DAKOTACARE provides a quarterly report to identify any problem areas and signify the savings the bank has incurred.

The employees have also said they appreciate the no-paper claims processing and use the DAKOTACARE website to search healthcare tips and obtain their flex balances, among many of the interactive features.

Case Management Case Study

Situation

A DAKOTACARE member was diagnosed with terminal metastatic lung cancer. She had used all of the skilled care benefits and was a perfect candidate for hospice. However, in her rural area of South Dakota hospice was not available. Hospice for the care she needed was only available in a larger city, which was over three hours from her home.

Solution

Hospice nurses could not drive the three hours to her home and knowing that a three-hour drive would have put much strain on family and friends of the member, a case manager for DAKOTACARE looked for better options. The case manager visited with the account manager and local hospital then negotiated a one-time hospice stay at the local facility.

The DAKOTACARE staff worked different angles and did everything in their power to provide a better option for the family, which allowed the member to fully utilize the  benefits available to her.

It was a difficult time for the member’s family and friends but they were very appreciative of the special arrangements and extra effort made by DAKOTACARE.

Case Management Case Study

Situation

A 50-year-old DAKOTACARE member had to have surgery for peripheral vascular disease.  Post-operatively, he developed acute respiratory distress with respiratory failure. He had to be placed on a ventilator and sedated. Unfortunately, the hospital where he had the surgery had difficulty weaning him off the ventilator and they requested he be transported to another hospital. The referred hospital was a non-participating DAKOTACARE facility and the costs to admit were around $5,600 per day.

Solution

Because of the extraordinary costs of the non-participating hospital, DAKOTACARE’s case manager went to work negotiating the best price for the family. DAKOTACARE was able to negotiate a cost savings of $4,200 per day and because the member could be admitted to the most appropriate hospital for his condition, fewer days were spent in the hospital.

Ultimately the member was able to recuperate more quickly, went home sooner and saved tens of thousands of dollars to receive the level of care he most needed…all because of the extra effort and negotiating skills of DAKOTACARE staff.

Pediatric Case Study

Situation

A 14-year-old DAKOTACARE insured family member was diagnosed with Hodgkin’s Lymphoma. The child was not able to travel to the clinic because of susceptibility to infections due to the chemotherapy regimen at the time. The mother of the child called DAKOTACARE to let them know they were receiving denials for clinic personnel to draw blood for laboratory tests in the patient’s home.

Solution

DAKOTACARE brought the situation to the attention of DAKOTACARE’s medical director. He determined there was medical necessity for the clinic to draw blood in the home. Clinic personnel were able to draw blood instead of having to pay extra costs for home health services.

This coverage not only saved the child from unnecessary infection risks, it also saved the family and the entire plan extra costs.

Pharmacy Case Study

Situation

Previously, some members on self-funded plans have pharmacy benefits that do not cover certain expensive self-injectable medications. If these injectables are obtained at retail pharmacies, members are required to pay the entire bill up-front at the pharmacy.  Members then must submit a receipt to the DAKOTACARE DESIGN claims department for reimbursement.

Solution

For convenience and cost savings, these members are now referred to specialty pharmacies or home IV infusion providers. These providers will work with the member and then automatically bill DAKOTACARE DESIGN directly under medical benefits for these injectable medications.

Because DAKOTACARE DESIGN recognized an opportunity to provide added member benefits, patients don’t have to pay the entire amount up front and all paperwork is handled internally, saving the member time and the plan reimbursement costs.

HeartLine Plus Case Study

Situation

Medicare-eligible South Dakotans with coronary or stroke conditions today face a number of potentially confusing choices in choosing health care coverage. HeartLine Plus has combined all of their needed medical coverage into one plan. In addition to Medicare Parts A and B coverage, HeartLine Plus provides the member with a comprehensive pharmacy benefit and a care management program, with a personal health advisor available to address cardiovascular needs.

One HeartLine Plus member, previously on Medicare, was experiencing severe back pain and depression due to the suffering and immobility. While she was on Medicare she was receiving no special care with a personal health advisor or any disease management tools.

Solution

Once she enrolled in the HeartLine Plus program, her personal health advisor encouraged her to visit with her physician and her pain management specialist to discuss options. The health care team weighed positives and negatives of each option and provided emotional support.

At this point the member has not selected her course of action but has expressed much appreciation to have objective support as she chooses her medical options.

HeartLine Plus is designed to help members become healthier and save costs on health care coverage, just as they are doing for this member.