Patient Advocacy at Memorial Sloan-Kettering Cancer Center
by Laura Ostrowsky
I am the Director of Case Management at Memorial Sloan-Kettering Cancer Center, an organization with limited managed care contracts. We are a specialty hospital providing state-of-the-art cancer care. Our physicians subspecialize in oncological disease states. For example, many hospitals have hematology oncology specialists providing care to patients with cancers of the circulatory and lymphatic systems (liquid tumors); we have separate services for leukemia and lymphoma. This degree of specialization results in physicians who treat large numbers of patients with relatively rare cancers.
We have always advocated for our patients and had a relatively aggressive program to contest denials of service/payment for care rendered. However, recently we decided to take a more proactive approach. In July of 2003 we developed a new program to work with patients seeking care at Memorial despite the network limitations of their insurance contracts. The goal of the program is to present a clinical argument to the insurance company to cover the patients’ care at Memorial. We target rare cancers, patients requiring non-routine treatment or procedures, as well as patients who had been misdiagnosed or mis-staged within network. We also advocate for patients whose treatment recommendation in network differed from the plan of care recommended by a Memorial physician. For the routine early stage cancer patient we recommend that they receive their care within network and refer them back to their provider. We also refer back when comparable care and treatment plan is available in network.
As a specialty hospital with ongoing clinical trials in many of our services we have been very successful in obtaining coverage for out of network treatment at Memorial even for patients from strict HMOs. Patients and families are very grateful for our help, and the staff in this area derives a great deal of satisfaction from assisting patients to get the best possible care for their disease. A secondary benefit are the relationships forged with non-network payers and their case managers. Once they learn that care at Memorial is the best or even only option for patients with specified diagnoses, we find that these case managers will actually seek care for their patients at Memorial and will preapprove out-of-network care. Additionally, we have signed contracts with a number of managed care companies to cover their patients for specified disease states. In a few cases they have signed contracts with us, including Memorial in their network for any patient with a cancer diagnosis.
Our approach to insurers is twofold. We provide clinical arguments when seeking network coverage for individual patients. These arguments include letters of medical necessity as well as journal articles obtained through literature searches to support our request for covered care at Memorial. When negotiating with insurance companies to develop contractual agreements we provide data on outcomes and costs that demonstrates the efficacy of care at Memorial and proves that overall cost through the continuum of care is lower.
The success of our program has lead to the expansion of this area from one nurse case manager to three people, two nurse case managers and an administrative assistant reporting to a supervisor who is also in charge of the retrospective appeals program. We continue to identify ways to deliver superior customer service and the “best cancer care anywhere.”
