Diagnoses:

End Stage Renal Disease; Renal Failure (chronic); Other Complications Due to Renal Dialysis Device, Implant and Graft; Diabetes Mellitus; Other and Unspecified Hyperlipidemia; Gout; Essential Hypertension; Coronary Atherosclerosis of Native Coronary Artery; Arterial Fibrillation; Atherosclerosis of Native Arteries of the Extremities with Intermittent Claudication; Other Congenital Hamartoses, Not Elsewhere Classified

Summary:

The client had been in medical case management for an extended time dealing with the denial of a kidney transplant from facilities and the fact that they could not locate a suitable live donor. The MRC Nurse Consultant continued to provide support, education and resources to the client and his family until a kidney transplant could be completed, which it was in June 2012, with a kidney donation from the client’s son-in-law. With MRC Nurse Consultant involvement, the client was encouraged to convert to Medicare as his primary insurer - which provided the benefit plan with significant cost savings. Since the transplant, the client is now on immunosuppressant medications that are very costly and being primarily covered by Medicare with the employer benefit plan being the secondary insurer. This provided a great deal of cost savings with coverage of the transplant and immunosuppressant medications.

Cost Savings:

The MRC Nurse Consultant coordinated with Swedish Medical Center to send to all records relating to the client's recent transplant evaluation to UWA, to avoid duplication of a complete repeat of the transplant evaluation. In addition, the MRC Nurse Consultant contacted six cardiovascular providers to request all records be sent to the UWA transplant director to avoid duplication of cardiovascular testing. Commonly requested cardiac testing prior to transplantation:


• Left Heart Catheterization: $ 11,915

• Left Heart Catheterization prof. fee: $ 1,765

• Imaging, Cardiac Catheterization: $ 1,834

• Imaging, Cardiac Catheterization prof. fee: $ 278

• Injection for coronary x-rays: $ 643

Cost Savings: $ 17,341

The MRC Nurse Consultant has been involved from the beginning with this transplant case. Although the client had the option of retaining his primary coverage through the employer benefit plan (and his preference), the MRC Nurse Consultant was able to demonstrate to the client the importance of him agreeing to Medicare being the primary payer to conserve his private insurance dollars since dialysis and transplant. This is an 80/20 percent savings for the account. The first year a total transplant treatment will cost approximately $262,000. 80% covered by Medicare and 20% covered by the employer benefit plan.

Cost Savings: $ 209,600

The MRC Nurse Consultant has been able to demonstrate to the client the importance of him agreeing to Medicare being the primary payer to conserve his private insurance dollars. The average monthly medication cost is $3,222. Medicare coverage is $2,578 and the employer benefit plan coverage is $644 per month. Medicare will continue to cover the transplant cost for 36 months.

Cost Savings expected for 36 months: $ 23,184

Total Cost Savings: $ 250,125