Managing the high costs of congenital heart disease

M_ChenAbout 40,000 children are born with congenital heart defects every year in the U.S. Many of these children need multiple surgeries and a lifetime of medications to keep their hearts functioning.

There are low occurrences of congenital heart disease (CHD) because the condition is relatively rare. However, it is a high-cost and clinically complex condition capable of taking a heavy financial toll on payers and self-funded employers.

Early identification

Many case managers may not recognize the signs of CHD because it occurs so infrequently. However, when a CHD diagnosis is made at the soonest point possible, it opens up opportunities for treatment options, facility choices, and timely clinical intervention.

  • Early identification — or identifying a CHD case in utero — grants the most ideal opportunity for Centers of Excellence (COE) education and referrals.
  • When CHD is identified after birth, and immediate surgery is not required, thHigh cost of CHD charte opportunity exists to educate the member about Centers of Excellence (COE) facilities. Claims data has shown that COE programs can provide better clinical outcomes while reducing average lengths of stay and overall charges.
  • A case identified after birth in which surgery must occur immediately is less likely to move to a different facility due to the baby’s fragile state of health.

Considerations for payers and self-funded employers.

It’s important to have a strategy in place for managing CHD cases, one that sufficiently addresses the following:

  • Do you know your historical spend on CHD management in your membership?
  • What clinical and network strategy do you have for managing CHD?
  • With whom do you partner to adequately identify and manage CHD in your membership?

Learn more about congenital heart disease, including the correlation between the volume of procedures performed at a facility and the delivery of superior outcomes, by downloading our CHD 5-minute brief.

About the author

Marjorie Chen, Product Director, Congenital Heart Disease Resource Services

Since 2010, Marjorie Chen has directed product management for Congenital Heart Disease Resource Services as part of the Optum Transplant Solutions team. In addition to her work on congenital heart disease services, Marjorie also leads product development for the Ventricular Assist Device Program.

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