A recent client was referred to us by a benefits advisor because the employee’s son had an urgent need for healthcare services that were not available.
The employee’s son is 15 years of age. He has a very severe mental health condition that requires specialized grief counselling and adolescent psychological support services. He has had 4 hospital admissions. Once released, the hospitals have handed the boy back to the GP with no follow up care.
WHEN PUBLIC HEALTHCARE SERVICES ARE NOT AVAILABLE:
The public system is failing this young fellow. He requires specialized services that are available as private pay services. The mother who recently lost her partner is not able to pay the $3,000 required for these services.
THE EMPLOYEE’S EXISTING BENEFITS PLAN:
We looked at the mother’s benefits plan:
$300 per Plan Year(s) for Chiropractor
$300 per Plan Year(s) for Osteopath
$300 per Plan Year(s) for Podiatrist/Chiropodist
$300 per Plan Year(s) for Massage Therapist
$300 per Plan Year(s) for Naturopath
$300 per Plan Year(s) for Speech Therapist
$1,000 per Plan Year(s) for Physiotherapist
$300 per Plan Year(s) for Psychologist
$300 per Plan Year(s) for Acupuncturist
The total annual allocation for this employee is $3400. Unfortunately, the benefits are in categories that will likely never be used. And $300 for psychological care will not do the job.
Our suggestion to the employer and the benefits consulting firm was to re-allocate $3000 of the total annual benefit of $3400 for the grief counselling and adolescent psychological services.
IMPORTANT CHANGES TO BENEFIT PLAN DESIGN:
Advisors could suggest to clients that there be another category added to the design called “catastrophic care”.
If the public system can not supply the required services, and that is becoming an issue with increased rationing of services, then the funding that has already been committed by the employer could be available to the employee to pay for these necessary services outside of the formal categories in the plan.
The number of catastrophic cases approved per year will likely be below 1% of employees. The catastrophic cases would require prior medical adjudication and would follow evidence based guidelines and best practices. A third party medical adjudication firm such as Rupert Case Management could provide the medical adjudication services and implement the treatment plans.
It is clear that current benefit plan designs can be improved by advisors by adding more flexibility and a new category called catastrophic care. The benefits plans could be changed to reflect the real needs of employees in an era of rationing and rationalization of healthcare services.