Advocacy Programs of Increasing Interest to Insurers and Employers

Consumers may spend more and get lower-quality care when trying to navigate the healthcare system on their own. Everyone may benefit when insurers guide them.

Consumers are no match for a healthcare system that can seem complex, inefficient, and expensive, and the employers offering their health insurance often are the ones who pay the price in higher premiums and medical expenses. Some are seeing the benefit in health plans that offer more handholding to guide consumers through the experience.

Concierge-type services have been offered for years, but they often were seen as a perk for top-tier clients, a way to help the lucky few avoid the hassle that the typical consumer experiences in the healthcare system. The outlook is changing now that employers are seeing the potential for better care and reduced costs by offering personalized assistance to the rank and file worker.

Insurers and employers are recognizing the value of providing a consumer advocate who can work directly with a consumer, supported by a team of multidisciplinary professionals, says Tom Meier, vice president of market solutions at Health Care Service Corporation (HCSC), a consumer-owned health insurer in the United States and a licensee of Blue Cross Blue Shield, serving nearly 15 million members.

The increased interest comes partly from the realization that the higher deductibles currently in use don't make consumers more thoughtful and engaged in using healthcare resources wisely, as many employers hoped, according to a recent healthcare industry survey. Instead, they just make them avoid healthcare altogether, including preventive healthcare.

Better utilization, lower costs

Some health plans are developing health advocacy programs, and there are companies such as Accolade that offer services to both employers and health plans. Accolade promises employers savings of up to 15% and says health plans can improve utilization and the member experience while reducing medical claims spend.

HCSC is addressing those goals with a program called Health Advocacy Solutions for large employer customers. It's a personal concierge program to address healthcare issues, answer questions, and encourage members to become advocates for their own health, Meier says. The program launched in January 2018 after a yearlong pilot program with a large client.

Six large employers have adopted the health advocacy solutions program and several more are considering it for the 2019 benefit year. The goal is to improve care and the customer experience, Meier says.

"But it's more than excelling at customer service. It's about moving away from focusing only on resolving customer problems and more toward becoming true advocates for our members, helping them navigate an incredibly complex healthcare landscape in ways that ultimately are going to deliver a substantially improved member experience," he says.

"We're also going to be able to influence the care they receive and reduce or mitigate a lot of waste from the healthcare system, eliminating a lot of the unnecessary medical care that occurs. We believe we're going to be able to achieve some pretty sustainable cost savings for our members and the employers," he says.

The key to making such a program work is to meld the clinical and nonclinical needs of consumers, Meier says. The traditional approach to care management has focused exclusively on the clinical issues—facilitating patient access to proper care and applying best practices, he says. Utilization issues were closely related, with insurers focused on issues such as length of stay and how to get patients to a lower-cost setting for care.

"On the nonclinical side, we focused on resolving customer problems like lost ID cards. Insurers wanted to make sure we were easy to do business with, answering questions our members had but not necessarily acting in a proactive way to prevent those problems" Meier says.

"With this program, we're reimagining the clinical side so we're no longer focusing on condition-specific solutions but instead focusing on the whole person and the whole population, looking for the best opportunities to intervene. We're doing that in a more real-time basis, when it is more meaningful for the member as opposed to a month after a situation occurred," he says.

Broader utilization management

Clinical concerns are addressed from a different perspective, Meier says, with a designated clinician looking at utilization management across different conditions, and including outpatient utilization more than in the past because so many more healthcare dollars are going there now.

HCSC also folds its pharmacy benefit management into the mix, because prescription coverage represents an increasingly large portion of medical expenses.

"We are sewing the clinical and nonclinical groups into one multidisciplinary team full of specialists—everyone from physicians, pharmacists, and social workers—to surround the consumer advocate who engages the member in both a reactive and proactive way," Meier says.

"There are ways to help people navigate the healthcare landscape that they may not even realize. We can help them, for instance, when they're in a PPO and need to know where's the best place to go for care, to get the care that is the most appropriate for them according to the literature," he says.

A health advocate may guide a consumer to alternatives to a spinal fusion, for example, that are less invasive, less costly, and that will provide a better quality of life afterward, Meier says. The patient benefits but so does the employer and the health plan.

The health advocacy program requires an investment from both HCSC and the employers choosing this option for their coverage, Meier says. The program is not overlaid on all HCSC plans because the additional expense must be covered by those employers who see the potential benefit, and that is why it appeals mostly to the largest employers.

"We have to look at whether this is something that will fit with their culture and whether the data show us that they're going to get the return that makes this worthwhile for them," Meier says. "If it looks right for them, we'll talk to them about switching over from one of our less intensive models to a solution like this health advocacy model. In those cases, we think there is a substantial yield to be had in managing their healthcare costs and in transforming their employees from passive to active participants in their care."