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Health Navigators: Guiding Patients Through the Healthcare System

For most of the 1980s and 1990s, health maintenance organizations (HMOs) indirectly discouraged healthcare consumerism by offering benefit designs with small (if any) copayments for virtually every service.

Emergency room visits, surgeries, diagnostics, maternity care, hospitalizations and brand name drugs came with little out-of-pocket expense to the insured. HMO plan participants had no insight to the cost of care with no incentive to be informed, therefore Americans had no idea how much their knee-replacements actually cost.

This ‘money is no object’ attitude toward healthcare drove high utilization and a devaluing of employer-sponsored benefits. As a result, Consumer Driven Health Plan (CDHP) products were born in the late 1990’s to incent consumerism and thereby reign in utilization and ultimately tamp down medical inflation. A decade later, CDHP adoption was in full swing and today, the majority of employers have implemented CDHP plans, often as the only option. Now, with high deductibles to satisfy, Americans have reason to shop around for healthcare just like we shop for consumer products. The problem is, shopping for healthcare isn’t quite the same as shopping for a sleeper sofa or an appliance.

When we need healthcare, we are usually sick or injured and that exponentially raises the anxiety level. It’s an emotional and mental strain, perhaps even more than a financial one, as we enter a system that is anything but simple.

Our healthcare delivery and financing (insurance) systems are complex, fragmented, overwhelming and the questions mount quickly: Do I really need to have this procedure? If so, is it going to be covered by my insurance? What is it going to cost me? Should I get a second opinion? From whom? Do I need a referral? Do I pay up front and seek reimbursement? Who’s responsible for my post-surgical care? Should I take the pain medications the doctors are prescribing? What are my alternatives? The list goes on…

For many of us, the questions and confusion become so overwhelming that we simply leave ourselves at the mercy of the doctor. We do what the doctor tells us to do and go where the doctor tells us to go because our neighbor, Phil, heard that his brother-in-law’s accountant’s veterinarian’s plumber, Bob, had a good experience with that particular doctor. And that is not good consumerism. As plan deductibles rose and the healthcare delivery system became more complex, large employers began to realize that their employees needed help. CDHP participants need guidance on how to be better consumers of healthcare. They need someone to navigate them through the system safely and effectively, advocating every step of the way on their behalf. Where there’s a need, an industry arises, and that brings us to the subject of this blog: health navigators.

There’s a wide range of available services in the health navigation genus. It could be as simple as a second opinion service for high dollar procedures or a data-driven, subjective quality ranking of providers; or it could be as comprehensive as a full carve-out of member services, provider services, disease management and care coordination.

The underlying idea is that health navigators, to one degree or another, assist a plan participant through the healthcare maze.

Call it health navigation, concierge member service, care coordination or patient advocacy, there are companies, separate from the insurance carrier or third party administrator (TPA), who will hold a plan participant’s hand throughout their healthcare journey. The health navigator will be there to answer the myriad of questions from someone who’s just been told they are facing a health crisis. This is a much more robust approach to member service than the typical insurance carrier member service model, which can confirm eligibility, check a claim status, or explain covered benefits. The health navigator also advocates on behalf of the patient, not the insurer, provider practice, pharmaceutical company or the pharmacy, nor the hospital system, lab network or radiology center. The health navigator is there to be a liaison between the patient and all of the other players involved, including providers, payer, TPA, pharmacists and community resources.

Often, plan participants leave a doctor’s office with a diagnosis, instructions for further testing and/or medications, a healthy dose of confusion, and this general thought in the head: What do I do now? Health navigators are there to answer that foundational question and all other questions that follow. Employers might pay for a health navigator program simply because they want to give their employees a better, high-touch member service experience, which results in peace of mind for the participant. This leads to employees who are more satisfied and appreciative of their employer-sponsored benefits program, but there’s likely to be a financial return on investment too. By smartly guiding members through the healthcare system, health navigators can steer members to lower cost higher quality providers and facilities; help members stay compliant with their treatment plan (avoid re-admissions); educate members on generic alternatives to expensive brand name drugs; eliminate unnecessary testing and procedures; and generally reduce wasteful healthcare consumption and spending. In doing so, full service health navigation/care coordination programs can generate initial claim reductions of up to 15% and then manage to lower trends thereafter.

To date, health navigation services have mostly been a large employer phenomenon, with self-funded plans leading the way. However, as with most innovative strategies in health insurance and employee benefits, health navigation and concierge member services are slowly making their way to smaller employers. There are a growing number of vendors playing in this space and a growing number of employers seeing the value. Contact your OneDigital consultant today if you are interested in learning more about health navigation services.