Chapter 3 Health System Navigation: The Role of Health Advocacy and Assistance Programs

Characteristics of the US Health Care System Disorganized – both benefits and medical delivery Expensive – we spend more per capita than any other developed country Technologically sophisticated – contributes to the difficulty of use Few consumers can figure it out on their own

Every person can be placed in a group according to their health status By conditions – asthma, heart disease, etc. Clinical severity – i.e. severity of heart disease, etc. Medications they take Company they work for Insurance plan they belong to Doctors caring for them Taking a “Populations” approach can help us examine the health system

Those who have a health problem Those at risk of getting a health problem Regardless of which group a person is in, help navigating the health care system is useful Ultimately there are only 2 populations of people

Those who can find their way through the health care maze Those who cannot Those who cannot find their way through the health care system tend are unlikely to reach the best possible outcomes and will drive up costs unnecessarily Health advocates also recognize 2 groups of people

Recent development – last 10 years Fee-based – paid either by employer or consumer directly Employer benefit model has gained significant traction Work in concert with patient’s physicians Private Health Advocacy Programs

Consumer engagement? Provide consumer education? Change consumer behavior? Organize the medical care system? Or, just help people cope and find solutions? Goals of health advocacy programs

Healthcare Cost Increases The Complexity of Health Benefits Programs Consumers Being Asked to Assume Greater Responsibility for Managing Their Own Health Medical Care System Disorganization and Inefficiencies Access to Care Problems Increasing Medical Technology and Super Specialization Information Overload Increasing Focus on Quality of Care and Patient Safety The Difficulty of Managing a Parent’s Health Issues Privacy Concerns No Where Else to Turn For Help Factors Driving Health Advocacy

The employer’s perspective Most Americans get benefits through their employers 95% of employers with >50 employees offer health benefits Kaiser Family Foundation: 2009 health premium for a family offour= $13, family health insurance premiums increased by 131% while wages increased 29% The employer’s perspective

Main focus is on cost of health benefits Want “value” for their investment Recognize that good health is good for business Attempts to constrain costs have resulted in multi-layered, difficult to use benefit programs The employer’s perspective

Usually “insured” – pays premium Offers relatively standard insurance programs Few people to help resolve employee issues Benefit brokers play a big role in selling and after-sale support The small employer’s perspective (<100 employees)

Mixed of insured (smaller) to “self-insured” programs Self-insured companies hire an administrator – could be a health plan or a Third Party Administrator (TPA) Start to see some customization of benefits – carve out pharmacy benefits to a Pharmacy Benefits Manager (PBM) Consultants as well as brokers sell and support clients The middle market employer’s perspective (100 – 1,500 employees)

Nearly all “self-insured” Plan administrator likely to be a health plan Customized benefits – “Best of Breed” approach Examples of carve-out programs: Pharmacy Benefits Manager (PBM) Mental Health Manager Disease Management Case Management Employee Assistance Program (EAP) Nurse triage service Dental plan Wellness program The large employer’s perspective (>1,500 employees)

Proffered Provide plans (PPO) dominate the benefits landscape In and out-of-network benefits introduce complexity – Reasonable and Customary (R&C) reimbursement and balance billing High deductible, “Consumer Driven” health plans The consumer’s perspective – consumer driven health care

Consumer has more “skin in the game” Does having to spend more of your own money makes you a better health consumer? Those in these plans get less care – Rand study 1070’s Data shows people in these plans get less of both the care they need and the care that they do not need Does any of this affect outcomes? High Deductible Health Plans

Doctors often try to ignore insurance issues Some physicians will try to help patients deal with administrative issues - to a point Don’t have the time or the skills Don’t get paid for helping patients deal with their health benefits Support health advocacy programs that foster a “medical home” relationship for the patient The physician’s perspective

Some health plans have their own advocacy programs Consumers in general do not trust their health plan 2/3 of consumers “worried” or “somewhat worried” that their health plan is more interested in making money than doing the right thing for its members Almost 50% of consumers report having had a problem with their health plan in the last year Advocacy programs have good relationships with health plans The health plan and administrator’s perspective

Engage the individual at their time of need Typically opt-in programs, not data driven Create trusted relationship with user Protect privacy – HIPAA Personal relationship between user and advocate Provide help with any health related issue consumer may face Health advocacy as an independent service

Utilization of advocacy services – 8 to 10% in large companies, 10 to 15% in small companies Use often mirrors what is going on in employer’s benefits program – change of carrier, plan design, etc. Over half of all initial calls related to an administrative issue – bills, benefits, appeals, denials, grievances Cross relationship between types of issues – clinical issues often lead to administrative concerns and vice versa The people who call needed some type of care for some medical issue and have a question or problem What help do consumers need?

Figure 3-2 Distribution of Clinical Cases Health Advocate, Inc. internal data. Cases completed January 2008–June 2009.

Access to care issues Finding physicians for common needs Identifying specialists Second opinions “Best” doctors, hospitals, Network participation status Personal desires and preferences Scheduling appointments Getting medical records transferred What help do consumers need?

Single point of contact thru the advocacy program Making connections to other benefit programs Right time, right place approach to get patient to the right program to meet their needs Referrals to disease management case management, PBM, EAP, nurse triage service May involve disability carrier, Family Medical Leave (FMLA) approval Provides coordination across a fragmented system What help do consumers need?

Consumer driven health plans assume that the consumer can be “activated” to engage in their own health management Those who perform well in Consumer driven plans may be “different” from the average individual – inherently more “activated” Advocacy programs can help activate consumers and help others who merely are trying to cope with their situation Can we change consumer behavior?

The health care system in the US will continue to struggle until we find some means to reduce costs Employers will continue to respond to the increase cost of health benefits by increasing the amount individuals must pay for their health care Individuals will have to assume a larger role in managing their own health and making health care decisions Health advocacy programs can help consumers make more informed and better health decisions, which can lower costs and improve outcomes Conclusions