Most people don’t think about how health care works until they need it to work for them. A new breed of advocate may help them navigate their coverage and care.
Michelle Ghibaudy, a health advocate for Blue Cross and Blue Shield Plans in Illinois, Montana, New Mexico, Oklahoma and Texas, recently answered a call from a member who wanted to complete a health survey.
The caller wanted to qualify for a reward under her plan’s incentive program for healthy choices.
During the call, however, Ghibaudy learned the woman recently moved and didn’t have a primary care doctor in her new city. Also, the member was a cancer survivor and would need a new oncologist. She was also due for a colonoscopy.
Ghibaudy helped the caller find an in-network primary care doctor, booked an appointment and gave her a list of in-network oncologists. Then she found a quality gastroenterologist nearby and the lowest-cost setting for the colonoscopy. That earned the caller another reward under a program offered under her plan to encourage members to shop for quality cost-effective care.
“A member wouldn’t necessarily think about doing all of that,” Ghibaudy says. But she was able to take care of it in one phone call because of a program called Health Advocacy Solutions.
In a word, the health care system can be confusing. Most people don’t think about how it works until they need it to work for them. That level of support for people needing help with health care is more important now than ever before.
We take the member out of the middle and don’t leave them with a to-do list.
Confusion drives up costs, both for members and the employers that provide health insurance. The total cost of health care per employee in 2018 is around $14,000, according to a 2017 survey of large employers by the National Business Group on Health.
To help, many employers are investing in services that may simplify the health care system for their employees, saving everyone money.
“There is a big increase in the number of employers offering decision support, concierge services and tools to help employees navigate the health care system,” Brian Marcotte, CEO of NBGH, said in a news release on the survey.
“The complexity of the system and proliferation of new entrants has made it difficult for employees to fully understand their benefit programs, treatment options and where to go for care,” Marcotte said.
Entrepreneurs and investors see a big opportunity to make money in simplifying health care. Companies have sprung up to provide services they say may smooth the path to the most affordable care options. Their services include care management, customer service and evaluating the value of medical services and facilities.
“As patients expect more and more of the health system — modeled after the seamless consumer experience they receive from other industries — we can expect to see more providers and startups offering services to reduce the friction between patients and the health system,” says Megan Zweig, director of research at Rock Health, a venture capital fund dedicated to digital health.
These types of services aim to save money in myriad ways. For one, engaging members in their care through phone calls and digital platforms may lower costs significantly by guiding them to lower-cost, higher-quality providers and care locations.
By easing the path to care, the approach may help members get and stay healthy, which can save money for self-funded employers that pay for their employee’s health care. With data and predictive analytics, services can also reach out proactively to members who may need help managing health conditions and avoid a costly hospitalization.
A national employer that was an early adopter of Health Advocacy Solutions has experienced a 7 percent reduction in overall health care costs from the prior year, seeing results from both clinical management and significantly increased member engagement.
Members are taking advantage of cost-effective locations of care, including virtual visits for non-emergent illness and digital self-service tools, reducing their out of pocket expenses and getting cash rewards when they shop for care.
Ghibaudy is seeing these market changes first-hand in her job with Blue Cross and Blue Shield Plans in Illinois, Montana, New Mexico, Oklahoma and Texas, under the Health Advocacy Solutions program.
“We take the member out of the middle and don’t leave them with a to-do list,” Ghibaudy says.
An insurer may have the upper hand on stand-alone companies providing these services because insurers have first-hand knowledge about benefits, networks and claims. “We can adjust claims and answer network questions right away,” says Lydia Ferguson, director of analytics consulting for the Health Advocacy Solutions product.
Under Health Advocacy Solutions, Ghibaudy works in a “pod.” The pod includes nurses and others who are trained to know what benefits are available to their assigned groups of members. Members have a single phone number on their member ID card that connects them directly to the pod for their questions.
The advocates help with claims, give out-of-pocket price estimates for procedures, locate in-network providers and more. The nurses provide holistic health management to coordinate care across medical and behavioral needs.
The health advocates also call members directly. They welcome new members to their health plan and educate current members about programs that may benefit them.
Recently, Ghibaudy made an outbound call to welcome a new member and make sure he had his member ID card. From that one call, she discovered the member had questions she could answer about his benefits. Also, his son needed surgery, so she was able to make sure the provider and facility were in his health plan’s network.
“That one call out to welcome him,” she says, “turned into getting all those things taken care of.”