Imagine a man getting ready for a month-long trip travelingthrough India. He goes to his travel agent, where she books thetrip for him, but expresses concern over him traveling there byhimself, especially considering he’s done little to no research onthe country. She provides him with maps and tour books, butrecommends he get a guide—someone who can show him around, speakthe language and understand the laws and customs.

The travel agent explains money will be saved since the guideunderstands the currency and, more importantly, how to negotiatefor goods and services so not to get ripped off. In turn, the pricepaid for hiring a guide will easily pay for itself. After the trip,the man realized hiring a guide was the best decision he could havemade.

Health care guide

Wouldn’t it be nice if we all had a guide for the stuff in lifewe don’t fully understand – such as health insurance and healthcare? Sure, it’s a long way from Mumbai, but for a lot of peoplethe health care system can be just as confusing – it truly is adifferent world.

After all, insurance and health care professionals have theirown language; consumers don’t know the cost of services or howto negotiate for a lower price; it’s not always clear where togo for a second opinion; and there’s a ton of fine print on bothinsurance and medical forms. No wonder people have troublenavigating the system.

If only we had somebody to hold our hand, somebody who knows theropes, somebody to advocate on our behalf. That’s exactly what CareAdvocates figured they could do—simply provide guidance wheneverconsumers need it.

Care Advocates, the newest member of the Gilsbar group ofcompanies, is one of a handful of organizations that recognized aneed in the health insurance world and set out to deliver asolution. The company says the services they provide are“surprisingly affordable,” but more importantly, are an integralpiece of the CDH puzzle—a piece some didn’t even realize wasmissing.

The need for guidance

For years now, employers and brokers have been asking people totake a more active role in their health care decision— to stopbeing health care users and start being health care consumers. Theproblem is that not everyone knows how to do that.

In fact, the Department of Health and Human Services says the“overwhelming majority of adults have difficulty understanding andusing everyday health information that comes from many sources,including the media, web sites, nutrition and medicine labels, and health professionals.”

The statistics are alarming. According to the NationalAssessment of Adult Literacy, people with higher health literacytend to be in better health, but the same study notes that only 12percent of adults score as proficient. Conversely, the NationalAdult Literacy Survey found that 75 percent of people with along-term illness had limited literacy skills. As the Center forHealth Care Strategies points out, “this may mean they know lessabout their conditions or how to handle symptoms.”

“Health literacy is needed to make health reform a reality,” HHSSecretary Kathleen Sebelius said when talking about a national planto improve people’s understanding of the health care system.“Without health information that makes sense to them, people can’taccess cost effective, safe, and high quality health services. But,HHS can’t do it alone.”

The plan calls for “improving the jargon-filledlanguage, dense writing, and complex explanations that oftenfill patient handouts, medical forms, health web sites, andrecommendations to the public,” HHS explains. “When people receiveaccurate, easy-to-use information about a health issue, they arebetter able to take action to protect and promote their health andwellness.”

Is this an EAP or a wellness program?

When thinking about the consumer-driven approach, it’s common toask whether you’ll be an employee assistance program or a wellness program. But Care Advocates is neither.

Employee assistance programs and wellness plans are intended tohelp employees make correct lifestyle choices and deal withpersonal problems that might adversely impact their workperformance, health and well-being.

Care Advocates, on the other hand, is a tool designed to enhancean employee’s benefits package. The company’s personal healthcare experts engage members and guide them through the complexhealth care maze, creating savings in both time andmoney.

They do this by serving as an independent, third party availableto help people use their benefits properly, understand claimsforms, and file appeals when necessary. Their experts also supportdecision making for Medicare issues and long-term careconsiderations, and licensed nurses and health care professionalsare available to assist in care coordination.

“The broker sells you the car; Care Advocates is the GPS,”says sales manager Sharon Alt. “Unless you want your clients tocall and ask for directions every time they get lost, you bettermake sure they have a good navigation system.”

Alt’s analogy makes sense, especially in light of the comingchanges with health reform. Not only is the government planning tocrack down on HIPAA privacy violations through increased employeraudits, brokers also are looking for ways to work more efficientlyas they anticipate reduced commission levels thanks to the MLRrequirements.

“By outsourcing the member advocacy role to experienced healthcare professionals, brokers can not only save valuable time butdeliver a better outcome while reducing their clients’non-compliance exposure,” Alt says.

Care Advocates provides six products designed to assistemployees and reduce the demands placed upon human resources.

The first provides counseling to members during open enrollmentso they can determine which benefits are the best fit forthemselves and their families.

The next two products are designed to make sure membersunderstand their health coverage. One breaks down a member’scoverage and benefits and explains them in simple terms whileanother give members access to specialists who can provide guidanceon claims, denials, and the appeals process.

Two other products are designed to help members navigate thehealth care system, saving them both time and money. One providesspecialized clinicians who guide members through a multitude ofavailable treatment options for any diagnosis. The other assistsmembers with out-of-pocket health care cost negotiations.

And because so many people make health care decisions not justfor themselves but for family members as well, a final productprovides members with support and guidance when caring for anelderly parent.

These services are normally bundled together to deliver acomplete solution that helps employees and their families get themost out of their benefits plan and effectively manage theiroverall health care.

About Care Advocates

Hank Miltenberger is president and CEO of Gilsbar, a health andbenefit management company with more 50 years’ experience servicinghealth plan members.

Hank brought Doug Layman on board in 2005 to lead the sales andmarketing efforts for its growing group of companies. Doug, alongwith Brian Connelly, Director of Product Development, came up withidea for Care Advocates, which was designed to help fill arapidly-growing void in the market. Simply put: employees need helpunderstanding their benefits and the health care system.

Advocacy is not new territory for Gilsbar. The company’s diverseand highly tenured team of benefits specialists, as well asclinical and nurse counselors, have helped thousands of membersover the years. They know the health care system like no one else,and now this unique service – where members are managed by healthcare experts – is available to employees and association membersacross the country.

Care Advocates serves as an extension of an employer’s humanresources department, allowing HR staff to focus on more strategicinitiatives. It provides third-party assistance with sensitive PHIissues, which helps avoid penalties and fines, and cuts down on thenumber of phone calls HR – and the broker – may bereceiving.

Eric Johnson is the director of education for HealthEquity,one of the nation’s leading HSA administrators. He can be reachedat 817-366-7536 or [email protected].