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

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

Health care guide

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

After all, insurance and health care professionals have their own language; consumers don’t know the cost of services or how to negotiate for a lower price; it’s not always clear where to go for a second opinion; and there’s a ton of fine print on both insurance and medical forms. No wonder people have trouble navigating the system.

If only we had somebody to hold our hand, somebody who knows the ropes, somebody to advocate on our behalf. That’s exactly what Care Advocates figured they could do—simply provide guidance whenever consumers need it.

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

The need for guidance

For years now, employers and brokers have been asking people to take a more active role in their health care decision— to stop being health care users and start being health care consumers. The problem 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 and using 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 National Assessment of Adult Literacy, people with higher health literacy tend to be in better health, but the same study notes that only 12 percent of adults score as proficient. Conversely, the National Adult Literacy Survey found that 75 percent of people with a long-term illness had limited literacy skills. As the Center for Health Care Strategies points out, “this may mean they know less about their conditions or how to handle symptoms.”

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

The plan calls for “improving the jargon-filled language, dense writing, and complex explanations that often fill patient handouts, medical forms, health web sites, and recommendations to the public,” HHS explains. “When people receive accurate, easy-to-use information about a health issue, they are better able to take action to protect and promote their health and wellness.”

Is this an EAP or a wellness program?

When thinking about the consumer-driven approach, it’s common to ask 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 to help employees make correct lifestyle choices and deal with personal problems that might adversely impact their work performance, health and well-being.

Care Advocates, on the other hand, is a tool designed to enhance an employee’s benefits package.  The company’s personal health care experts engage members and guide them through the complex health care maze, creating savings in both time and money. 

They do this by serving as an independent, third party available to help people use their benefits properly, understand claims forms, and file appeals when necessary. Their experts also support decision making for Medicare issues and long-term care considerations, and licensed nurses and health care professionals are 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 to call and ask for directions every time they get lost, you better make sure they have a good navigation system.”

Alt’s analogy makes sense, especially in light of the coming changes with health reform. Not only is the government planning to crack down on HIPAA privacy violations through increased employer audits, brokers also are looking for ways to work more efficiently as they anticipate reduced commission levels thanks to the MLR requirements.

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

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

The first provides counseling to members during open enrollment so they can determine which benefits are the best fit for themselves and their families.

The next two products are designed to make sure members understand their health coverage. One breaks down a member’s coverage and benefits and explains them in simple terms while another give members access to specialists who can provide guidance on claims, denials, and the appeals process.

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

And because so many people make health care decisions not just for themselves but for family members as well, a final product provides members with support and guidance when caring for an elderly parent.

These services are normally bundled together to deliver a complete solution that helps employees and their families get the most out of their benefits plan and effectively manage their overall health care.

About Care Advocates

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

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

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

Care Advocates serves as an extension of an employer’s human resources department, allowing HR staff to focus on more strategic initiatives. It provides third-party assistance with sensitive PHI issues, which helps avoid penalties and fines, and cuts down on the number of phone calls HR – and the broker – may be receiving. 

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