Coordinating key health careadvocacy services at top-performing firms are dedicated nurseallies who often establish personalized relationships withemployees and plan members. (Photo: Shutterstock)

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As the nation's health care delivery marketplace growsincreasingly more complex, it creates confusion, a lack ofcare coordination and disengagement for millions of frustrated anddisillusioned consumers.

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Left to manage the fragmented system are health plan sponsorsalready dealing with myriad other issues. The result is that healthplan members make ill-informed decisions about important healthcare conditions that often lead to sub-par outcomes.

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Related: Confusion and risk-aversion driving poor benefitchoices

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To address this troubling reality, more employers and healthplans are exploring the option of working with outside clinical advocacy firms. These organizationsprovide employees and dependents, as well as health plan members,with concierge-level care often provided by nurses who act aspatient advocates and allies. Services range from surgery supportto second opinions on anything from knee or hip replacements and acancer diagnosis to help with acute care issues or coveragequestions.

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Benefit pros, whether consultants or in-house executives, canimprove and enrich their benefit offering by better understandingthe services these programs offer, the role of program nurses, andwhich programs will provide the most value for theirorganizations.

Robust service offering

Familiarity with these programs is also crucial for benefitleaders since their outcomes, cost and programs offered vary. Thegoals of clinical advocacy programs are to provide education andinformation to patients that lead to improved productivity, greateremployee/member satisfaction and lower cost.

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There are now more than a dozen national firms providingclinical advocacy and related services (e.g., second opinions),making it a multi-billion-dollar industry. According to theNational Business Group on Health 2020 Large Employers' Health CareStrategy and Plan Design Survey, "the use of tools and programssuch as second-opinion services, advocacy support and onlinedecision making is now at 78 percent" of large employers, up 7percent from the previous year. The services provided in theseprograms typically include:

  • Medical and surgery decision support
  • Second opinions from top national specialists
  • Assistance with finding a regional specialist
  • Complex care support for patients facing cancer or otherserious diseases
  • Behavioral health guidance in finding therapists or programsfor addiction, substance abuse, etc.
  • Claims advocacy to assist patients with billing or benefitquestions, which is often one of the top reasons patients reach outto programs offered

Role of nurse allies

Coordinating those services at top performing firms arededicated nurse allies who often establish personalizedrelationships with employees and plan members. This hands-onpersonalized, or concierge-level, care is how these programs differfrom traditional care-coordination approaches.

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To understand and appreciate what these nurse allies do,consider the experience of "John," an employee of a large globaltechnology firm who thought he had a kidney stone. Following aroutine checkup, his doctor recommended a CT scan given his familyhistory of kidney cancer. Thinking he might need surgery, Johnbecame concerned, not knowing whom to call or where to turn. Hedidn't know his doctor well, and he was also hard to reach. Johnknew his company offered decision support, and so he decided togive it a try.

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He was assigned a nurse ally. She had seen cases like thisbefore and became concerned about a kidney cancer diagnosis. Thenurse helped John quickly (vs. waiting weeks) get an appointmentwith one of the best urologists in his area. Further testsconfirmed her suspicion, and John underwent surgery for renal cellcarcinoma.

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The care continued after his treatment. Concerned that hischildren were at risk for the disease, John's nurse ally identifieda geneticist in his area who could provide the necessary tests.That's a service few health plans – or even physicians in today'smarketplace – will provide.

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Today John is back at work. What could have been a costlyillness with devastating consequences for John was treated quicklyand efficiently, reducing lost productivity and excess costs forthe employer, as well as greatly improving John's quality oflife.

Outcomes and costs

The true value of partners providing enhanced care coordinationand employee support for medical needs must be measured in terms ofemployee satisfaction, outcomes and overall ROI. For example, forone large employer group offering a second opinion program, about72 percent of the initial provider recommendations were reviewed byexpert clinicians in that field, resulting in treatmentsrecommended or changes in current therapies.

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This level of intense expert medical oversight leads tosignificantly improved outcomes, lower costs and higher employeesatisfaction. Employers with second opinion programs for electivesurgeries can save nearly $20,000 per case on average.

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Costs for programs vary and depend on specific features offeredand the size of the population covered. In general, well managedprograms offer an ROI of 4:1. Ask for examples and to speak withcurrent and past clients for more insights on cost.

What to look for in a partner

Benefit pros—whether internal employees or externalconsultants–can distinguish themselves in a competitive marketplaceand provide better service health plan sponsors and members byrecognizing the growing need for assistance with care coordinationand support for those facing elective surgeries or chronic andcomplex illnesses.

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However, there are multiple issues to explore when consideringif, when, how and who to tap to develop a clinical advocacyinitiative. To maximize value, health plan sponsors need readyaccess to data on the performance of their medical support partnersin terms of conditions treated, cost savings, comparative outcomeimprovements, patient satisfaction, wait times, etc. Look forpartners that routinely provide these insights.

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Additionally, in today's competitive employment market,employers are often looking for solutions and services that improvethe overall employer brand. Benefit leadership can help theirorganizations or customers access partners that will help themdevelop the reputation and positioning as a caring employer bygiving employees the support needed to get the most from theirhealth care benefits.

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Key features to look for in a clinical advocacy partnerinclude:

  • Experience and a proven track record providing servicesneeded.
  • Ability to fully integrate programs with health benefitpartners and payers to ensure coordinated care.
  • Technology to enhance the member experience, ensure efficiencyand provide the reporting and insights employers need to gauge theprogram's performance and value. That could mean having access toproviders via mobile phone, video consultations, record collectionstorage, and analysis of the program impact on care costs andoutcomes.
  • Excellent customer support, especially from the nurse allieswho are often the key point of contact and care coordination forhealth plan members. Look for vendors who have satisfaction ratesover 95 percent and a Net Promoter Score (NPS) of over70.

Finding new ways to support employers

The nation's convoluted health care system is likely to becomeeven more complicated and confusing in the coming years, especiallyfor those with chronic and complex illnesses. To ensure maximumvalue, health plan sponsors need to fully understand what programsare available and how to access them as well as offer clinicalconcierge-level service to help members navigate the system and getthe support needed based on their care needs.

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Benefit leaders can help employers provide their eligiblepopulation with the support needed by identifying partners with theexperience and capabilities to meet the needs of the organizationand its health plan members.

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Nurse allies are on the front line of an ongoing battle toimprove the clinical outcomes of health plan members, and in theprocess, help employers contain rising health care costs. Offeringtheir expertise will not only help accomplish these key goals, butalso improve patient satisfaction. It also can be seen as a prudentinvestment in talent management in a tight economy. Moreimportantly it's an approach that provides value for both theorganization and the consumers, employees and patients served.Jessica Hennessey is the senior vice presidentof clinical operations with ConsumerMedical, a leading clinical advocacy andsecond opinion company working with top employers and health plansnationwide and covering more than 4 millionconsumers. 

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