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

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

To address this troubling reality, more employers and health plans are exploring the option of working with outside clinical advocacy firms. These organizations provide employees and dependents, as well as health plan members, with concierge-level care often provided by nurses who act as patient advocates and allies. Services range from surgery support to second opinions on anything from knee or hip replacements and a cancer diagnosis to help with acute care issues or coverage questions.

Benefit pros, whether consultants or in-house executives, can improve and enrich their benefit offering by better understanding the services these programs offer, the role of program nurses, and which programs will provide the most value for their organizations.

Robust service offering

Familiarity with these programs is also crucial for benefit leaders since their outcomes, cost and programs offered vary. The goals of clinical advocacy programs are to provide education and information to patients that lead to improved productivity, greater employee/member satisfaction and lower cost.

There are now more than a dozen national firms providing clinical advocacy and related services (e.g., second opinions), making it a multi-billion-dollar industry. According to the National Business Group on Health 2020 Large Employers' Health Care Strategy and Plan Design Survey, "the use of tools and programs such as second-opinion services, advocacy support and online decision making is now at 78 percent" of large employers, up 7 percent from the previous year. The services provided in these programs 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 other serious diseases
Behavioral health guidance in finding therapists or programs for addiction, substance abuse, etc.
Claims advocacy to assist patients with billing or benefit questions, which is often one of the top reasons patients reach out to programs offered

Role of nurse allies

Coordinating those services at top performing firms are dedicated nurse allies who often establish personalized relationships with employees and plan members. This hands-on personalized, or concierge-level, care is how these programs differ from traditional care-coordination approaches.

To understand and appreciate what these nurse allies do, consider the experience of "John," an employee of a large global technology firm who thought he had a kidney stone. Following a routine checkup, his doctor recommended a CT scan given his family history of kidney cancer. Thinking he might need surgery, John became concerned, not knowing whom to call or where to turn. He didn't know his doctor well, and he was also hard to reach. John knew his company offered decision support, and so he decided to give it a try.

He was assigned a nurse ally. She had seen cases like this before and became concerned about a kidney cancer diagnosis. The nurse helped John quickly (vs. waiting weeks) get an appointment with one of the best urologists in his area. Further tests confirmed her suspicion, and John underwent surgery for renal cell carcinoma.

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

Today John is back at work. What could have been a costly illness with devastating consequences for John was treated quickly and efficiently, reducing lost productivity and excess costs for the employer, as well as greatly improving John's quality of life.

Outcomes and costs

The true value of partners providing enhanced care coordination and employee support for medical needs must be measured in terms of employee satisfaction, outcomes and overall ROI. For example, for one large employer group offering a second opinion program, about 72 percent of the initial provider recommendations were reviewed by expert clinicians in that field, resulting in treatments recommended or changes in current therapies.

This level of intense expert medical oversight leads to significantly improved outcomes, lower costs and higher employee satisfaction. Employers with second opinion programs for elective surgeries can save nearly $20,000 per case on average.

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

What to look for in a partner

Benefit pros—whether internal employees or external consultants–can distinguish themselves in a competitive marketplace and provide better service health plan sponsors and members by recognizing the growing need for assistance with care coordination and support for those facing elective surgeries or chronic and complex illnesses.

However, there are multiple issues to explore when considering if, when, how and who to tap to develop a clinical advocacy initiative. To maximize value, health plan sponsors need ready access to data on the performance of their medical support partners in terms of conditions treated, cost savings, comparative outcome improvements, patient satisfaction, wait times, etc. Look for partners that routinely provide these insights.

Additionally, in today's competitive employment market, employers are often looking for solutions and services that improve the overall employer brand. Benefit leadership can help their organizations or customers access partners that will help them develop the reputation and positioning as a caring employer by giving employees the support needed to get the most from their health care benefits.

Key features to look for in a clinical advocacy partner include:

Experience and a proven track record providing services needed.
Ability to fully integrate programs with health benefit partners and payers to ensure coordinated care.
Technology to enhance the member experience, ensure efficiency and provide the reporting and insights employers need to gauge the program's performance and value. That could mean having access to providers via mobile phone, video consultations, record collection storage, and analysis of the program impact on care costs and outcomes.
Excellent customer support, especially from the nurse allies who are often the key point of contact and care coordination for health plan members. Look for vendors who have satisfaction rates over 95 percent and a Net Promoter Score (NPS) of over 70.

Finding new ways to support employers

The nation's convoluted health care system is likely to become even more complicated and confusing in the coming years, especially for those with chronic and complex illnesses. To ensure maximum value, health plan sponsors need to fully understand what programs are available and how to access them as well as offer clinical concierge-level service to help members navigate the system and get the support needed based on their care needs.

Benefit leaders can help employers provide their eligible population with the support needed by identifying partners with the experience and capabilities to meet the needs of the organization and its health plan members.

Nurse allies are on the front line of an ongoing battle to improve the clinical outcomes of health plan members, and in the process, help employers contain rising health care costs. Offering their expertise will not only help accomplish these key goals, but also improve patient satisfaction. It also can be seen as a prudent investment in talent management in a tight economy. More importantly it's an approach that provides value for both the organization and the consumers, employees and patients served. Jessica Hennessey is the senior vice president of clinical operations with ConsumerMedical, a leading clinical advocacy and second opinion company working with top employers and health plans nationwide and covering more than 4 million consumers.

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