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Benefits Business New tools for the new generation of health care Providing health care advocacy helps clients and adds value By Len Strazewski Whenever the health claims forms stop making sense, the specialist referrals take months, and the medical bills seem higher than they should be, whom do you call? Most of the time, your health insurance customers turn to you, their agent or broker, for help when health plan complexity gets them down or their insurer’s claim decisions don’t square with their understanding of their coverage. And the pleas for help are likely to be on the rise, industry experts say, as consumer-directed health plans (CDHPs) pressure consumers to make more sophisticated choices about their health care, and complicated managed care plan provisions make those choices more difficult. The agent often becomes the court of last resort for confused policyholders—unless they already provide outside support for their customers, says Martin Rosen, executive vice president of marketing for Health Advocate, Inc., in Plymouth Meeting, Pennsylvania. Then they can turn the problems into marketing opportunities. “Everyone has experienced problems navigating the health care system,” Rosen explains. “From finding an appropriate health care practitioner for a specific concern, dealing with the administrative paperwork or just preparing for a doctor’s office visit, everyone who has insurance has experienced some difficulty managing the coverage.” Founded by former Aetna Health executives in 2001, Health Advocate was formed to help group sponsors and their respective employees and members throughout the country deal with issues they encounter while accessing the health care and insurance systems. Company services, which range in cost from $1.25 to $4.95 per employee per month, include health coaching, administrative consulting on coverage and paperwork, and referrals to practitioners and health care facilities. Services are provided to plan participants, spouses, children, and parents of participants. The company now has more than 1,000 commer-cial clients, including employers and third-party administrators and a growing number of agents and brokers who purchase services on behalf of their clients, Rosen says. What’s driving the company growth? The rise of CDHPs is creating new levels of concern for health consumers, Rosen explains. As CDHP plan participants confront their increasingly complicated health care decisions, they are realizing their need for resources and expertise not generally available from their doctors. As a result, they are turning to their agents, brokers and insurers for help, he says, and the people who provide that assistance are likely to win a competitive edge. “We are working with many agents and brokers who are purchasing the services for their clients and absorbing the costs as a value-added that they can use to help differentiate themselves from their competition,” he says. And coupled with the prospective cost savings of CDHPs, the combined package of services makes for a powerful new product that can open doors to new customers, he notes. Insurers are also recognizing the need for health advocacy services. In October, HealthNow New York, Inc., in Buffalo, New York, the parent company of BlueCross BlueShield Western New York and BlueShield of Northeastern New York, became the first health plan to build a health advocacy service into its coverage, making it available to all policyholders and dependents for all levels of health coverage, including traditional low deductible health plans, CDHPs, and Medicare supplemental coverage. “Health literacy and the ability of individuals to access, understand, and use health-related information and services to make appropriate health decisions is one of the most important issues we face in today’s health care systems,” said HealthNow New York President and Chief Executive Officer Alphonso O’Neil-White in announcing the decision. And while the service is now restricted to CDHP plan participants, it is likely to be of greatest benefit to plan participants that need to make more choices about their care, adds Cheryl Howe, BlueCross BlueShield’s executive vice president of operations. “The movement toward consumer-directed health is happening very rapidly and it is clear to us that if these plans are to succeed, we need to be able provide assistance to our members to use these plans effectively. “However, it is not just CDHPs that pose the need for advocacy. Anyone who has had a senior parent attempt to work through the new Medicare Part D prescription drug benefits realizes that the system has become so complicated that without access to expertise, participants will have difficulty,” she says. Howe says the need also extends beyond health plan administration to a growing need for assistance in locating alternative therapies, for instance chiropractic and massage therapy, for more comprehensive care and dependent care services such as elder care and home health services for parents of plan participants. HealthNow will absorb the cost of the service into its existing pricing, she notes, and will assist its agents and brokers with promoting the additional service to their clients. Meanwhile, the need for advocacy services continues to grow as employers continue to move toward CDHP models and health premiums continue to increase. Both are continuing industry trends, says the latest research. According to a recent study conducted by the Santa Monica, California-based RAND Corporation, CDHPs can reduce health care utilization and reduce costs. But the cost containment devices may also have a negative affect on the quality of care. “The evidence from early adopters of these plans and similar changes in health insurance shows that great cost-sharing leads to reductions in health care use and expenditures,” said health economist Melinda Beeuwkes Buntin, co-director of the Bing Center for Health Economics at RAND and lead author of the study. “But what we don’t know is how this will affect overall health care quality and patients’ health,” she wrote. Buntin estimates that if all privately insured non-elderly Americans were moved from low-deductible health insurance plans to high-deductible CDHPs, the result would be a one-time health care cost reduction of 4% to 15%. However, if the CDHPs were paired with HSAs, the savings would only be about half as much. The study results indicate that when people pay more out-of-pocket for health care, they do indeed tend to spend less on what could be called “inappropriate or unnecessary” care, such as antibiotics for simple viral infections or emergency room use for noncritical health problems. Buntin says the study also indicates that health care consumers are less likely to forego appropriate care just to reduce their own out-of-pocket expenses, thanks to CDHP plan designs that waive or reduce deductibles for preventive care or provide financial incentives for enrolling in disease management programs and wellness initiatives. However, the study also confirmed that CDHP participants are struggling to find reliable information on quality and price. As this need grows, agents and brokers who can direct their customers to quality health information or independent advocates who can help them make and manage better choices may come out the heroes of the new generation of health care. * The author |
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