Steering Toward Better Health: The Power of Patient Advocacy in Self-Funded Health Plans

by | Apr 23, 2024 | Uncategorized

If you needed surgery, wouldn’t you want the best surgeon? How would you determine who’s the best? You might ask friends or neighbors, but their responses have biases based on limited quality indicators. This is where Patient Advocacy comes into play. Also known as Healthcare Navigation or steerage, Patient Advocacy is a strategy to direct patients to the highest-value care, combining quality and cost-effectiveness.

Informed nurses often serve as the patients’ advocates, providing much-needed guidance in our complex healthcare environment. This cost-containment strategy in self-funded health plans creates a win-win situation by managing the plan’s potentially largest expenses upfront and enhancing your employees’ and their families’ health outcomes and experiences.

Patient Advocates helps members make well-informed decisions about their health by providing guidance in several different ways:

  • Choosing providers based on quality metrics.
  • Understanding treatment options and obtaining qualified second opinions for major treatments like surgery or cancer care.
  • Communicating effectively with healthcare providers.
  • Navigating through low-value care that drives up costs without improving outcomes.

Quality Over Quantity

The traditional healthcare model focuses on quantity over quality. For instance, traditional PPO networks prioritize having the most providers instead of selecting those providers by healthcare quality indicators. Similarly, the fee-for-service model incentivizes a higher volume of patients and services, maximizing revenue rather than focusing on patient health.

Quality matters; medical errors are the third leading cause of death in the U.S and poor outcomes result in longer hospital stays, infections, and reoccurrences. By consulting with a Patient Advocate, employees are steered towards high-value care, focusing first on quality and ensuring a reasonable cost. 

Recently, my family experienced firsthand the value of Patient Advocacy through our independent self-funded plan. When we needed surgery, I was initially uneasy about the surgeon’s level of expertise. After contacting our plan’s Patient Advocacy, I discovered the surgeon was relatively inexperienced, having performed the procedure only a few times. They redirected us to a seasoned surgeon in Atlanta who has performed the surgery many more times. I am much more at ease about the surgery, and I could never have  done this research alone. 

Another advantage is that our deductible will be waived for the surgery because we used Patient Advocacy to select our provider. This incentive is a smart move by employers because the costs avoided by ensuring high-quality care far exceed the deductible, not just in terms of better health outcomes but also in evaluating and choosing cost-effective providers.   

Cost Matters

The cost of healthcare services can vary significantly even within the same town. Take, for instance, a chest CT scan that varies from $224 to $2,250 in the Asheville market. These price variances are largely driven by hospital network negotiations rather than quality metrics.

So, how do patients find out the cost of a service? Recent legislation, including Transparency in Coverage rules requires hospitals to make their negotiated prices public, a move toward price transparency. However, due to the complexity of healthcare pricing and some hospitals’ reluctance to share information, true cost transparency has been slow to benefit consumers.

Patient navigation can bridge this gap, having access to claims data and resources to inform patients about the actual costs of services before they make appointments.

The Role of Primary Care

Primary care physicians play a crucial role in steering patients towards high-quality care, so it’s essential that patients have easy access to a primary care provider who is truly engaged in their health. This highlights the benefits of Direct Primary Care (DPC).

DPC doctors have more time to manage most of their patient’s care and coordinate other services as needed. Unlike traditional primary care providers, DPC doctors aren’t pushed by financial incentives to refer to specific specialists. Instead, they focus on building networks grounded in proven outcomes and patient satisfaction, ensuring that care remains both personal and effective.

Who will steer your employees?

It’s not a question of whether your employees will be steered towards certain providers, but who will do it? Without intentional guidance in your health plan, local hospital systems will become the default decision-makers in your employees’ healthcare choices. Incorporating patient navigation can ensure that employees receive care that is not only higher quality but also more cost-effective.

Are you ready to take control and optimize your health plan with Patient Advocacy? Engage with independent consultants and Third-Party Administrators to design a plan that benefits everyone involved. Let’s start creating healthier outcomes together!