7 Success factors when considering advocacy or concierge services
6 minute read•Navigation Insider
Recent surveys of self-insured employers spotlight the same trend: Many of them plan to add healthcare advocacy, concierge or navigation services to their benefits.
What’s fueling this trend? Here’s what the surveys said:
Cost control. Helping HR teams build and activate robust benefits programs. Employee satisfaction — enough to make positive impact on talent retention and recruitment. Given those upsides, interest in these services isn’t surprising. What might surprise HR leaders is how crowded this service category has become.
By some estimates, more than 30 independent vendors offer some type of navigation, advocacy or concierge services. That leaves benefits leaders with questions, such as, “What’s the difference among these similar-sounding solutions?” And, “Which one will deliver on my organization’s strategic goals?”
Quantum Health invented independent consumer healthcare navigation and care coordination when it launched in April 1999. Doing so established “navigation” as a new service category in the healthcare and benefits marketplace.
Since then, many insurance carriers and third-party administrators developed buy-up versions of their member services. Some refer to them as concierge or navigation. Dozens of start-ups also came to market, with services they describe as healthcare or benefits advocacy, concierge or navigation.
How should benefits pros sort through all the vendors and vernacular? First, don’t get tangled in terminology. Instead, consider the labels not as competing, but complementary.
For starters, most vendors strive to offer a “concierge” level of service. That is, a more “white glove” consumer experience compared with a limited, transactional member services model.
Meanwhile, “advocacy” is a term many vendors use to describe either their core capability or one part of their comprehensive navigation service. A way to think about advocacy: It’s about stepping in to help members after issues arise. Coverage for a treatment is denied, for instance, or a surprise bill arrives.
Navigation, the category’s original descriptor, continues to be its most encompassing term. But many vendors now use it to describe widely different types and levels of service, creating confusion for benefits professionals. In some cases, “navigation” is heard as a synonym for “member services,” limited to guiding members to providers or answering their questions about coverages and out-of-pocket costs. Sometimes, online benefits portals and provider cost-quality search tools on their own are credited with providing “navigation.”
However, most observers would agree that true navigation in today’s marketplace combines benefits education, help finding in-network, high-quality providers, as well as individualized care coordination for members who live with chronic conditions or face significant medical procedures and treatments. These services are provided by benefits and clinical experts. They help members not just with benefits questions, but in making informed, cost-conscious decisions throughout their healthcare journeys. And they are complemented — not replaced — by digital self-service tools for members. For example, Quantum Health describes its navigation model as “human-centered, tech-empowered.”
Bottom line: There are no official definitions for advocacy, concierge or navigation. In fact, some consultants and their employer clients now issue requests for proposals (RFPs) that don’t even attempt to define the terms. Instead, they focus on probing what a vendor actually does to create value for employers and members, how long they’ve done it, and what results they can show for it.
When HR and benefits leaders decide to upgrade from a traditional member services model, or to change independent vendors, ultimately your goals matter more than vendors’ labels. Those goals likely include:
To get these kinds of results, benefits leaders need a vendor that offers more than concierge service or even the most aggressive advocacy. Instead, you’ll need a partner that proactively guides and supports members, beginning to end, through their highly individualized benefits needs and healthcare journeys.
Below are seven capabilities. When a vendor offers most or all of them — in a highly integrated, single-point-of-service way — there is real potential for employers and members to experience an advanced, even state-of-the-art, navigation solution. Benefits leaders can use these criteria as a checklist to delve beyond how vendors describe themselves to discover (and compare) what they actually do and deliver.
Digital- or mobile-first benefits information products can go only so far in helping a member who is intimidated by healthcare and benefits complexity while also struggling with a medical concern. The most advanced navigation makes smart use of digital tools, but is built around human, one-to-one listening and problem-solving.
When comparing vendors, look for how artificial intelligence and digital channels and tools enable member engagement by benefits and clinical experts. It’s that combination which will get members to the right care, at the right time, with quality and cost factored into care decisions.
Basic navigation answers members’ questions about coverage, providers and out-of-pocket costs. The most expansive solutions guide members to all the benefits offered by an employer. They also uncover health issues and anticipate benefits needs members might not be thinking to ask about.
This approach helps employers get stronger benefits utilization and ROI. Plus, it aligns with a vision of dramatically enhancing members’ benefits experience while providing “whole person” support for their physical and mental wellbeing.
A truly advanced navigation solution engages the clinicians and facilities providing members’ care. This starts with being the single point of contact when providers need to confirm members’ benefits eligibility and get authorization for services and treatments.
Why does this matter? Many authorization requests — for testing to confirm a diagnosis, or to approve an inpatient surgery — signal it’s time to engage with that member. The navigation partner can get a jump-start on helping the member understand their benefits and make informed, cost-effective decisions. Engagement can begin weeks, even months, before any claims get processed.
Provider engagement also allows collaborating with a treating physician to reinforce a member’s treatment plan, working with a hospital team to ensure a member’s timely discharge, or deciding to move a member’s specialty drug infusions to a more convenient, less expensive site of care.
In short, don’t be surprised if the most advanced, forward-thinking vendors interact more with providers than members. It means they engage ultra-early to have positive impact on the member experience, claims costs and health outcomes.
Today’s most advanced solutions blend benefits guidance and clinical care management. Many employers especially value when nurses act as personal care guides for members who have serious health risks or chronic conditions.
Between regular doctor visits, one-on-one conversations with a caring, trusted nurse helps educate members on their conditions and medications, encourages them to set and achieve health improvement goals, and finds ways to overcome barriers that could cause a member to fall behind on treatment.
This same model is effective when a member needs hospital care. Preadmission engagement makes sure the member understands their condition, the upcoming procedure and relevant benefits. Engaging with the hospital team is a form of advocacy, seeing to it that the member gets high-quality care, but wasteful care and discharge delays are avoided. Finally, postdischarge planning and engagement helps ensure the member is set up for recovery, with reduced chance of readmission.
A member who feels discriminated against by the healthcare system needs an advocate. A member struggling to pay for prescriptions, or find reliable transportation to doctor visits, needs a concierge. But not just a well-intentioned guide. Instead, an expert who’s savvy about drugmakers’ copay assistance programs, and aggressive in finding ride services offered by local agencies or nonprofits.
Members of all genders, races and incomes can face barriers to care and wellbeing caused by social determinants of health and other health equity hurdles. That’s when navigation gets put to the test. Does a vendor’s model do more than educate members on their benefits? Does it go above and beyond to help them overcome access and equity barriers by guiding them to community resources and support services?
If a navigation model only supports members who have health challenges, you’re missing the opportunity to help your healthiest members stay that way. That can be a costly miss, both for members’ long-term health and your organization’s claims cost trend.
Advanced navigation takes even the most basic member inquiries — even requests for a replacement ID card — as a chance to guide and inform. This can mean encouraging members to designate and regularly see a primary care provider, to make cost-conscious use of emergent care options (e.g., telehealth, urgent care and emergency room), and to stay current with vaccinations and health screenings.
Finally, an advanced advocacy or navigation vendor functions as a strategic partner, working with HR and benefits teams to implement, measure and refine your benefits strategy. It guides members to value-based provider networks. It helps maximize utilization of point solutions and other benefits. It could even spot gaps in benefits that might keep some employees from equitable access to healthcare.
In these ways, the term “navigation” is a strategic opportunity, not just another vendor label. The best solutions will function as both compass and catalyst. They provide services and insights to activate your benefits design. They inform and support all your members, whether it’s for basic benefits question or complex healthcare needs. Ultimately, they help you reach strategic health-outcome, cost-management and member-experience goals.
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