When an employer shifts from being fully insured to self-insuring for health benefits, healthcare costs — and plan members’ health literacy — take on even greater financial importance and impact. Instead of an insurance carrier’s profitability hanging in the balance, now it’s the employer taking on financial risk.

For that reason, self-insured employers have every incentive to help employees and their dependents become cost-savvy healthcare consumers. Unfortunately, there’s only so much HR and benefits teams can do to educate and motivate members before they actually need care.

Typically, it’s only when members face an illness or emergency that they’ll focus on coverage details and potential costs. In those moments, research shows, they often struggle to understand cost specifics and make informed, confident decisions.

The good news? An independent healthcare navigation solution can be a powerful cost-control strategy, informing and guiding members in real time toward cost-effective decisions and behaviors.

Research says: Consumers struggle with healthcare costs

In early 2023, Quantum Health partnered with Employee Benefit News to survey more than 500 U.S. employees about their healthcare and benefits experience. Among other findings:

  • Respondents said understanding how much services will cost was the most difficult aspect of their experience.
  • Having to pay an unexpected bill was their most common challenge.
  • Within the past year, more than half received care that was more expensive than expected.

Price transparency tools help users make cost-aware decisions. However, nearly one-third of employees said their benefits plans do not offer such tools. Another 24% said the tools are hard to access. And 17% said they don’t even know whether such tools are available.

When members struggle to understand and anticipate costs, it means they and their employers almost certainly pay more for healthcare than if members were more confident and better informed.

Given that downside, it’s especially noteworthy that 77% of employees said they typically navigate healthcare alone, or with the help of a family member or friend. In other words, more than three quarters of employees attempt to navigate healthcare and its costs without expert guidance.

How navigation informs plan members’ health literacy

The right independent healthcare navigation solution equips self-insured employers to support cost-aware decisions and behaviors among members. Navigation Insider recently interviewed leaders from Quantum Health’s training team to understand how the company’s Care Coordinators foster health literacy and, in the process, help both members and their employers control costs. Examples include:

Encouraging designation and use of a primary care provider (PCP)

The Care Coordinators routinely advise members to establish their “medical home” with a PCP (often a family medicine doctor or internist). Members also are encouraged to visit the PCP for both regular checkups and emerging medical concerns. This guidance helps keep them from “self-referring” to specialists, which starts care journeys on a higher cost trajectory and can lead to unnecessarily complex and costly treatments.

Promoting consistent preventive care

Quantum Health’s navigation model consistently guides members to stay current with vaccinations and preventive screenings, which can help them avoid or postpone complex diseases and chronic conditions. The Centers for Disease Control and Prevention estimates that chronic diseases such as cancer and diabetes drive more than $4 trillion in annual healthcare costs in the United States.

“Personal health literacy is the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.”
— Healthy People 2030, Centers for Disease Control and Prevention

In a 2022 study of clients’ healthcare utilization, when analyzing 17 preventive care services, Quantum Health found that members it serves received all 17 services at levels above industry benchmarks — in some cases by double-digit percentages.

Guiding cost-effective emergent care

In these scenarios, Care Coordinators routinely inform members of their full range of benefits and care options. They listen actively to help members weigh urgency, convenience and cost variables to arrive at well-informed decisions.

Educated on their options, often members choose urgent care or telehealth, or even opt for a next-day PCP visit, instead of what would likely be more-costly, time-consuming trips to the emergency room. In the same 2022 utilization study, clients saw avoidable ER visits decline while urgent care grew at a rate four times that of ER use.

Steering care in-network

Negotiated pricing with a network of providers is one of the primary ways self-insured employers seek to control healthcare costs. Employers typically structure health plans to offer no coverage, or considerably less coinsurance, for out-of-network (OON) care. Those restrictions put more of the financial risk on members.

Still, OON care isn’t always a free pass for employers. Depending on rates charged by an OON provider, even a reduced coinsurance split can have cost implications above and beyond negotiated in-network (INN) charges.

When employers implement Quantum Health, the company’s Care Coordinators become the single point of contact for both members and providers seeking benefits coverage and eligibility details. Providers’ service authorization requests, and members needing help finding a provider, all get steered toward INN care when possible. In the 2022 study, clients consistently saw their percentage of claims paid INN increase year over year.

Optimizing the employer’s benefits ecosystem

In a moment of need or crisis, employees and their loved ones often don’t recall or know how to access all their benefits. Care Coordinators are trained to educate members calmly and thoroughly on the employer’s full benefits offering.

Given this real-time support, members who need a provider get reminded of the transparency tool available to them. In fact, their Care Coordinator will even use the tool to research a list of high-quality, cost-effective providers, saving the member time and effort.

When appropriate, members and their providers also are educated about, and helped to engage with, any condition-management point solutions or centers of excellence available to them. Employers typically purchase these benefits based on the partner’s ability to deliver improved outcomes and cost-effective care.

Influencing where care gets delivered

Many times, members simply don’t know what they don’t know when it comes to making cost-aware healthcare decisions. One of those knowledge gaps is how the site of care can drive costs.

For example, Care Coordinators carefully review providers’ authorization requests to see whether certain procedures can be done at outpatient versus inpatient facilities. Quantum Health’s Pharmacy Services team also reviews medical specialty drug treatments to ensure that those typically high-cost injections and infusions are being administered at the most cost-effective site. Navigating healthcare on their own, most members would not feel confident or comfortable questioning these sorts of utilization cost drivers.

In the 2022 study, Quantum Health clients consistently saw increases in surgeries performed in outpatient, ambulatory surgical center or medical office settings, while utilization of more-costly inpatient procedures declined.

Similarly, a 2023 internal analysis of medical specialty drugs utilization found that treatment costs fell by an average 48% when Quantum Health intervened with a member and their provider to advise shifting care to a more cost-effective site. In fact, in 30% of those cases, Quantum Health guided treatment to the ultimate convenience of the member’s home.

Many advocacy and concierge services rely on digital tools to let members self-serve for healthcare and benefits answers and information. Besides offering members an online portal and mobile app, Quantum Health’s Care Coordinators allow the company’s model to be hands-on in providing member support. It’s that combination of human-centered, tech-empowered service that makes possible the examples of highly personalized, in-the-moment benefits education and healthcare guidance described above.

Navigating health benefits concepts and costs

The phrase “health literacy” often brings to mind members struggling to grasp copays, coinsurance and other unfamiliar terminology and concepts built into health plans. And Quantum Health’s Care Coordinators frequently help members navigate those complexities, as well.

They’ll explain the various terms and help members know where they stand in accumulating dollars toward deductibles and out-of-pocket (OOP) maximums. They’ll also advocate on a member’s behalf when a provider attempts to collect an unusually large up-front payment for services based on the member’s unmet deductible. In those cases, providers can usually be convinced to accept only the applicable copay at the point of service and to bill any remaining charges through the standard claims process.

At the other end of that spectrum, members often do know whether their health plan covers 100% of costs after they reach their annual OOP maximum. But even in those cases, Care Coordinators are trained to consistently educate members on coverage limits and guide them toward cost-effective benefits and care options.

So, whether it’s day one of a new plan year, or a member is inquiring about cosmetic Botox injections now that their OOP maximum is met, the right navigation solution — member engagement after engagement — consistently promotes clinically appropriate, cost-conscious decisions and behaviors.

Over time, doing so helps elevate an individual employee’s health literacy, as well as that of an employer’s entire plan population.

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