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Analysis

Advocacy Programs of Increasing Interest to Insurers and Employers

By Gregory A. Freeman  
   March 28, 2018

"We're also going to be able to influence the care they receive and reduce or mitigate a lot of waste from the healthcare system, eliminating a lot of the unnecessary medical care that occurs. We believe we're going to be able to achieve some pretty sustainable cost savings for our members and the employers," he says.

The key to making such a program work is to meld the clinical and nonclinical needs of consumers, Meier says. The traditional approach to care management has focused exclusively on the clinical issues—facilitating patient access to proper care and applying best practices, he says. Utilization issues were closely related, with insurers focused on issues such as length of stay and how to get patients to a lower-cost setting for care.

"On the nonclinical side, we focused on resolving customer problems like lost ID cards. Insurers wanted to make sure we were easy to do business with, answering questions our members had but not necessarily acting in a proactive way to prevent those problems" Meier says.

"With this program, we're reimagining the clinical side so we're no longer focusing on condition-specific solutions but instead focusing on the whole person and the whole population, looking for the best opportunities to intervene. We're doing that in a more real-time basis, when it is more meaningful for the member as opposed to a month after a situation occurred," he says.

Broader utilization management

Clinical concerns are addressed from a different perspective, Meier says, with a designated clinician looking at utilization management across different conditions, and including outpatient utilization more than in the past because so many more healthcare dollars are going there now.

HCSC also folds its pharmacy benefit management into the mix, because prescription coverage represents an increasingly large portion of medical expenses.

"We are sewing the clinical and nonclinical groups into one multidisciplinary team full of specialists—everyone from physicians, pharmacists, and social workers—to surround the consumer advocate who engages the member in both a reactive and proactive way," Meier says.

"There are ways to help people navigate the healthcare landscape that they may not even realize. We can help them, for instance, when they're in a PPO and need to know where's the best place to go for care, to get the care that is the most appropriate for them according to the literature," he says.

Gregory A. Freeman is a contributing writer for HealthLeaders.


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