Patient Navigators a Remedy for Unshoppable Healthcare

One cost containment strategy some big employers such as Lowe's are using is to enlist sophisticated help to steer employees toward higher quality, lower cost healthcare.

Thanks to high deductibles and coinsurance, people are shopping for healthcare—a little bit.

Some of them are shopping for the modalities you already know about—imaging, office visits, maybe some lab work—and elective procedures, to a small degree.

But if you think shoppable healthcare will forever remain limited to blood tests and MRIs, with the occasional knee or hip thrown in, you probably ought to think again.

Much of the rest will likely be subject to severe pricing pressure too. That pressure won't come from the consumer/patient. Shopping for healthcare is too complex for them to do it alone. The pressure is coming from employers.

What's different this time is now many of them are getting sophisticated help, in the form of patient navigators who know at least most of the secrets of negotiating with an industry many say is unshoppable because it is monolithic, has inscrutable billing methods, and whose difficulties are exacerbated by the stress ill patients are already under.

It's happening already. One place it's evident is with large employers. Many of them, notably, Boeing, Pepsico, Lowe's Inc., and others, have integrated cost and quality into where they steer their employees for care, and patient navigators are busily deploying their capabilities on behalf of employers and their employees.

In many cases, navigators are embedded within benefit programs, acting as an essential tool in bringing efficiency to employer-provided healthcare. This is especially true for companies that employ traditional health plans as third-party administrators only.

Bob Ihrie runs one of the more innovative and experimental employers in the United States when it comes to healthcare. In his 15 years as senior vice president of human resources at Lowe's Inc., the home improvement retailer has struggled with many of the same health issues among its employees as every other employer: obesity, diabetes, hypertension—conditions that stem from unhealthy lifestyles, and which are associated with expensive and disruptive health interventions for those who cannot control those conditions.

Ihrie says that despite the complicated nature of the work patient navigators do on behalf of Lowe's employees, the services of patient navigators are the last thing employees at Lowe's want to give up. The company's simple message to employees resonates with them. "Get the care you need, use the system wisely and participate in improving or maintaining your health over the longer term."

Patient navigators make that task much simpler.

Telemedicine's Role
For example, nearly half of Lowe's employees don't have a primary care physician and consequently struggle with scheduling issues. For those folks, the navigator might recommend a service called Teladoc, in which the patient is able to consult with a physician over the phone for diagnosis of minor issues, and for referral to other professionals if it's something that can't be handled on the phone. A Teladoc visit also costs half the patient co-pay of a traditional physician office visit, and there's no waiting.

Executing on the company's "use the system wisely" instruction to employees, a navigator fronts all the company's health plans, and the phone number on the back of the employee's insurance card goes straight to the navigator.

"This is based on our assumption that our people are infrequent users in the healthcare system and that it's impossible to be an expert," Ihrie says.

Navigators help employees with everything from getting an appointment, to knowing what questions to ask doctors or hospitals. All of it is directed toward eliminating what Ihrie estimates is 30% of spending on health that represent waste, "because it's a significant cost as an employer."

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For more complex issues, the navigator might refer the patient to Lowe's centers of excellence program, which offers eligible medical plan members access to hospitals and health systems preapproved by Lowe's that have demonstrated high quality care and high patient satisfaction for a host of select procedures.

One such program is Lowe's agreement with Cleveland Clinic for necessary heart procedures, which has been ongoing since 2010. Patients have no copay or coinsurance if they choose to use the Clinic for such procedures.

"The pitch [to employees] is get the best care for free," Ihrie says. "That really got our employees thinking about the fact that there are alternatives to what your doctor recommends. Almost every situation has lots of options and we want people to make informed choices."

Lowe's has similar programs for knee and hip replacements and back and spine procedures.

Ihrie says using navigators to help employees with their healthcare choices is essential to being able to continue to provide healthcare benefits long term, which he says many large companies want to continue to be able to do. He predicts many small employers will eventually move toward moving their employees to the public exchanges and paying the penalty for doing so under the PPACA because they can't or won't use such tools.

"Almost all small employers are moving in the exchange direction," he says. "I haven't seen any large employers move that way for a number of reasons. We want to do this as long as it makes sense. We talk openly with employees that we're a self-insured plan, and we all need to participate, and improve health over time to make it affordable for all of us."

Currently, Lowe's uses three navigators—Accolade, Quantum Health, and an Optum product, and Ihrie says the company is having "a little bit of a bake-off to see who provides the best service in controlling costs and customer satisfaction."

All three are proving successful at improving employees' appreciation of benefits and "they hit a home run" in terms of customer satisfaction, Ihrie says.

"When I came back to run the health plan, I was getting stopped by employees who said, 'whatever you do, don't get rid of [the navigators].' I think we've finally got some real momentum on our people understanding our strategy and helping us control claims."