Benefits: My Advocate

Health advocate services help employees navigate the health care system.

By Nancy Hatch Woodward Jun 1, 2013
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Making benefits decisions often requires a great deal of impersonal analysis, but sometimes a story that touches an HR professional’s heart can strongly affect those decisions. Ed Isakson, PHR, director of HR for the Archdiocese of Indianapolis, knows this personally. A few years ago, an employee’s spouse had an unusual form of cancer, and the couple’s insurance company denied coverage for her doctor-recommended injections. The patient was a nurse and knew how to navigate the system, so Isakson advised her to appeal the decision. The insurance company relented, and the woman received four years of treatment.

“I went to her funeral, and her children talked about how wonderful those four years were,” Isakson says. “I walked out wondering if she had not been a nurse and known how to navigate the health care system, would she have had those four years with her family? Probably not.

“So, in 2011, we decided to offer a resource to help all our people navigate the health care system, get the most from their insurance benefits and receive the best possible care.” The organization started looking for a health advocate.

The field was wide open. Health advocates come in myriad forms, from individuals who work locally and may accompany a client to a doctor’s visit to larger, national players that offer comprehensive services.

“It’s a new field,” says Joanna Smith, founder and past president of the National Association of Health Care Advocacy Consultants in Berkeley, Calif. Founded in 2009, the group is attempting to provide best practices and a code of ethics for the field. “It takes a while,” Smith says. In 2007, her company, Healthcare Liaison Inc., began offering training and credentialing for health advocates with medical backgrounds—the first program of its kind in the country. There are a couple dozen programs now, but currently no national entity regulates training and credentialing for health advocates.

Finding the Right Health Advocates

“It’s critical for clients to know what services they need,” Smith says, “so they can find the right advocate, because everybody doesn’t do everything.”

The level of services often depends on the size of the vendor. Local providers may offer only a few choices, while national vendors—such as Guardian Nurses Health Care Advocates, Health Advocate Inc. and Cigna—provide comprehensive arrays of services and let employers choose the ones they want.

Jonathan Markus, senior manager of compensation and benefits at CNA, a think tank in Alexandria, Va., with 750 employees, says that during the past five years, its employees have used health advocates to:

  • Resolve claims issues.
  • File appeals.
  • Get general information about plans.
  • Find doctors.
  • Receive support for specific health conditions.

The Archdiocese of Indianapolis, with 5,900 employees, offers health-related and administrative services through its vendor, Health Advocate, including providing reminders of when employees are due for physicals.

HR professionals at Austin Hardwoods of Denver Inc., a wholesale and retail lumber supplier with 42 employees, chose to start with a single service last year—biometric screenings and a follow-up meeting with a life coach from Cigna—but wants to include educational seminars in the future.

While most health advocates are registered nurses, others come from social service or behavioral health backgrounds, have worked in the insurance industry and understand billing and coding, or are medical researchers. Some vendors have physicians serving as medical directors.

Larger health advocacy companies’ staffs may include all of the above, while local advocates may team with other organizations to coordinate specialties. For instance, Smith has affiliates that provide research, pharmaceutical advice or other services that her company does not offer. In either case, employees usually are assigned one person who oversees their case.

Paying Fees and Establishing Eligibility

In general, employers pay for the services of health advocates and do not pass the cost on to employees. Health Advocate, Guardian Nurses and Cigna charge clients monthly rates per employee, but Guardian Nurses also offers hourly rates, and Cigna provides some services at flat rates.

Most health advocates provide services for whomever the employer wants covered, including spouses, dependents, parents and parents-in-law. Some employers, such as CNA, offer the benefit to all of the above, whether the person is on the company’s health plan or not.

Others limit coverage in various ways. All employees are covered at Dickinson College in Carlisle, Pa., and at Riddle Hospital in Media, Pa. The Archdiocese of Indianapolis and Utah State University in Logan restrict access to just those individuals enrolled in the organizations’ health insurance plans. Austin Hardwoods currently covers only the individuals on its health plan, but it intends to include employees who are not on the plan next year.

Encouraging Higher Utilization Rates

Many health advocacy programs log low utilization rates by employees. Betty Long, a registered nurse and founder and president of Guardian Nurses, says the typical utilization rate is about 6 percent to 7 percent. “It’s always a challenge to get employees to engage with us,” she explains. “They’re fearful, [and] they don’t understand, so it’s our job to make sure they know what the benefit is and how it can help them.”

Marty Rosen, co-founder of Health Advocate, says its clients’ utilization rates typically range from 10 percent to 50 percent. The vendor provides employers with an annual statement listing the times employees or family members contacted the vendor. Last year, for example, Dickinson College had 425 interactions between its 850 full-time employees and Health Advocate.

CNA also receives regular interaction reports from the vendor, but it is difficult to tell what percentage of employees are using the service annually, Markus says, because the reports do not differentiate whether it’s employees or their parents or parents-in-law using the service.

Isakson is not surprised by low utilization rates. “We never expected the majority of our people to use it because, in a typical year, the vast majority of people are not dealing with complicated health issues,” he says. “It’s kind of like the 20 percent of people who are driving 80 percent of claims. It’s really designed for a small segment of our population.”

Rhonda Renaud, comptroller at Austin Hardwoods, believes that more people will take advantage of the company’s biometric screenings in the future as participants’ concerns about privacy and continued health coverage fade away. “When we went through it in 2012, no one found out about anyone’s health information through Cigna and no one’s insurance was dropped, so hopefully people will feel more comfortable doing it this year,” she says.

Promoting Advocacy Services

Lack of communication about available health advocacy services is another reason for low utilization rates, says Nancy Hedstrom Wigley, Cigna’s vice president of product development. Many employees don’t understand what health advocates do.

Cigna, Health Advocate and Guardian Nurses all provide clients with informational materials, but many employers also develop their own resources.

At Utah State University, the utilization rate of the health advocacy program increased 28 percent from 2010 to 2011, to approximately 1,600 interactions for the university’s 3,300 employees. Dayna Barrett, interim wellness coordinator at the university, estimates that 30 percent to 40 percent of eligible employees use the service.

She attributes part of the increase to communication efforts such as coverage in its Be Well Newsletter and print materials from the vendor. Barrett also meets with new hires to promote the services and tries to incorporate program information into the university’s wellness challenges—for example, giving employees points for going to the Health Advocate website and completing health risk assessments.

Riddle Hospital provides information about its vendor on the hospital’s website, during open enrollment and at annual health fairs for its 1,700 employees. To gain support from the top, Mary Louise Ciciretti, HR director for the hospital, says Guardian Nurses held educational sessions for the leadership team.

Measuring the Return on Investment

Although numbers are fuzzy, many experts say the return on investment appears to be strong in some areas. “ROI is really within your acute and chronic populations, where employers spend a lot of money,” Wigley says. “If the employee is not costing the employer anything, but the employer is making an investment in that person’s health, your ROI is going to be a lot softer.”

In determining ROI, Wigley and others suggest looking beyond straight dollars and considering how health advocates reduce HR professionals’ hours and increase employee productivity and presenteeism.

Bernadette Pham, assistant director of benefits at Dickinson College, notes that before the college offered health advocacy services, employees would often come to HR seeking assistance with health care bills, benefits structure questions and second-opinion options because they were uncomfortable calling their doctors or the insurance company. “We would assist them, but that’s not really something we should be getting into” because it could raise privacy concerns under the Health Insurance Portability and Accountability Act.

Adds Utah State’s Barrett: “Instead of us spending our workdays trying to find a new doctor or specialist, the health advocate does that for us and sends the employee an e-mail with a list of in-network doctors, the next available appointment, the location and telephone number.”

Isakson at the Archdiocese of Indianapolis saw a “very welcome” reduction in HR phone calls when his employer began offering a health advocacy service. But the service also delivers “value added beyond what we can do,” he explains. It helps employees understand their conditions and provides access to resources such as the organization’s health care carrier’s claims system, he says. “It not only saves us time; it gets a better result for the employee.”

The Archdiocese has had five consecutive years of no health care premium increases and no plan design changes, but Isakson admits it is hard to attribute that to one factor: “We have a very active wellness program and are very active in terms of health care cost transparency. We use Health Advocate to great effect, and we’ve done a lot of employee communications about consumerism in terms of our health savings account.” He adds that the cost of using Health Advocate is relatively small, less than 1 percent of health care plan costs.

Markus says CNA has saved $5,000 to $10,000 annually as a result of using health advocates, in addition to raising employee productivity.

Barrett says Utah State’s vendor offers an online cost-saving estimator that employees can use, and health advocates can help employees decide the best course of action in terms of costs and risks. These tools should save the university money and reduce its insurance costs, she says.

Lending a Helping Hand to Employees

For all the talk about ROI, employers indicate that they are most appreciative about how advocacy services have helped their employees. Ciciretti mentioned an employee who has a serious chronic illness and had tapped all of the local resources and was not getting better. Guardian Nurses did a national search to find experts in the field, she says, “and I’m just delighted to say the employee went out of network to the expert and is doing so much better.”

Rusty Thompson, a salesman at Austin Hardwoods, saw his experience go viral in a Cigna video posted on Facebook. He was getting ready to take a polar plunge to raise funds for the Special Olympics, but his biometric screening at work a few days before the plunge revealed that his blood pressure was so high he needed immediate medical attention. “We could’ve lost him,” Renaud says. “Saving him matters more than ROI.”

Nancy Hatch Woodward is a freelance writer based in Chattanooga, Tenn.

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