Health Care Advocates Help Employees Through Serious Diagnoses

​An employee informs you that she recently received a cancer diagnosis. She is afraid and overwhelmed. The diagnosis is a lot to process. The complexity of navigating doctor appointments, treatments, transportation and child care amplifies the stress.

Care advocates and counselors can help guide critically ill employees through the complexities of the health care industry. These support services are often available through employer-purchased health plans or, if not, can be purchased as separate benefits. The key is to make sure your workers know the benefit is available.

"Surprisingly enough, between 40 percent and 70 percent of employers of all different sizes already offer a service like this," said Sue Lewis, chief strategy officer of ConsumerMedical. "This service is gaining momentum because consumers are struggling with the diagnosis, the cost equation and out-of-pocket expenses."

Having a single point of contact who can coordinate the details of second opinions, billing, claim denials and more streamlines the process so the patient can focus on herself. As a result, patients are receiving needed support and overall medical costs are lower.

"These services drive value, and we're seeing a higher quality of care for the patient and savings on average of $17,000 per customer," said Shawna Dodds, vice president of product development at health services organization Cigna.

An annual review with your benefits consultant or health insurance contact can help you discover if this is a benefit already available to your employees and, if not, how to add it. Here's how the service works and why you may want to consider it.

Getting Started

The requirements vary from employer to employer for implementation and launch. Once a decision is made to introduce enhanced support, the largest task employers have is sharing data with the provider.

"Typically, that lift is relatively low, and we work to create those communications for the employer," said Adam Johnson, vice president at business process outsourcing provider Alight Solutions. "Once data is aggregated, a communication campaign to the employees is the final step."

Depending on the insurance company and the services offered, once the data is set up, the insurance company takes over. For example, Cigna reaches out to enrollees once they have been diagnosed with cancer to assign them a nurse care coordinator.

"By helping point people to the right person, we have seen an overall decrease in hospitalizations and emergency room visits, which has translated into better care and lower costs," said Dr. Bhuvana Sagar, national medical executive with Cigna.

Employees covered under this plan can receive:

• Support understanding the cancer diagnosis.
• Help coordinating physicians and treatment plans.
• Guidance on who to call if they are unsatisfied or not receiving the right care.
• Assistance navigating a denied claim and how to file an appeal.
• Help ordering medical supplies and finding the best prices and financial aid for prescriptions.
• Post-discharge follow-up and more.

"If an additional opinion is necessary but has been denied, we work with the plan to gather the appropriate materials from the patient and provider to appeal the denial," Johnson said. "In so many cases, the provider doesn't submit the appropriate documentation. The employee may believe their employer doesn't want them to get care when the provider has just made a clerical error."

Costs for Care Advocates

More employers are asking for these services, and insurance companies are responding. Four of the 5 major payors that contract with ConsumerMedical incorporate these services, according to Lewis.

Self-insured groups traditionally purchase these services separately, she said. For example, the care advocate may be paid by the hour or by the case, but now many are starting to ask health plans to aggregate their services as part of their plans.

Talk with your benefits consultant or health plan contact and ask if clinical advocacy or second opinion services are provided as part of plan coverage so that neither the employer nor employee is exposed to additional costs.

"For Cigna, these are not additional costs. They are included within medical and pharmacy benefits," Dodds said. "If employers want to offer the same support post-treatment, there are extra costs."

Encouraging Employees to Use Advocates

Promote the availability of care advocates to staff as you would other wellness benefits. Put the information on intranet sites, in newsletters and direct mailings to make employees aware of the service so when they need it, they'll know how to access it.

"Putting it on the back of ID cards can also help," Lewis said. "Some companies are offering incentives such as $400 to use a care advocate prior to surgery. Others require employees to call these services prior to surgery, or the employees are penalized $1,000 without a consultation because the data shows 30 percent of elective surgeries are unnecessary."

A serious illness doesn't impact just the patient. Caregivers and family members experience stress, too, in coping with the situation. Similar services for caregivers may soon become part of the support network.

"We are piloting a study focused on what support we can give caregivers," Dodds said. "Because of the stress on them, they may delay their own care, which makes it difficult to provide care, so we're working to understand the holistic needs and how to address them."

Katie Navarra is a freelance writer in New York state.