Complexities in the Healthcare System Create Opportunities for Brokers

Take a look at clinical advocacy programs

 After what she thought was a routine mammogram, Wanda Jones (pseudonym) got the call women dread. She had a spot on her right breast, and it was cancer. She got the news while at work and immediately told a colleague and her manager. She and her colleagues spent the next several hours crying and trying to figure out what to do, from how to tell her family, to what this would mean for her job.

The following day, reassured her employer would support her, while at work, Wanda went online researching her diagnosis and treatment. Her health plan called and said they could get her in to see a cancer specialist, in four weeks.  What was she to do before then? She didn’t have an established relationship with a primary care provider.  She didn’t know whom to call, what to expect, or what to do. The confusion and lack of support led to considerable anxiety and, understandably, impacted her productivity at work.

Employers are Demanding a Better Way

Unfortunately, Wanda’s experience is all too familiar for employers and employees in California. However, to better support workers facing chronic or serious conditions, increasingly, employers are turning to independent outside resources. Partnerships with clinical advocacy firms are of interest to both fully and self-insured populations. The primary goal of these programs is to help employees get optimal care, and the most from their benefits, by helping the member navigate their medical needs and the healthcare system.

Why? Primarily because healthcare today can be a complex, confusing and often daunting experience. It’s estimated that less than half of employees fully understand their healthcare benefit. That lack of knowledge can result in reduced quality of care, lower adherence to therapy, and poor outcomes.

Here’s where clinical advocacy partners, which provide services ranging from decision support to second opinions, can provide value. These programs allow brokers to bring useful value-added services to their customers and their eligible population. Additionally, clinical advocacy programs can help brokers provide innovative solutions to their book of business.

Programs offered typically include:

  • Medical Decision Support. Usually initiated by a high-touch telephonic model, supported by an app, portal, or artificial intelligence (AI) app to guide eligible members for any medical condition, including Behavioral Health. Often can connect with specialists who may not be part of the existing network plan but who could provide immediate help.
  • Second Opinion Support. In many instances, patients want a second opinion from a recognized independent authority (e.g., one not affiliated with their insurer) about a diagnosis or treatment options. Algorithms help match the member with high-performing specialists for their condition, in their network, within a geographic area.
  • Virtual guidance to help alleviate time-consuming trips to provider/ease for employees and lessens geographic limitations. Most importantly, remote expert options remove geographic barriers to ensure the member receives the best advice from the specialist that is an expert with their condition.
  • Scheduling assistance with the best providers. Due to limited capacity and member demands, the average wait time for specialists in California is now 30+ days – but that often doesn’t mean the patient sees the actual provider at that visit – just the office appointment. High-performing clinical advocacy firms can reduce the time it takes to get appointments with leading specialists in the network to days, alleviating stress, saving time.
  • Decision support for elective surgeries like hip, knee, lower back, bariatric. These procedures are often made based on personal choice, not clinical recommendations and can be costly for employers. Clinical advice can help the employee make decisions that are best for them and their situations.
  • Engagement Strategies to ensure employees are taking advantage of all benefits offered, such as onsite informational meetings, mailings, proactive calls and, increasingly, effective integration and referral from other employer health benefit providers.

What to look for in a partner for your employer clients

Brokers can help to distinguish themselves in the competitive benefits’ marketplace and provide better service to employers by recognizing the growing need for assistance with care coordination and support for employees with chronic and complex illnesses.

There are a number of companies providing these services, especially in California. It’s important to look for partners that provide the support needed. Key features to look for include:

  • Experience and a proven track record providing services needed.
  • Ability to fully integrate programs with health benefit partners and payers to ensure coordinated care.
  • Technology to enhance the member experience, ensure efficiency and provide the reporting and insights employers need to gauge the performance and value of the program. For example, access to providers via mobile phone, video consultations, record collection storage, and analysis of the impact of the program on care costs and outcomes.
  • Excellent customer support, especially from the nurse allies who are often the key point of contact and care coordination for employees. Look for vendors who have satisfaction rates over 95 percent and a Net Promoter Score (NPS) of over 70.

What to expect

The true value of partners providing enhanced care coordination and employee support for medical needs must be measured in terms of employee satisfaction, outcomes and overall ROI. In terms of cost, employers with second opinion programs can save nearly $20,000 per case. About 72% of second opinion programs for one program resulted in treatments recommended or changes in current therapies and more than 20% resulted in a changed or corrected diagnosis based on clinical review from leading physicians in the related specialty. This level of intense expert medical oversight leads to significantly improved outcomes, lower costs and employee satisfaction.

To provide the most value, plan sponsors need ready access to data on the performance of their medical support partners. They need to know about conditions treated, cost savings, comparative outcome improvements, satisfaction, wait times, etc.  Look for partners that routinely provide these insights.

Additionally, in today’s competitive employment market, employers are often looking for solutions and services that improve the overall employer brand. As a broker, you can help employers access partners that will help them develop the reputation and positioning as a caring employer by giving employees the support needed to get the most from their healthcare benefits.

Finding new ways to support employers

The nation’s healthcare system is likely to continue to become even more complicated and confusing in the coming years, especially for those with chronic and complex illnesses. To ensure maximum value from existing benefits, employees need to fully understand what programs are available, how to access them, and have clinical concierge-level service – to help them navigate the system and get the support needed based on their care needs.

Brokers can help employers looking to provide their eligible population with the support needed by identifying partners with the experience and capabilities to meet the needs of the organization and its workers. Because of improved outcomes, the result is a win, win, win – for employers, employees and the brokerage team.

Angela Barrie is the vice president of employer solutions for Consumer Medical.  She has more than 20 years of benefit consulting experience for large employers and has worked with many of the nation’s top benefit consultants, including Willis Towers Watson, Aon, Accolade and Gallagher.  Additional information is at