Advocacy: Creative Solution To Health Coverage Woes

By

Over the last few years, employers have pulled out all the stops to mitigate the impact of rising health care costs on employees.

Certain approaches used by employers, like tiered prescription programs, have yielded mixed results. Other approaches, like dramatically increasing co-pays or gutting coverable benefits, have alienated large groups of employees and spurred others to leave their companies for perceived greener pastures.

Maybe it’s optimism on their part, but a number of experienced benefits professionals still ask us hopefully about the perfect plan, benefits technology tool or consumer-directed strategy that will solve their problems in year one, no less.

Sadly, there is no benefits technology or consumer-directed strategy that alone makes possible the perfect plan. Too many diverse elements are at play we all know this.

There is a powerful and underestimated way of creating more plan value for employers and employees, however, and that is through advocacy. This is not legislative advocacy, but literally the commitment to make advocacy and advocates readily available to employees.

Why is advocacy destined to be the difference-maker?

Because even though most people already have familiar resources in their day-to-day lives such as accountants, lawyers and counselors when it comes to their health care, they have no comparable resources.

Advocacy offers one of the best approaches to helping people navigate the perils of the system while at the same time providing another way to control costs.

Some of our firm’s largest accounts passed through the managed care-health maintenance organization era retaining their indemnity plan. They have managed to maintain these plans while not restricting availability or utilization of care averaging medical care inflation at levels well below 50 percent of the national average.

They have accomplished this by providing their employees with a combination of education, assistance and advocacy a true hands-on approach to health care.

o Education comes in the form of written and online resources on subjects like drug interactions, illnesses and disease both acute and chronic.

o Assistance is provided in the form of benefit plans: EAP, wellness and disease management. Also key is active human resources assistance in helping employees resolve issues.

o Advocacy arrives in the form of out-sourced professional advocates who liaise with health care providers, insurance plans and perhaps other related community resources. We have termed this overall approach, advocacy.

It should be noted that this might have been more easily accomplished before the Health Insurance Portability and Accountability Act, or HIPAA. Today in the post-HIPAA environment, this approach will need to take into consideration a “Fire Wall” and other methods of maintaining individual privacy.

Here are three examples of particularly successful advocacy initiatives, supplied by Blue Bell, Pa.-based Health Advocate Inc.:

Case History 1: A health advocate received a call from a parent about his son who, during a review of x-rays for his broken arm, was discovered to have osteoporosis. The child had a complicated prior medical history but was now an active 10-year-old. His orthopedist had referred him for a further evaluation, but the physician could not see him for 4 months.

Intervention: The health advocate arranged for a pediatrician to review the child’s medical records. The child, it was found, had not had basic bone metabolic studies. We were able to schedule an appointment with a pediatric endocrinologist at an academic pediatric hospital, who was able to see the child within three weeks.

Case History 2: A member contacted his personal health advocate, concerned he had received a balance bill from his health insurance carrier for the “uncovered” amount above the Usual and Customary Rate for a surgical procedure. He asked us to review the bill and help him appeal the insurer’s adjudication of the claim.

Intervention: The member faxed the claim information to his personal health advocate. The advocate obtained the operative report and had it reviewed by a physician expert in billing matters of this sort. It was clear that the provider had coded the case incorrectly, resulting in the balance bill. The insurer reprocessed the claim, saving the member approximately $3,000.

Case History 3: A member called the advocate because he was having a problem getting his pharmacy to refill a prescription medication he was taking for a chronic condition. Because of the package size available and the dosage his doctor had prescribed, he needed the medication refilled every four days. His health plan interpreted his prescription to be a 30-day supply and refused coverage for the refill.

Intervention: A personal health advocate contacted the pharmacy and explained the situation to the pharmacist. He agreed to refill the medication so that the member would not go untreated while the health advocate worked on a long-term solution.

In discussing the matter with the pharmacist, it was clear that the doctor’s instructions on the prescription did not match the member’s understanding of how he was to take the medication.

The advocate spoke with the physician, who rewrote the prescription, clearly explaining how the medication was to be dispensed and how often it was to be taken. The advocate then contacted the health plan’s pharmacy department and explained the package size and dosage issues. This satisfied their drug utilization review criteria, permitting the member to refill his prescription without interruption.

Clarifying the instructions on the prescription also allowed the pharmacy to dispense multiple vials of the medication at one time so that the member would have to make fewer visits to the pharmacy.

Advocacy puts teeth into the concept behind “Consumer Driven.” The employee gains the knowledge necessary to make informed decisions, which can lead to reduced health care costs. Advocacy also provides a clearly structured demonstration of company commitment to employees. Moreover, as an advocacy program is utilized, employee morale improves as employees relate their positive experiences and improved health outcomes.

Consumerismworks in this country, and one of its names is advocacy.

is CEO, Travers, Okeefe Inc., a New York City-based employee benefits brokerage and consultancy.


Reproduced from National Underwriter Edition, April 19, 2004. Copyright 2004 by The National Underwriter Company in the serial publication. All rights reserved.Copyright in this article as an independent work may be held by the author.