Optimizing benefit value with health advocacy 

Employees and their families often feel overwhelmed when it comes to making healthcare decisions. Whether they’re searching for a new pediatrician, managing a chronic condition, or facing a serious diagnosis, trying to navigate the healthcare system on their own can be confusing. In most health plans, there are multiple ways to access care, which can lead to a fragmented member experience.

Healthcare advocacy programs offer support and guidance to health plan members in making care decisions, encompassing enhanced customer service, clinical support, behavioral health, centers of excellence, and more. Ideally, healthcare advocacy acts as a central “front door” – helping members figure out what they need and guiding them to the right resources and level of care.

According to Mercer’s National Survey of Employer-Sponsored Health Plans, nearly half (48%) of all large employers (500 or more employees) provided the members in their largest medical plan with access to a health advocate or navigation service beyond the plan’s standard customer service. In some cases (15%), services are provided through the health plan for an additional fee, but most often (33%) the employer engages a different vendor to provide specialized services.

Navigation + advocacy = Navigacy

Traditionally, healthcare navigation and advocacy operated as separate functions. However, with the rise of digital support tools, these areas have largely converged to deliver a more comprehensive member experience — a service we call “navigacy,” which members can access online and by phone. Digital navigation focuses on providing easy access to benefits through digital channels; it may also point members to health programs that can help them save money and offer transparency tools with information on provider cost and quality. Personalized advocacy centers on delivering tailored support to improve member experience and outcomes.

Together, they can improve experience and support better health management by:

• Offering digital navigation and personalized digital support
• Offering concierge-level support, like helping members choose a doctor and booking appointments for them
• Directing members to the right programs within their employer’s benefits, such as behavioral health, employee assistance programs, family-forming benefits, wellness programs, or condition-specific support like for diabetes, hypertension, or musculoskeletal issues
• Helping members find high-quality care and make informed decisions
• Providing extra support for those with complex medical needs
• Improving overall health outcomes by connecting members with the right services when they need them

Considerations for employers

If you don’t yet offer enhanced navigation or advocacy services, there are two basic models to consider.

• Overlay advocacy is a service that helps patients navigate the healthcare system, find quality care, and get the right treatment. It’s meant to serve as a front door to the services provided by the medical carrier, not to replace them — the carrier still handles care management, utilization management, provider networks, basic customer service and claims. Overlay advocacy is easier to implement and generally less expensive than a carved-out model.
• Carved-out advocacy is provided by a third-party organization outside of the medical carrier. The goal is to offer unbiased support focused solely on the patient’s best interests. Advocates help with insurance issues, medical bills, treatment options, and managing care and can work directly with patients, families, or caregivers. Like overlay advocacy, carved-out advocacy can be a valuable resource for patients dealing with complex health needs. Carved-out advocacy services replace carrier case management programs and provide varying levels of clinical support; they may or may not provide utilization management services. While this approach is more costly and complex, by providing designated or dedicated support from clinical and non-clinical advocates at favorable staffing ratios, a well-managed carved-out program can yield higher engagement across the full population and higher member satisfaction.  

Final thoughts

When implementing an advocacy program, especially a carved-out model, it’s crucial to work closely with vendors to ensure the new services are seamlessly integrated with existing benefit programs. It’s equally important to establish clear and meaningful success metrics. Recommended measures include program utilization rates, reductions in administrative workload, ROI, member and client satisfaction, clinical engagement, clinical outcomes and other relevant indicators. Clear goals are the only way to hold vendors accountable for achieving collective success and positive outcomes.