Employers, insurers lend hand navigating health care system

Patients left confused or daunted by the health care system may soon have a new ally: their employer

These aides, called navigators, are available at no additional charge. They also can help people get second opinions, appeal coverage denials or consider other care options.

It's an expansion of the services that have been available for years for people facing cancer treatment. Advocates say navigators can be a resource for other patients, too.

Nanci Steinebach used one provided by her employer, a large rehabilitation hospital in Grand Rapids, Michigan. She got help successfully fighting an insurance coverage denial of her son's emergency room treatment for a severe migraine. A navigator at Mary Free Bed Rehabilitation Hospital also has worked with Steinebach on a weight-loss program.

“She helped me take that leap, just to try it out,” Steinebach said.

Tessa Patton, one of the hospital's navigators, said she does a lot of health coaching. She also spends a lot of time helping people figure out costs and explore other treatment options.

That may mean telling them where to get an imaging exam for $300 instead of $700 or helping an employee consider physical therapy instead of back surgery

In a survey of 147 large employers that cover about 15 million people, 60% said they are offering programs to help people navigate the health care system, according to the Business Group on Health, which does policy work and research for big companies. That’s up from 39% last year.

“There’s a growing number of employers that recognize that this health care system is way too fragmented and complex for any employee to effectively navigate,” said the nonprofit's CEO, Brian Marcotte.

UnitedHealthcare, the nation's largest health insurer, has made more than a thousand navigators available to customers in the past few years, focusing on those with Medicare Advantage coverage.

Mike and Susan McNally of Port St. Lucie, Florida, first used a UnitedHealthcare navigator when Mike was preparing for shoulder surgery a few years ago. Susan McNally said their hospital was pressuring them to make a co-insurance payment of nearly $700 upfront, before the year ended. She also was getting calls from doctor representatives about pre-surgery payments.

“Everybody wanted money,” she said.

Navigator Kimberly Eklond intervened. She contacted the hospital and told the couple they didn’t have to pay anything early and could actually make no-interest payments after the procedure.

More recently, Eklond helped the couple research surgeons for a neck surgery Mike McNally needed.

“Having an insurance company that is willing to help and guide and make suggestions, it’s awesome,” said Susan McNally.

UnitedHealthcare’s navigators operate mostly by phone. Other programs work in person. Blue Shield of California is putting some navigators in doctor’s offices.

The retail giant Walmart has steered employees for years to well-known providers such as the Mayo Clinic for difficult surgeries like organ transplants. Now it wants to bring that concept to more routine care.

It’s testing programs that directs patients to high-quality doctors in their local markets. It’s also testing health care assistants for its employees in the Carolinas.

Doctors and patient advocates say navigators can be helpful because people often sign up for insurance without fully understanding the coverage. Patients who have little experience with the health care system also can struggle when confronted with a crisis.

Cancer patients, in particular, must deal with multiple tests and treatments that require time off work and often are delivered at different locations. Stanford University’s Dr. Lidia Schapira said cancer centers have used navigators to coordinate care for about 25 years.

“It requires a lot of skill, tenacity and resources to really get access to quality cancer care,” she said.

Patients often prefer a neutral, third-party to guide them, said Courtney Jones of the Patient Advocate Foundation, a nonprofit that helps people deal with medical bills and problems accessing care. Even so, Jones said navigators supplied by insurers or employers can be helpful because they’re experts in areas like coverage details.

Some doctors have said they worry about the growing role insurers are playing in patient care, either by employing doctors or by requiring more reviews of surgeries beforehand.

But benefits experts say navigators aren't focused on micromanaging care. They are more concerned with making sure patients understand all their options and get good help.

“The employer is not telling you whether you should get a knee replacement or go through physical therapy,” said Paul Fronstin, an economist with the Employee Benefit Research Institute. “You’re trusting your employer to give you access to the best providers of health care.”


Follow Tom Murphy on Twitter: @thpmurphy