‘Health concierges’ and other helpers cloud health services [Pittsburgh Post-Gazette]

March 25--Health care can be a tangle of red tape and frustrating dead ends, both on the clinical side and on the insurance end of things. But now, with the emergence of "health concierges" and "health care navigators" -- telephonic nurses and aides who walk customers through the intricacies of America's jumbled health system -- customers can feel they have somebody on their side.

At the same time, the proliferation of these advocates means it's getting harder to know who's working for -- or with, or against -- whom.

Health insurers Highmark Inc. and UPMC Health Plan offer their own services -- Highmark's is called myCare Navigator while UPMC offers health care concierge services. For-profit insurers have them, too -- Aetna has "care advocate teams."

Hospitals also have in-house advocates that help patients during their stay, especially those patients with serious diseases or chronic conditions.

And then there are the private advocates who work for the patients alone, charging an hourly rate for their services -- which typically include settling billing disputes between doctor and insurer.

Independent physicians, meanwhile, are concerned that the insurer-based navigators are trying to steer customers to providers of choice, and also that patients may be bewildered by the number and variety of advocates now available to work on their behalf.

Which, somewhat ironically, is the exact opposite of what advocates hope to accomplish.

"I think it's fair to say that we have a complex health care system now," said Cecil Wilson, immediate past president of the American Medical Association. "The [navigator's] attempt is to take some of the bewilderment out of the system."

So concerned are some physicians about the various "navigators" that the American Medical Association took up the issue at a recent policy meeting in New Orleans late last year. The association approved a resolution calling on the AMA and the American College of Surgeons to "ensure that patient navigators are free of bias, do not have any role in directing referrals and do not usurp the physician's role in and responsibility for patient education or treatment planning."

The resolution also says navigators should "refrain from any activity that could be construed as clinical in nature" -- such as making specialist or pharmaceutical recommendations, or interpreting test results.

"Navigating the health care world can be challenging. Successful patient navigation programs can help to eliminate some complexity patients face, and barriers to care," said Jennifer Hanscom, chief operating officer of the Washington State Medical Association.

But "as the field of patient navigators develops, the WSMA would like to see some clear definitions or standards of training requirements," she said.

One of the pioneers in the young field of patient advocacy is Health Advocate Inc., which turns 10 this year and was founded by former health insurance executives. Based in Plymouth Meeting, Pa., Health Advocate is the company that operates and fields phones calls for Highmark's new, free myCare Navigator hot line.

The company was created when Executive Vice President Martin Rosen and his co-founders realized there was no good answer to the question: "Who's the go-to person to help the individual navigate issues?"

Given the overwhelming range of issues a policyholder has to deal with, "what dawned on us was that [there] are instances where things fall through the cracks," Mr. Rosen said.

While Highmark is now a client, most of his clients are businesses and unions, which hire Health Advocate to assist employees solve health-related problems. Not only does Health Advocate benefit the employee, but it's also of benefit to the employer, Mr. Rosen said.

"At the workplace, most employers want their employees working," he said. But employees who spend hours on the phone, haggling with insurers and physicians, aren't getting work done.

Simply put, employees who spend hours fighting the health care system -- even if the employee is healthy, and even is dealing with a family member's problem -- were "affect ing productivity," he said.

Health Advocate custom-builds navigator service packages depending on the client (it has 8,500 clients, large and small, and more than 500 employees). Highmark's service, for example, will help callers find a specialist, transfer medical records and test results, or schedule an appointment.

It won't, however, help customers on the clinical end -- choosing among treatment options, or understanding a diagnosis -- nor will it help them deal with denied claims, which is something Highmark's existing customer service staff is supposed to handle.

Steven Nelson, Highmark's senior vice president of product and development strategy, said Highmark's market research showed that 92 percent of the company's customers wanted help with these sorts of record-keeping and scheduling tasks. It was a gap in Highmark's support services.

Before, if you wanted to schedule an appointment or move records from one doctor to another, "we would have given you some advice, but we would not have done those things," Mr. Nelson said in an interview last month.

Elisabeth Schuler Russell founded the Virginia-based Patient Navigator LLC, a four-person shop that has been around for eight years, after personally navigating her 2-year-old daughter through treatment of an inoperable brainstem tumor.

She said patients ought to be aware of who's footing the bill for the navigator service -- the hospital, insurer, employer, physician or even yourself.

"Their version of a patient advocate is going to be quite different than what I do," she said of Highmark and other insurers. "Insurance companies are all about saving money. We're all about getting patients the care that they need."

What all parties agree on is that as health insurance and health care become more consumer-driven and retail-oriented, patients will need a helping hand.

High-deductible plans, individual policies, health care exchanges and shrinking corporate HR offices all have the effect of "putting a lot more of the decision-making on the customer," Mr. Rosen said.

And as health care overhaul and the 2010 Affordable Care Act take fuller effect, patient advocates will become more commonplace, said Dr. Wilson of the AMA. The general concept of a patient advocate -- whether on the payroll of the hospital, the insurer or the physician's practice -- jibes with one of the goals of the federal act, which is promoting "patient-centered care" and accountable care organizations.

Integral to all of those care models is a caseworker or patient manager who keeps an eye on a patient's total health picture and can help manage care proactively, rather than reactively.

The goal of the patient advocate -- indeed, the goal of the entire health care apparatus -- should be "better continuity of care -- people getting the right care, at the right time, at the right place," Dr. Wilson said.

Bill Toland: [email protected] or 412-263-2625.

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