Jack London holds patients’ hands in emergency rooms. He expedites insurance claims and searches for out-of-network medical specialists. And, when the situation requires it, he’ll arrange a medical evacuation from a foreign country.
London is a health care advocate and the executive director of Patient Pal. His company is one of a growing number of health care advocates acting as intermediaries for corporations that want to improve employees’ ability to navigate a maze of medical care options and questions about insurance reimbursement coverage for rare diseases. London’s health care advocacy and benefits consultancy is part of APEX Management Group, a division of Gallagher Benefits Services. London, who is based in Las Vegas, counts MGM Mirage and Caesars Entertainment among his clients.
Advocates are often former insurance company employees, hospital administrators, mental health workers as well as nurses. Hired by corporations, they advocate specifically for employees. They are also known for fat Rolodexes and close relationships with hard-to-reach doctors.
"Our job is to help assist employees in navigating through myriad health care and insurance systems," says Jane Cooper, president and CEO of Patient Care, an advocacy organization based in New Orleans. "With companies facing increasing health care costs, and passing those costs on to employees, many consumers are now increasingly interested in learning more about their medical care. The average person doesn’t know where to start."
But patient advocates like London and Cooper often do.
"When a child needs an organ transplant, Jack helps the family who doesn’t know where to turn to find the right specialist," says Cynthia Kaiser Murphy, senior vice president of human resources for MGM Mirage, which self-insures medical coverage for more than 40,000 employees each year. "As an advocate, Jack fills a big void in today’s challenging system, whether there’s a need for an employee to cope with a rare disease or a medical crisis."
One such crisis came in the aftermath of a fatal car crash in Mexico. A woman died in the accident. Her 14-year-old daughter suffered head trauma and broken bones, and both she and her father were stranded in the city of Sonora. The father, who worked for a large casino company, called his benefits department in Lake Tahoe asking for help.
"We stepped in because the department wasn’t prepared to handle a cross-border medical emergency," says London, who coordinated the girl’s transfer to an orthopedic surgical unit in San Diego using an air ambulance service in his network of contacts. "The transport arrangements took about two hours of phone work," London says. "The casino company paid $10,000 less in emergency transport costs than the price quoted for the same services by the girl’s Mexican physician."
Groups like London’s and Cooper’s will do everything from researching comparative hospital rates and outcomes for specific procedures to investigating physicians’ credentials and their malpractice history. A big part of the work is negotiating disputed medical claims, an arena exacerbated by double-digit insurance rate hikes and mountains of management controls.
And many insurance administrators offer conflicting interpretations of what constitutes "standard" benefits versus those considered experimental, high-risk, high-cost, discretionary or subject to inappropriate use.
"Employers are running into a lot of hassles and complaints about expensive insurance and benefits claims from their employees," says Larry Gelb, president and CEO of Care Counsel, an advocacy organization in San Rafael, California.
"Since many of the health plans have been purchased by publicly traded managed-care firms, and many consumer-driven plans are now out there, the dominant mindset of ‘How can we reduce costs and pay a claim as late as possible so we can get the most money from the float?’ hasn’t been selling very well." Employees and employers want more, Gelb says.
This is driving health advocacy into the mainstream. Care Counsel, for example, is now advocating for employees in such organizations as the American Cancer Society, the city of San Diego and Bentley Systems, a growing software engineering firm with 1,600 employees in Exton, Pennsylvania.
Medical insurance carriers are not far behind. Blue Cross of Montana is beginning to offer advocacy services for its own employees through Health Advocate. The advocacy organization, based in Blue Bell, Pennsylvania, is the largest in the country, serving 560 client organizations and more than 600,000 employee subscribers.
Raising the white flag
What’s made advocacy a critical element for employers and employees is the advent of consumer-driven health care, which requires consumers to shoulder more financial responsibility and to make more of their own health care choices. They might or might not be prepared--or willing--to make such choices.
Large employers, many of which self-fund their medical plans rather than paying premiums to insurance carriers, increasingly favor open-access plans that eliminate the primary physician gate-keeping that’s common in a standard HMO. But such plans place more burden on the employee. With more employer programs shifting to consumer-driven plans that require employees to pay deductibles of $500 to $1,000 and more, individuals are becoming increasingly stressed about shopping around for the services and drugs they buy.
Their employers are not always able to clarify their choices, says Marty Rosen, executive vice president of marketing for Health Advocate. "Corporate benefits people are waving a white flag because critical issues are at their doorstep and they can’t deal with them any longer."
For example, privacy regulations under the Health Insurance Portability and Accountability Act affect a human resources department’s ability to handle sensitive and confidential employee health information. If, for instance, information on an employee’s health problem ends up in her employment file, the employer could be subject to a lawsuit for violating HIPAA’s privacy provisions. Outside advocates are often needed to provide a "firewall" to protect employee privacy while offering access to medical specialists, Rosen says.
Gelb agrees. "All of our clients have communicated to employees not to call HR for claims issues but to bring them to CareCounsel, where they will be handled without the company being privy to protected health information."
Further, insurance carriers that administer corporate plans can make mistakes--miscoding or rejecting legitimate claims. "A lot of the carriers go for ‘plain vanilla’ interpretations and miss the nuances of benefits that are truly designed into these programs," Rosen says.
He and his associate Dr. Abbie Leibowitz, executive vice president and chief medical officer of Health Advocate, cite a case where a woman in her 40s with a heart condition suffered a stroke as a complication. Her employer’s insurance company denied a noninvasive cardiac procedure designed to solve the problem and eliminate further clots. "The procedure’s cost was a tenth of open-heart surgery," with much faster recovery times, Leibowitz says. "But the carrier initially rejected it as experimental. This was a gray area in which the insurance company got caught up in the rules. But we were able to make a cogent medical argument that ultimately resulted in the insurance company approving the procedure."
Like other health advocacy organizations, Leibowitz says his company’s biggest value for clients lies in independence--the ability to render an objective view of any employee claim or clinical-care problem. "The object isn’t to wrangle benefits that aren’t in a plan, but to uncover the options that are there," he says.
Ultimately, advocacy works as a form of risk management for corporations, carriers and employees alike. "Advocates are driven by the belief that quality care is efficient care," says Joe Martingale, a national leader for health care strategy at Watson Wyatt Worldwide’s New York office. In many instances, he argues, good decisions cost less, and "the most efficient outcome is the highest-quality course of treatment that gets people in and out of the system as efficiently as possible."
But despite the "bargain" price for advocate services--most companies charge employers $1 to $ 4 per employee--certain claims remain unproven. For example, when many advocacy companies, including Health Advocate and Patient Care, report that they can demonstrate return on investment on the order of 2-to-1 and even 2.5- or 3-to-1 for large clients, they’re describing the ROI of the advocacy fees.
"For example, if an employer invests $50,000 in patient advocacy, the ROI is going be on the order of $125,000," says Patient Care’s Cooper. Meanwhile, savings in worker productivity vary and are measured in patient-care surveys with soft questions like "How much time did we save you?"
Other criteria are related to cash savings, meaning how much money an advocacy group can save a client by getting unpaid claims resolved. A third category is "root cause" or "efficiency" savings that result when a "disconnect" in the patient’s health care organization or administration is solved positively. The bottom line, though, is that ROI reports are still soft, Gelb says.
By the same token, advocacy groups may not be able to claim their independence if large insurance carriers add them to their benefit mix. "For example, if we sign up Blue Cross of Pennsylvania for our (advocacy) services, suddenly we’re covering 500,000 subscribers to a health plan," he says. The advocate is then "in danger of ethical compromise where you may not be able to totally fulfill your role as an independent advocate. You may be compromised if you push the (client) too hard on claims issues and ruffle too many feathers."
Despite these problems, advocacy is still a powerful draw for companies seeking help with employee medical problems. "It’s huge," says Joyce Hess, a human resources manager with Bentley Systems Inc., a company using Care Counsel’s services. "They’re a confidential source, and they provide tools to help our people make better health care decisions. In this day and age, that’s a requirement."