Helping Hands

Patient advocacy programs seen as engine that powers not only health engagement, but also reference-based pricing model

By Bruce Shutan | The Self-Insurer

Patient advocacy programs have gradually emerged as a critical link between efforts to engage self-insured group health plan participants in better decision-making and growing use of reference-based pricing (RBP) methods to control soaring costs.

Without assistance from a patient advocate, who acts like a concierge of sorts, “employees are accessing a complex system with one hand tied behind their back,” observes Chris Fey, CEO of Big Bang Health, a full-service health care startup that made advocacy the hub of its approach.

In fact, having access to this invaluable service could be a matter of life or death. “Unless you have a care advocate or complete trust in your physician’s diagnosis, you’re operating at a disadvantage,” he cautions, citing a recent Mayo Clinic study suggesting that 20% of diagnoses by primary care physicians are actually incorrect. “As they go down that misdiagnosis trail, they’re spending up their deductible, and then they’re getting tested or are going to trigger the employer claims data. That’s going to drive up their costs one way or the other.”

Even among patients who are diagnosed correctly, Fey says the research suggests they have only about a 50/50 chance of receiving their recommended evidence-based cure guidelines.

The mission of a patient advocate is to send patients to the right provider who will not only accept negotiated prices, but also demonstrate quality in their practice or institution, says Tim Martin, EVP and general counsel for Payer Compass, LLC. The result will be “better clinical and financial outcomes on the back end,” he adds.

One key to success is establishing a lasting relationship with medical facilities that allows health plan members unfettered access to the care they need. This collaborative approach also eliminates any worries they might have about incurring unaffordable out-of-pocket costs for critical services.

Martin, who sees see some plans with a zero deductible, cites an old adage: “It’s easier to get forgiveness than it is permission, but we find in this business, it’s generally better if you get permission than to seek forgiveness.”

Patient advocacy proponents in the growing RBP space have been busy trying to build a better mousetrap for their self-insured clients. Noting that elective admissions account for more than 90% of admissions, one industry insider developed a pre-pricing technology tool that adds to the pre-authorization process. The result is less than 2% RBP pushback from providers compared to a 5% to 10% range across the industry.

“That’s been dramatic in terms of telling them what they’re going to get paid before services are rendered, and if they don’t like the number, we can negotiate it up front and they can continue with the admission,” explains the source, speaking on the condition of anonymity.

With more than 20 regionally focused databases to price all medical services nationally, his firm also negotiates safe harbor provider agreements with the hospitals to avoid balance billing.

Marketplace traction

Slightly more than half of 2,544 employers surveyed provide their employees with access to a health advocate for help finding the right medical provider, compare costs and resolve claim disputes, according to Mercer’s latest National Survey of Employer- Sponsored Health Plans. The number is a bit higher in Aon Hewitt’s 2017 Health Care Survey, which found that 59% of employers provide advocacy services and 29% may add them in the next three to five years.

With virtually all Fortune 1,000 companies self-funding their health benefits, anywhere from 50% to 75% of them offer some sort of internal or external patient advocacy, surmises Abbie Leibowitz, M.D., chief medical officer and president emeritus of Health Advocate Solutions, a subsidiary of West Corporation. He adds that “it is a broad definition of services that doesn’t truly lend itself to standardization around any industry model.”

The pain points, of course, are particularly raw for self-insured employers that take on the full risk of all medical costs, according to Fey, who also notes the possibility of an impact on reinsurance costs. But he says advocates can help steer patients to a proper second opinion and meaningful quality comparisons. They also can offer “the correct set of directions to navigate the system” en route to a better clinical outcome and improved savings, he adds.

When industry pioneer Health Advocate Solutions began 17 years ago, its biggest challenge was explaining why the service was needed. But nowadays, Leibowitz says “everyone wants to be your health advocate.”

Several factors have driven the company’s growth in the self-insured marketplace. They include the popularity of consumer-driven health plans (CDHPs), changes in benefit structures, narrow networks and a reluctance to hire more HR staffers to help employees navigate their way through an often confusing system.

Steve Kelly, president and CEO of ELAP Services, has seen scores of players unfurl shingles as patient advocates. However, there must be baseline measures for which these new ventures pass muster. “Our conviction is that it really has to be durable and follow the patient for an extended period of time,” he says.

That means a willingness to stand in patients’ shoes with a specific objective in mind that transcends providing general information over a toll-free hotline. It includes an awareness of how employees can acquire services without the risk of a balance bill or out-of-network charges.

“The better reference-based pricing plans out there have a strong patient-advocacy component, which I think is really critical to success,” reports Steve Gransbury, president of accident and health at QBE North America. Another key is the efficacy behind advocacy programs, he says.

RBP represents a strong cost-management technique for both self-funded plans and employees in terms of reining in out-of-pocket expenses that are rising with high-deductible health plans and CDHPs, according to Gransbury. Without patient advocacy, which arm plan participants with the necessary resources to work with providers, he dismisses RBP as simply “a tool in a vacuum.”

The power of this arrangement is in promoting clear communication among several stakeholders along the way to efficacy and cost savings. “Patient advocacy works really well when there’s a three-party call with a provider, advocate and the plan participant,” he observes.

Addressing problem spots

An example of where patient advocacy can make a significant difference in improving outcomes and bending the cost curve is outpatient infusion therapy, or more specifically, dialysis. Those charges tend to be quite high, Gransbury says.

Patient advocates play an indispensable role in explaining re-priced benefit payments under the RBP model to providers who were accustomed to charging much higher amounts under a previous model, he notes.

The thinking is that they also eliminate high anxiety associated with patients receiving a substantial balance bill through this transparent approach and can steer them to the right providers in the first place.

Advocates typically analyze medical and pharmacy claims data, including biometric screening results and self-reported information, and produce a personal profile of each patient, Leibowitz explains. What’s particularly helpful is that early recommendations can be made to avoid larger concerns down the road.

A diabetes diagnosis, for instance, would require more than just a routine annual medical exam. The eyes and kidneys also need to be checked alongside a peripheral neuropathy exam and hemoglobin A1C measurement – additional appointments that a patient advocate could set up.

If a health plan member wants to review her maternity coverage, Leibowitz says a health advocate can certainly explain the benefits, but the real value of this service transcends those issues. It’s in asking questions about issues that may be hidden from view. For example, did the individual already touch base with an obstetrician if she’s pregnant, or are there any high-risk factors that would require fetal maternal health expertise?

“We go to the market with ‘empowered health,’ which is a collection of data-driven, proactive outreach and intake services that attempts to engage people in the clinical discussion about how to improve their health,” he reports.

“The ultimate value of health advocacy is helping people get better care and the best possible medical outcome.”

Kelly is well aware of the “full-contact game between medical providers trying to maximize revenue, in our opinion, on the backs of employees,” which necessitates a comprehensive approach. His firm offers robust legal representation for employees or dependents who are being pressured by way of a balance bill or collection action from a medical provider.

There has been “a tremendous passivity” on the part of employers in terms of how they pay for health care services, he says, including a lack of investigation into amounts charged for various medical services. What often happens is that they simply turn over these tasks to an administrator or insurance company and step out of the picture.

It’s not unusual for ELAP Services to come across a CT scan routinely billed at anywhere from $3,000 to $6,000 and then discounted 30% or 40% when it costs hospitals just $200 to perform. “So we believe that employers not only have the right, but also an obligation to challenge these bills,” Kelly exclaims, noting how it’s also their fiduciary responsibility to do so.

In the absence of this approach, he laments that employers “have no option but to push more costs down to the employee in the way of outof- pocket costs or more premium share. So it’s kind of like a dog chasing its tail.”

Revenue cycle management software platforms lack the data necessary to discern what transpired during each hospital stay, explains Mike Dendy, vice chairman and CEO of AMPS. This makes it impossible for health care payers to determine reasonable charges. He describes hospitals as “the 800-pound gorilla in most communities,” afraid to flex their muscle so that patients might pressure their employer to cover large unpaid balances.

“You’ve got some hospitals who claim to be financially strapped, and I’m sure that’s the case,” Dendy observes. “But you’ve got hospitals making money hand over fist, as well, and they have these protective programs called certificates of need, which basically eliminates all competition that they can have in a specific market. So hospitals are unregulated utilities, for the most part.”

Another problem, he says, is that so-called BUCA plans, third-party administrators and others under the PPO model have no incentive to police self-funded payments. Their focus is simply on securing hospital discounts and collecting per-employee per-month fees from employer groups. PPOs typically overpay by about 30%, which he says RBP can prevent.

Without patient advocacy and RBP, he laments that hospitals will continue to act as creditors collecting grossly overcharged bills, while higher co-pays and deductibles for health plan members will remain as a misguided strategy to mitigate cost increases for employers.

“The value of the advocate is to explain to the hospital or physician, ‘here’s why you got paid what you got paid and to the member, ‘here’s how it was calculated and why you’re getting balance bills,’” Dendy says.

Transitioning from a traditional PPO involving BUCA plans to RBP is no casual undertaking and requires careful communications for members and providers alike, according to Ed Day, CEO of HST. Patient advocacy represents the centerpiece of this model.

While some firms outsource the patient advocacy component, his provides an in-house service with highly knowledgeable administrators because “it is such a critical function of client retention and persistency.”

Noting an increase in fiduciary burden for employer-sponsored retirement plans, Kelly says “it seems to be rather hands-off on the health and welfare side. That’s kind of a paradox. We’re not sure why that is, but all we can do is urge employers to be more proactive and take a firmer grasp of the reins to managing their plans.”

A wise investment

The price of not having patient advocacy in place may be too steep for most health care payers. Any “frictional” costs associated with these services “could be very wise investments to support reference-based pricing,” according to Gransbury. “When you’re limiting catastrophic claims to 200% or 300% of Medicare, they largely represent a more impactful discount than what the PPO may allow for. As the cost of the claim gets higher, you start to lose the power of the discount if the underlying network contract has outlier provisions,” he says.

When determining any return on investment (ROI) for patient advocacy, results are ultimately benchmarked against control groups. “Because we have the claim data, we know what it costs,” Leibowitz explains, “and because we have that total claim data, we can look across and say here’s what the impact of that was in medical costs for the employer. So we calculate an ROI based on people that engage with us compared to people that don’t.”

Although Health Advocate Solutions doesn’t outwardly promise specific savings, clients can realize up to 9:1 ROI in some cases. Leibowitz acknowledges “a healthy skepticism” of ROI and believes it’s best to focus on delivering better care and improved outcomes, which, of course, can save employers money.

The company applies data and information to employee engagement in a way that’s relevant to each individual and works across various communication platforms. Having a telecommunications giant as a parent company allows Health Advocate Solutions to leverage user-friendly technology for everything from automated outbound calls to remind patients about doctor appointments to emails or text messages related to their conditions.

ELAP Services has seen its clients typically reduce their year-over-year overall health care spend by 20% with the help of patient advocacy integrated into the RBP process, or as Kelly describes, “metric-based” pricing. “It’s critical that the plan members are supported and advocated for,” he explains.

None of the hundreds of thousands of claims Payer Compass has processed was ever litigated because of a transparent approach with medical providers that avoids adversarial communication. It stands in stark contrast to some service providers whom Martin describes as going “nuclear” by having lawyers send threatening letters.

Patient advocacy in conjunction with RBP has saved self-insured employer clients 70% to 74% on average compared to before they had patient advocates in place – savings that can be passed onto health plan members. “Many employers don’t even take a premium out of people’s checks for these plans, and when they do, it tends to be a much smaller premium,” he notes.

Bullish forecast

While patient advocacy programs can serve as a tremendous cost-savings tool for self-insured employers, it’s not a standard practice. Martin believes “there’s a mindset to overcome,” noting how PPOs gradually lost their effectiveness over the past 30 years. “A lot of agreements are still tied to percentage of charges” and simply accepted as a cost of doing business, he explains.

The future of RBP, powered by patient advocacy, looks bright. Day notes that CalPERS, the nation’s second-largest health plan behind the federal government’s employee benefit plan, has adopted this approach alongside GE, Walmart and Safeway. He sees more of this activity trickling down market from jumbo groups to those with between 500 and 25,000 lives.

Leibowitz expects patient advocacy will extend to the disability and workers’ comp areas in the future, as well as behavioral health – noting that there are more than 3 million members of an employee assistance program (EAP) serving his corporate clients.

While paying reasonable charges is a key objective behind patient advocacy, Fey believes there’s much more to this approach than meets the eye. “If you’re getting the wrong treatment directions half the time, that’s really a human-performance issue because you’re not getting better and you’re spending money,” he explains. Misdiagnosis can lead to stress, anxiety and depression – necessitating the involvement of an EAP and more holistic approach.

Over the past 30 years, he has seen most people struggle to navigate the system, “whether it’s pharmacy benefits, medical plan design, or the cave of behavioral health.” Fey is determined to reposition these elements to mirror more of “a human performance discussion around the enterprise the peak operating performance of the individuals in the enterprise.”

Employee Assistance expert to share how employers can  respond to and prevent harassment

Plymouth Meeting, PA, June 6, 2017 — West’s Health Advocate Solutions, a leading independent clinical healthcare advocacy provider, announced today that Matt Verdecchia, M.S., CEAP, Senior Trainer/Organizational Development for EAP+Work/Life Services at Health Advocate, will present a session during the Society for Human Resource Management (SHRM) 2017 Annual Conference and Exposition, to be held June 18-21, 2017, in New Orleans.

Verdecchia, who specializes in workplace training programs and has more than 30 years of experience in the behavioral health field, will discuss the critical issue of “Insensitivity or Harassment: Where Is the Line?” on Tuesday, June 20 at 7:00 AM CT.

Harassment in the workplace continues to make headlines across the country, but understanding how to appropriately address this issue can help organizations prevent incidents from escalating and reduce risk.

“Understanding what constitutes harassment is the first step toward stopping it,” said Verdecchia. “Harassment can have negative repercussions throughout the organization, but it is possible to take steps to proactively prevent inappropriate behaviors from becoming harassment.”

Verdecchia will share an overview of this issue as well as offer important information about how session participants should effectively and appropriately respond to incidents to protect their employees and decrease liability for their organization. Attendees will also learn the difference between disrespect and harassment, why employees have a difficult time reporting harassment, and how to avoid frequent mistakes when addressing issues of harassment and discrimination.

The SHRM Annual Conference & Exposition is the largest conference for human resources professionals, drawing thousands of participants each year to learn more about the latest developments and strategies from renowned industry experts.

For more information about Verdecchia’s session and the SHRM 2017 Annual Conference & Exposition, please click here. Attendees can also stop by the Health Advocate’s booth #355 to learn more and view a demo of Health Advocate’s new member engagement website and mobile app.

About West’s Health Advocate Solutions

West’s Health Advocate Solutions makes healthcare easier for over 11,500 organizations and their employees and members nationwide.

Our solutions leverage a unique combination of personalized, compassionate support from healthcare experts using powerful predictive data analytics and a proprietary technology platform including mobile solutions to provide clinical support and engage members in their health and well-being.

Our members enjoy a best-in-class, personalized concierge service that addresses nearly every clinical, administrative, wellness or behavioral health need. Our clients benefit from high levels of engagement, improved employee productivity and health, and reduced medical costs, while simultaneously simplifying and upgrading their health benefits offerings.

For more information, visit us at www.HealthAdvocate.com

 

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By Emma Court | MarketWatch

After his daughter was born, Ted Phillips wasn’t expecting to get slapped with a $3,500 bill from the hospital’s anesthesiologist.

Phillips, who works in health care in Boston, Mass., soon found out that while the hospital was in-network, the anesthesiologist was not. The hospital’s billing office told Phillips he’d have to pay it.

Undeterred, he kept making calls — to the hospital, the anesthesiologist and the insurer — and was eventually able to resolve the issue.

Still, the back-and-forth did cost Phillips, albeit in a different way: he spent about five to seven hours making the phone calls, mostly while at work. Most of the offices involved “are open 9 to 5, which is difficult,” he said.

“I work in this industry, I’ve dealt with this back-and-forth, I’ve dealt with insurance for this long now,” he said. “How many people just pay that bill because they don’t press it?”

The problem, one many consumers face, has gotten a lot easier for Phillips since then. Now, through his health benefits at work, he has access to a medical bill advocate, that helps individuals navigate their medical bills and the complex terminology of health insurance plans.

Medical bill advocates and other such third-party businesses have sprung up in the gaps and blind spots of America’s complicated, fragmented health care system. These services make sense of health bills for consumers and even fix errors in them.

In the process, these businesses can reduce wasteful health-care spending and possibly even improve health outcomes. Their numbers have exploded. And they’ve become even more important as high-deductible health plans — which put employees on the line for thousands of dollars in out-of-pocket expenses — have increased in popularity.

But these services face a persistent challenge: many employees don’t know that they have access to them.

Though confusing medical bills are pervasive, utilization rates for professional help remains low. The ultimate success of these businesses will hinge on how well they use technology to change awareness and access, according to many in the sector.

The business of medical bill advocacy

For decades, advocates have warned consumers that their medical bills could be rife with errors.

That would appear to be a consumer issue, but it’s also a problem for employers, since they provide health insurance to a majority of Americans and pay the lion’s share of the cost.

“Smart employers who want to save their money and their employees money know the best way to slash health-care costs is to improve benefits,” said David Chase, a health-care entrepreneur who now runs a nonprofit institute. Medical advocacy services are “one piece of that,” he said.

Advocates like Pat Palmer, who has been working on medical billing issues for 24 years, encourage individuals to request an itemized bill and search for clear mistakes, such as being charged for more time in the hospital than you actually spent there, or for a drug that you never got.

But for other, more-complex errors, most consumers find the experience of making calls to the health insurer and medical provider overwhelming. Often, the task requires specialized understanding about the health-care system and how it works, the nuances of an individual’s health plan and even a level of medical knowledge.

Then there are the logistics. It can be hard to even find a time during the workday, or a place at work, to make these calls.

“You’re in the hallway, on the phone with the biller, the insurance company. Before you know it, an hour has gone by,” said Dr. Raffi Terzian, senior vice president of clinical operations and senior medical director at Health Advocate, a leading company that works with employees to navigate health care and insurance problems. “It’s a time sink. It’s a time robber.”

Moreover, insurance brokers and human resources departments don’t have the ability — or the bandwidth — to answer all of peoples’ questions, especially as high-deductible health plans increase the number of questions asked, said Jason Dzurka, director of marketplace solutions at Maxwell Health, a benefits platform for small- and medium-sized businesses that is also Phillips’ employer.

Hospitals are trying to make medical billing better and more affordable, said Tom Nickels, executive vice president of government relations and public policy at the American Hospital Association. He said they’re working on tools for better price transparency and that they “pledge to work with patients” on billing issues.

But in the meantime, others have picked up the slack — and are paying for it. In the individual health insurance market, services from health technology company HealthJoy come at an additional cost to the consumer.

When it comes to employer-sponsored plans, the employer or even the insurance broker may pay, since “they see it as a valuable service for the cost,” said Dzurka. “And when you compare it to the cost of health care, it’s substantially lower — a very small percentage.”

Confusing medical bills pose a problem both to worker productivity and to employee benefits more generally, said Brian Marcotte, chief executive officer of the nonprofit National Business Group on Health, which represents large employers on health policy issues in Washington, D.C.

In other words: If workers don’t understand their benefits, they probably aren’t benefiting from them.

“Employers are recognizing that the system is too complex for employees to be sophisticated enough to navigate this,” he said.

Beyond medical bills

Tricia Taylor’s 13-year-old daughter uses an insulin pump to manage her Type 1 diabetes. That can mean testing her sugar levels as many as 10 to 12 times a day using a FreeStyle test strip, the only kind her insulin pump works with.

But Taylor’s insurance company wanted her daughter to use a different type, and wouldn’t cover the FreeStyle strips. The expense was adding up, costing Taylor about $180 a month, she said.

After working with the health-care technology company Accolade, which is offered as a benefit at the propane company she works for, Taylor was able to get the strips covered. The trick turned out to be a letter from her daughter’s doctor, explaining that the FreeStyle strips were the only ones that worked.

“It was a big, big blessing,” Taylor said. With some time, she might have been able to figure it out on her own. But “it was time that, as a working parent, I did not have.”

Now, Accolade is helping Taylor with something new: finding an in-network facility for her daughter.

Help with chronic diseases is just one of the many services these businesses now offer.

Health Advocate, which works with nearly 12,000 employers and health insurers to serve more than 40 million members, can answer “nearly any question related to health care that you can think of,” Terzian said, from coordinating care to helping with medical decisions, finding doctors and second opinions, providing wellness services and more.

These are available not just to the employee but also typically to their spouse, dependents and parents or parents-in-law, he said.

Folding in so many services makes these businesses more attractive to employers. And increasingly, the scope of companies with access to health advocacy services is growing beyond large employers to companies of all sizes.

It’s also a way to engage more people, who call in about one issue — often, about their medical benefits or understanding a medical bill — and can then find out about the other services offered.

“A client will call us for often a simple question related to their bill or benefits plan — is this doctor in network, what’s my deductible,” said Samantha Steinwinder, Accolade’s vice president of marketing. “In most cases the health plan will answer the question and send them on their way. We use the call to find out what’s going on in the individual’s life… it helps us uncover what’s happening with the health-care system with that individual.”

How it all hinges on technology

Unlike a lot of other services and technology platforms people use, customers can go months or years without interacting with a health advocacy service.

This creates an “out of sight, out of mind” effect that is one of the industry’s biggest problems, Marcotte said: “If I don’t need it, I don’t think about it. And when I do need it, I forget that it’s available.”

The mission of these businesses will hinge on data and technology, and how well they’re used to communicate with and engage consumers.

For example, “if I’m contemplating surgery, there may be indications in my claim data that triggers a flag,” and sends a push notification to the patient about decision support services, Marcotte said. Other data triggers could prompt similarly personalized information and resources, he said.

We’re “at the tip of the spear of a lot of this. It’s growing and it’s growing rapidly,” he said.

Health Advocate says that of those who have access to their service, 40% have used it at least once, with the figure rising to 90% under “best practices.”

Technology may also provide a lift. Maxwell Health says it sees higher utilization of Health Advocate through its platform than Health Advocate does alone, which it attributes to its technology.

Since these services work best when they’re both convenient and immediate, many health advocacy businesses have structured themselves for the smartphone era.

HealthJoy, which aims to be the “Siri for health care,” is mainly a mobile application, with emails and push notifications structured to move customers into the app (although there is the option to call in). The company works with about 15,000 members from the individual market, and recently started contracting with employers, of which it now has 100.

“It’s really hard to be top of mind as a point solution. So we really focus on trying to say ‘we’re help for anything,’” said Chief Executive Officer Justin Holland. “We’re trying to be air-traffic control.”

The company has focused more on cost-cutting moves like telemedicine and prescription drug savings than medical billing, at least for now, said Holland. That, paired with a recent move to work with employers, is reflected in the low utilization rates for its medical bill service, or about 8% of its employer membership, he said.

“You’re not going to use an app like ours like Candy Crush,” Holland said. But “80% of people just pay [a medical bill] and they remember after, ‘Oh, I have this service I could use.’”

Opioids in the workplace

By Harold Brubaker & Jane M. Von Bergen | Philadelphia Inquirer

Former Phillies pitcher Dickie Noles had a 1980 World Series ring on his finger and trouble in his heart.

“I had been drinking and messing around most of my life,” he said.

Opioids were not Noles’ addiction of choice. Alcohol was.

But because he nearly lost his life, his job, and his career to booze, Noles, who now handles employee-assistance programs for the Phillies, helping ball players with addictions, gambling, marital woes, and any other problem, knows what it means to struggle with an addiction.

And he also knows how help from the workplace can make all the difference, as it did for him.

At Caron Treatment Centers, a large addiction-treatment provider based in Berks County, it is evident that opioids are a major workplace issue because the vast majority of patients are employed when they arrive, officials said.

Between 2012 and 2016, the number of Caron patients reporting the use of opioids climbed 50 percent, and about one quarter of Caron’s patients in 2016 reported using heroin, said Douglas Tieman, Caron’s president and chief executive. Heroin use was negligible among Caron patients four years ago, he said.

“Opioid addiction is a public health crisis in America,” Tieman said. “It affects businesses every day — productivity of the workforce as well as the well-being of the individual employees and their families.”

While inpatient treatment is a key part of recovery from opioid addiction, experts said, employee assistance programs, or EAPs, such as the one headed by Noles, provide a crucial front door to treatment.

“EAPs have always been front and center in addiction, but this has brought a whole new level to what we do,” said Sharon O’Brien, director of FirstCall, an EAP owned by Main Line Health. “We’ve been doing more manager training geared toward helping the managers identify someone who’s impaired because you have to be really careful with all the HR and legal issues involved.”

That is especially true because opioid addiction often starts with a prescription. “There are plenty of people taking pain medications that need to, but there are also many people taking opiates that are not yet on heroin, but they are headed in that direction,” O’Brien said.

Tina Bruckner, a Main Line Health employee, used FirstCall for help with a family member.

“When it started four years ago, I didn’t know where to turn,” said Bruckner, a senior executive assistant at Paoli Hospital. FirstCall helped her access inpatient and outpatient services for her family member at Mirmont Treatment Center in Media. With the blessing of top Main Line Health executives, Bruckner later formed a support group for Main Line Health employees going through similar crises.

In addition to EAPs, another strategy for employers is the use of tighter controls on prescriptions paid for by employer-sponsored insurance, though it is too soon to say how much that is helping, said Joe DiBella, executive vice president and managing director for the health and benefits practice at Conner Strong & Buckelew, an insurance broker with dual headquarters in Philadelphia and Marlton.

“This is a new and emerging phenomenon. The crisis has become so unprecedented that it is only in the last year or so that employers and [pharmacy benefit managers] have begun to put tighter controls and mechanisms around the prescribing patterns with respect to narcotics,” DiBella said.

EAPs, by contrast, have been around for decades and are rooted in helping employees with alcoholism.

But there is a big difference between helping employees with alcoholism and helping them with opioid addictions, said Gregory P. DeLapp, chief executive of the Employee Assistance Professionals Association, a trade group in Arlington, Va.

One difference is the change in the drug and the other is the change in the workplace. Both changes make it less effective for companies to use the threat of being fired to persuade opioid addicts to undergo treatment.

People are changing jobs more often, DeLapp said, making both the employer and the employee less willing to invest in job retention. “If you take away the fact that your job may be [at stake], you’ve lost a significant leverage point,” he said.

Traditionally, the last thing addicts give up is their job, long after they lost their families.

The second big difference has to do with the drug.

“With alcohol and most other drugs,” DeLapp said, “problems develop over time.”

What also develops over time is a work history of bad performance, absenteeism, safety violations, insubordination — all of which could point the employee to an assistance program or lead to their dismissal.

“With the opioids, it is so rapid that you aren’t going to have the reams of documentation of job-performance issues,” DeLapp said. “The person is going from injury to addiction to near-death in months to a year instead of in decades.”

Still, the rules for the manager who sees early warning signs that an employee may have a substance abuse — increased absenteeism, absences on Mondays and Fridays, long lunch hours, concentration problems — have not changed, said Bert Alicea, executive vice president of the work life division of West’s Health Advocate Solutions in Plymouth Meeting.

The manager, who should have received training on how to detect suspicious signs, should say to the employee, Alicea advised: “Because of what I am observing right now, I am medically concerned about you. Based on my observation, I need to have an evaluation done, which includes a drug and alcohol test.”

By no means should the manager informally diagnose the employee as an alcoholic or a drug addict, Alicea said.

Alicea also said employees should receive training, not just how to avoid dangerous use of addictive prescription drugs themselves, but also on how to deal with coworkers who are abusing drugs and could threaten workplace safety.

Trade unions have pushed to educate members.

Last year, the Allied Trade Assistance Program, a nonprofit created by 23 Philadelphia-area trade unions to provide help for drug, alcohol, and mental-health issues, landed a $482,000 government grant to create an online drug and alcohol education program aimed at the unions’ 14,000 apprentices as well as high school students who might enter the building trades.

So far, 2,500 young people have taken the eight-hour training, offered in chunks adaptable to smartphones, iPads, and computers, said Kenneth Serviss, executive director of the assistance program. Quizzed beforehand, the students see scores rising 60 percent in a follow-up test to determine whether they absorbed the material.

Serviss said that changing the culture of the construction site presents a challenge, but it’s possible to influence the behavior of the future building trades workforce. “We create this tough persona,” Serviss said. “If a problem comes up, they are unwilling to get help, and they hold things in. People need to be able to come forward without having the stigma attached to it.”

But there is an urgency to the work. “There’s a genetic component,” since susceptibility to addiction can be inherited and many unions include grandfathers, fathers, sons, and nephews. “We are a brotherhood.”

Episode 6 – Translating Healthcare Analytics with Dan Shields

Click to view this on Vimeo

Data analytics can be used to uncover key insights about the health of employees and provide information that shapes workplace health and benefits program. In this episode of Health Advocate’s Ask the Expert series, Dan Shields, Vice President and Product Specialist with West’s Health Advocate Solutions, discusses how organizations can translate and utilize data analytics to improve the health of their workforce.

Partners Connected Health Expands Services, Improves Patient and Provider Convenience, for Online Second Opinion Service

Boston, April 26, 2017 — Partners Connected Health today announced it signed a new agreement with West’s Health Advocate Solutions, expanding the services of its Online Second Opinions Service to include the collection of medical records and diagnostic test results (radiology and pathology). Health Advocate is a leading independent clinical healthcare advocacy provider. Partners Online Second Opinions Service (POSO), managed by Partners Connected Health, provides access to world-class hospitals affiliated with Partners HealthCare, offering patients and their physicians, all over the world, easier access to expert medical specialists.

“With the addition of Health Advocate’s services, we are removing any additional burden on the patient to collect their medical records, better helping patients access quality care from anywhere in the world,” said Joseph C. Kvedar, MD, Vice President, Connected Health, Partners HealthCare. “POSO now offers a comprehensive and highly competitive online second opinion program, delivering expert medical opinions from some of the world’s leading healthcare specialists at Partners-affiliated hospitals, and a more convenient experience for both patients and providers.”

Health Advocate has extensive clinical advocacy expertise helping individuals navigate the complexities of healthcare to get the care they need, including obtaining second opinions. Health Advocate’s experienced clinical team of Personal Health Advocates, registered nurses, and medical directors will provide confidential support to patients seeking second opinions via POSO and coordinate the collection and submission of medical records for physician review, simplifying a typically challenging process for patients.

Partners Online Second Opinions service has provided thousands of patients and physicians remote access to the many specialists in the Partners HealthCare network, a Harvard Medical School-affiliated healthcare delivery system, including Brigham and Women’s Hospital, Massachusetts General Hospital, Dana Farber Cancer Institute and Spaulding Rehabilitation Hospital.

A recent review of POSO consultations found that in 90% of the medical cases reviewed, Partners HealthCare specialists recommended a complete change in the treatment plan, suggesting profound implications for clinical care. In addition, in 5% of cases, the consulting specialist recommended a new diagnosis.

“Health Advocate’s goal is to make healthcare easier, and we’re proud to work with Partners Connected Health to have our Personal Health Advocates provide expert support to these patients,” said Abbie Leibowitz, M.D., F.A.A.P., Chief Medical Officer, Founder and President Emeritus of West’s Health Advocate Solutions. “By connecting our personalized support with Partners Online Second Opinions Service, patients will have the help and resources needed to make informed decisions about their health.”

West’s Health Advocate Solutions

West’s Health Advocate Solutions makes healthcare easier for over 11,500 organizations and their employees and members nationwide. Our solutions leverage a unique combination of personalized, compassionate support from healthcare experts using powerful predictive data analytics and a proprietary technology platform including mobile solutions to provide clinical support and engage members in their health and well-being. Our members enjoy a best-in-class, personalized concierge service that addresses nearly every clinical, administrative, wellness or behavioral health need. Our clients benefit from high levels of engagement, improved employee productivity and health, and reduced medical costs, while simultaneously simplifying and upgrading their health benefits offerings. For more information, visit us at www.HealthAdvocate.com

Partners Connected Health

Partners Connected Health is leveraging information technology – mobile phones, tablets, wearables, sensors and remote health monitoring tools – to deliver quality patient care outside of traditional medical settings. Partners Connected Health programs are also helping providers and patients better manage chronic conditions, maintain health and wellness and improve adherence, engagement and clinical outcomes. The Connected Health team creates and deploys mobile technologies in a number of patient populations and care settings, and is conducting innovative clinical studies to test the effectiveness of mobile health technologies in various clinical applications, including medication adherence, care coordination, chronic disease management, prevention and wellness. Please visit www.partners.org/connectedhealth.

Partners HealthCare

Partners HealthCare is an integrated health system founded by Brigham and Women’s Hospital and Massachusetts General Hospital. In addition to its two academic medical centers, the Partners system includes community and specialty hospitals, a managed care organization, community health centers, a physician network, home health and long-term care services, and other health care entities. Partners HealthCare is committed to patient care, research, teaching, and service to the community. Partners is one of the nation’s leading biomedical research organizations and a principal teaching affiliate of Harvard Medical School. Partners HealthCare is a non-profit organization. Please visit www.partners.org.

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Barbara Kiviat | Consumer Reports

You may be able to lower the amount you owe significantly

Many consumers facing a big medical bill don’t consider one possible remedy: negotiating a lower price. Insurance companies pay nowhere near posted rates, so why should you?

Many Americans already struggle to pay their medical expenses. A full 20 percent of working-age adults with health insurance report having problems, according to a Kaiser Family Foundation/New York Times survey. Among the uninsured, more than half do.

So if you’re already having difficulty, it can be especially daunting if you’re on the hook for a huge medical bill because of a high deductible, an out-of-network charge, a procedure that isn’t covered, or being uninsured.

If you know your insurance won’t cover a procedure, it’s best to negotiate the price beforehand. “You can discuss it before you go in,” says Adria Gross, a medical billing advocate and CEO of MedWise Insurance Advocacy. “What the fee is going to be and if you can bring it down.”

If your doctor can’t reduce the price, you might want to reconsider the procedure or have the doctor suggest alternatives that are cheaper or that are covered by insurance.

But if it’s a medical necessity, or an emergency, you may end up having to negotiate after the bill arrives. It may feel odd to bargain with a hospital or doctor, but doing so could reduce what you owe by up to 50 percent.

“The first step that most people don’t take is to ask,” says John Jackson, executive director of CareCounsel, an outfit that provides health advocacy services through employer-sponsored health plans.

How do you go about doing that?

The billing office is a good place to start, but don’t expect the person who picks up the phone to cut a deal. “The first response will be no, I can’t do anything,” says Abbie Leibowitz, chief medical officer of Health Advocate, an advocacy and health assistance company. “You have to be persistent. Figure out who in the organization has the authority.”

Keep asking for the manager of the person you’re talking to—even if that takes you all the way up to the chief financial officer, Gross says. Then use these tips to help you:

Frame your request around your ability to pay. This may work if you’re in a health plan that comes with a high deductible, as a growing number are, or if you’re uninsured. “If you owe $10,000 and you’re telling me that it’s going to be impossible for you to pay, then I’m more likely to negotiate—to make sure I get paid at all,” Jackson says. Just be prepared to provide documentation showing that you really don’t have the money.

Talk about wanting to pay a fair price. Medical pricing is a system built on discounts: No insurance company would ever pay sticker price, yet that’s what’s on the bill you receive. Pricing transparency websites such as Healthcare Bluebook can give you an idea of what health plans actually pay medical providers, often a fraction of the amount charged. “You should not feel guilty about asking for a fair and reasonable price,” says Pat Palmer, president and founder of Medical Billing Advocates of America. “When there is a 50 percent or 100 percent markup, that’s not fair and reasonable.”

Research the prices insurers pay. One strong case for getting a discount after the fact is if you are billed for the services of an out-of-network provider you didn’t agree to see, like when an in-network hospital uses an out-of-network anesthesiologist in the operating room. In fact, many states are working to pass laws to reduce patients’ liability in such situations. The best negotiating tactic there is to ask to be charged what your insurance company would have paid for an in-network provider.

Offer to pay the balance in full. More generally, a good move (if you can afford it) is to offer to immediately pay off the balance of the bill. Medical providers get stiffed for about 20 percent of what they bill individuals, says Leibowitz, so there’s an incentive for them to take less money if getting paid is a sure thing. Medical advocates find that they can often get a 15 percent to 20 percent “prompt pay” discount.

Turn to a medical billing advocate. Last, if you can’t get far on your own, a medical billing advocate can help. Employers sometimes offer access to advocates as a benefit, so check on that first. Hiring an advocate on your own can be expensive—some take a flat fee and others charge a percentage of the money they save you (25 percent is typical). Just make sure to thoroughly investigate the qualifications of an advocate ahead of time. With so many Americans struggling to pay their medical bills, there are a lot of people out there who are quick to say they can help.

Episode 4: The Value of Clinical Advocacy

Beyond the standard support of administrative issues like claims and billing, clinical advocacy helps employees make more informed, value-based decisions for their health, reducing costs and improving outcomes. In this episode of Health Advocate’s Ask the Expert, Dr. Abbie Leibowitz, Chief Medical Officer, Founder and President Emeritus at West’s Health Advocate Solutions, discusses the value of clinical advocacy.

By Bruce Shutan | Employee Benefit Adviser

In the era of smartphones, tablets, apps and wearable devices, employees appreciate technology platforms. However, they still value a human touch from experts when making decisions about their workplace benefit programs, according to a new report by Health Advocate.

In fact, 73% prefer a phone conversation as their No. 1 communication preference to discuss healthcare cost and administrative information, 71% say the same about personal or emotional wellness issues (71% also mention a website or portal) and 66% cited a phone call when managing chronic conditions.

Other key findings show a strong preference for face-to-face conversations. Sixty-five percent rank this method for discussing personal or emotional wellness issues and 61% said the same for managing chronic conditions. In addition, 56% apiece cited the in-person communication channel for physical wellness benefits as well as healthcare cost and administrative information.

As part of Health Advocate’s “Striking a Healthy Balance: What Employees Really Want Out Of Workplace Wellness Communication” study, more than 500 full-time U.S. employees and 150 HR leaders were surveyed.

In the middle of the discussion

Abbie Leibowitz, M.D., the company’s founder, chief medical officer and president emeritus, believes industry producers are ideally positioned to suggest the right communication balance. “We work very collaboratively with benefit brokers and consultants,” whom he describes as “a very important part of our distribution channel.

“We always bring the broker or the consultant into the middle of the discussion,” he continues. “When we provide our data information dashboards, the broker can become consultative in the relationship by being in touch real-time with what the data shows.”

As healthcare benefits became more complicated from an administrative standpoint, Leibowitz says brokers realized that they just weren’t able to handle the sheer volume or complexity of problems that arose. Instead, he believes their focus should be on helping employers design programs that best match with their strategic healthcare priorities “and provide the best possible access to care at the lowest reasonable cost.”

Given the nation’s preoccupation with texting and social media, he was surprised by the preference for human interaction and expected much higher reliance on technology platforms across the population.

But upon closer examination, the desire for greater assistance made perfect sense. “At this point, everybody’s in a high-deductible health plan and has greater responsibility for managing the financial responsibility for their healthcare,” Leibowitz observes, adding that “the benefit structure inside companies has become much more complicated.”

Leibowitz has seen several shifts in outsourcing healthcare assistance — from bundling services from a single carrier to a best-in-breed approach that carves out disease management, pharmacy benefits, behavioral health or wellness.

The industry is now at a point of adding to that fragmentation with programs that focus on second opinion, decision support, pricing and transparency, he says.

While every company sets its own health and wellness priorities, Leibowitz says the common thread is better communication helps dramatically elevate the level of employee engagement, and as a result, overall program success.

Experts will share strategies to engage employees, improve outcomes and reduce costs

Plymouth Meeting, PA, January 24, 2017 — West’s Health Advocate Solutions, the nation’s leading clinical healthcare advocacy company, announced today that its annual Solutions Series of webinars will start January 31 with a session about understanding healthcare ROI. The series will feature industry thought leaders discussing a number of current health and benefits topics, including employee engagement, pricing transparency, population health and wellness, and data analytics, among others.

“Healthcare is complicated and ever-changing, but by simplifying the experience, it’s possible to make it easier for employees to take charge of their health and for organizations to realize the potential positive impact,” said Abbie Leibowitz, M.D., Chief Medical Officer, Founder and President Emeritus, West’s Health Advocate Solutions. “Our Solutions Series offers organizations the opportunity to hear the latest about key industry topics and issues from leading experts in their field, gleaning useful strategies they can apply within their programs.”

Sessions occur on the following Tuesdays at 2 PM ET:

  • January 31: Bending the Curve. Evaluating the true return on investments of health benefits programs.
  • February 7: Total Population Wellness. Leveraging the power of prevention and intervention.
  • February 14: A New Generation of EAP+Work/Life Services. Lowering stress and healthcare costs.
  • February 21: Beyond Navigation to Integration. Multi-faceted clinical advocacy to encourage value-based health decisions.
  • February 28: Boosting Participation. The importance of incentives to drive engagement.
  • March 7: Targeted employee Engagement. New personalized ways to drive empowered action.
  • March 14: Analytics for Better Outcomes. Integrating employer data to uncover trends, risk drivers, and opportunities for targeted interventions.
  • March 21: Empowered Health. The power of a one-call solution for better outcomes and lower costs.
  • March 28: Taking Engagement to the Next Level. Putting healthcare in the palm of your hand.
  • April 4: Biometrics. A proven way to impact outcomes and improve wellness programs.

How to Register

To register for individual webinar events or the entire Solutions Series, visit www.HealthAdvocate.com or call 866.799.2655.

About West’s Health Advocate Solutions

West’s Health Advocate Solutions makes healthcare easier for over 11,500 organizations and their employees and members nationwide.

Our solutions leverage a unique combination of personalized, compassionate support from healthcare experts using powerful predictive medical data analytics and a proprietary technology platform including mobile solutions to provide clinical support and engage members in their health and well-being.

Our members enjoy a best-in-class, personalized concierge service that addresses almost any clinical, administrative, wellness or behavioral health need. Our clients benefit from high levels of engagement, improved employee productivity and health, and reduced medical costs while simultaneously simplifying and upgrading their health benefits offerings.

For more information, visit us at www.HealthAdvocate.com

 

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