The Need for a Next-Generation Healthcare Champion

By Miles Varn, M.D., Chief Medical Officer of PinnacleCare

For more than a decade, expert medical opinion and treatment decision support services have remained stagnant. Over time, this has led to a suboptimal experience for individuals, exacerbated by changes in health benefit design, delivery of care and the continued rise in medical costs. A next generation is now emerging, capable of responding to the complexity of the environment with greater value for individuals and employers. This next generation promises better cost management, improved outcomes, greater engagement and more robust support by providing patients with a highly personalized and holistic approach.

Background

Expert medical opinion and decision support services were first delivered through insurers and administrators via complex case management or second surgical opinion programs. They were structured primarily for savings for the insurer. As such, they engendered suspicion among patients that the goal was cost containment — often, against the patient’s best interest.

Recognizing the need for an independent and comprehensive solution, an industry of third-party firms emerged offering unbiased reviews of a diagnosis or procedure, as well as recommendations regarding physicians or facilities that might best handle care. The core service set remains largely unchanged today, after 20 years, primarily focused on referring to specialists from a database rather than objectively facilitating access to a curated list of top experts. Enhancements have been incremental, emphasizing initial physician contact or introducing technology to substitute for human interaction.

Leading employers have viewed the resource as a valuable solution, with 22% of large employers currently offering the service and 27% planning to adopt an approach over the next several years. Renewed interest in expert medical opinion and treatment decision support is fueled by a rapidly changing health care environment and new employer and patient needs.

There are two primary forces compelling change:

· Employer and patient needs have evolved. Benefit designs have shifted from modest fixed-dollar copayments to high deductible plans with significant patient cost-sharing. Patients are overwhelmed with a plethora of web-based medical information ranging from competent to questionable. And navigation through the health care system has become monumentally more complex.

· Employer views have changed. They are now intent on providing a differentiated employee experience, with health care playing a critical role.

A recent national survey of large employers indicates that 96% of respondents view the improvement of the employee health experience as a top priority in the next two to three years. Employers want a holistic approach to employee health, going beyond just physical health to now incorporate emotional, financial and social support.

Patients also need a deeper experience. They are less desirous of “one and done” encounters. They value a flexible, personalized longitudinal relationship with the ongoing support. And they want curated and preference sensitive referrals to top specialists as well as guidance about the financial ramifications of care options.

At the same time, employers value patient needs and see them as deeply embedded in an optimal employee health care experience.

Meanwhile, both patients and employers want a champion, including a flexible experience with an advisor, delivered directly with technology as an enabler, not as a replacement for human interaction.

Next Generation of Healthcare Advisory Services:

Expert medical opinion purveyors have remained largely static with dated approaches, product-based rigidity, lengthy, often obsolete provider rosters and myopic interest in collecting data, opining and referring. Employers are often inured to the vendor choices available and have not tested the marketplace in years, if not a decade or more.

Next-generation services that champion the needs of the member are finally emerging. They offer an updated approach that builds on longstanding core competencies and a unique network of specialists and Centers of Excellence. They focus on driving patient awareness and understanding, highly personalized decision support, access to an ongoing health champion throughout care and access to treatment for medical conditions that require specialized services. These are coupled with unique and continually updated referral networks that are actively curated and refined. And they offer a team-based approach consisting of personal advisors, research, physicians and referral specialists, behavioral health experts and insurance advocates to ensure collaboration and recommendations that are grounded in the best research, patient preferences and best available referrals.

These services align with the employer’s workforce value proposition, addressing a broad definition of patient well-being, collaboration with other health partners engaged by the employer and recognition of the need for clear patient understanding of both treatment options and personal financial consequences.

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