If you or a loved one has ever been hurt or sick, you know well that healthcare and insurance systems are complicated; the challenges can seem endless and overwhelming.

Health navigation helps individuals and companies through these challenges. It includes clinical services, of course, but it’s much more than that. Knowing what services are needed, where to get them, and in what timeframe are critical elements to getting on the right path to recovery.

Fundamental Premise of Health Navigation

People can’t always tell at the onset how serious an injury or illness is. So, sometimes they go to an ER when they could have gone to a doctor’s office, or they go to a doctor’s office when they could have cared for themselves. Other times people underestimate or don’t recognize symptoms, and look back wishing they had realized how serious something really was – this regret can make them more likely to overreact the next time they are confronted with a health concern.

The fundamental premise of health navigation is getting people the care they need when and where they need it, which removes burdensome guesswork. A best-in-class health navigation provider should:

• Have clinicians which navigate people to the right level of care at the right time, in the right place.
• Have systems to help people determine the severity of each case and the best course of action for treatment.
• Provide the needed care or guide patients in self-care whenever possible.
• Make a referral when further care is required

People know overtreatments and over prescribing exist, but they don’t know how to tell when it is happening to them. What’s the best practice?

Evidence-Based Medicine

Evidence-based medicine is the best practice; it represents the science of proven medical effectiveness. Protocols, algorithms, and guidelines need to be built on evidence-based medicine. As a result, unnecessary treatments and prescriptions are avoided while required treatments are obtained right away.

People want to believe that all providers follow best practices, but still unnecessary care persists, including surgeries, prescriptions, therapy, and other interventions that contribute to high costs for everyone.

The healthcare and insurance systems have evolved to include many conflicts of interest, financial biases, and administrative costs. Effective navigation requires guiding patients to the right destination rather than following the momentum and pressures of a complex claims-driven system. Working with a provider who operates transparently and without conflicts of interest offers the key difference of advocating for patients rather than treating them.

Access to Care

It can take weeks to get an appointment. Lack of access to care drives frustration and drives people to go to more expensive options such as urgent care centers and ERs.

Clinics can and should be convenient and accessible, mobile units should go to patients, virtual health services should be available on-demand 24/7, and a telephonic triage service should be pre­loaded with clinics that accept walk-ins and new patients. In addition, staff should know the in-network providers in their patient’s communities, establish relationships, and have the tools necessary to gain appointments.

Serious illness and injury involves a lot of emotion, which affects people’s decision making. It feels awkward to tell a provider you want a second opinion or other options. It is not easy to know if a provider is in-network or out-of-network, and it is near impossible to find out in advance what services cost.

Decision Support

Navigation requires decision support – not just information, but recommendations. People need reassuring, they want to know the risks, and they appreciate assistance.

Health navigation gets people through the system to achieve better clinical outcomes and lower costs. That’s good for individuals, and it’s also good for their employers, who bear much of the cost of caring for their employees and their families, and who want their employees to be healthy and productive.

Author Curtis H. Smith, Executive Vice President, joined Medcor in 1995. He helped develop Medcor’s injury triage system and holds several US and foreign patents on injury assessments methods.  Smith has taught and practiced in EMS as paramedic and dispatcher.  He currently supports Medcor’s business development and marketing teams. http://medcor.com. Contact: csmith@medcor.com

This is a good question that seems simple, but is actually complex and can be answered in many ways.

How Much You Spend On Claims Bigger Factor Than How Many

First, here is a practical rule of thumb based on our experience over many years: most insured’s who have 100 or more claims per year find triage to be justifiable by any measure, regardless of their industry or state.  The savings from avoiding unnecessary claims and by improving in-network utilization far outweigh the cost of the triage call.

Also, many organizations with fewer than 100 claims find triage to be financially justifiable.  Here’s an example.  If an insured has 24 claims a year averaging $2,000 each, they would spend $48,000 a year on those claims.  Even a mediocre triage service could help avoid 25% of claims, saving $12,000.  (A top performing triage service could save almost twice as much!)  The 24 triage calls would cost under $2,400, yielding a net savings after triage fees of $9,600 or 4 to 1 on the triage investment.   In actuality, many claims incur much more than $2,000 each, and additional savings in claims administration fees and productivity are often realized.

The determining factor in cost justification is usually what an insured spends on claims, rather than its number of claims. High claims costs justify triage faster.

Here are some other considerations:

– Insured’s who are self-insured realize the savings from triage immediately.  Even on referrals which become claims, good triage providers improve in-network utilization, generating savings on medical fees.  Top tier triage providers also direct referrals to the right level of care (e.g. an occ health clinic vs an ER), generating additional savings.

– Employers in fully insured programs may think that they cannot benefit from triage because they incur the cost but the savings accrue to their carrier.  In fact, they save in several ways, though it takes time – here is one example: they improve their experience modifier, which significantly impacts their premium cost in the future.

– Some insured’s in time-sensitive industries with specialty jobs calculate that triage’s ability to help keep workers on the job is worth more than the claims savings.

– One of the most important considerations is the medical outcome – call it the “human factor.”  The best triage service is focused on getting the right care for the injured employee.  Sometimes that means early identification of a serious condition, or an unrecognized risk, and making a referral that creates a claim because it’s the right thing to do for the injured employee.

Bottom line: insured’s can justify triage in a variety of ways, not just by cost or claims count.  The quality and consistency of the triage provider is a key factor, too – poor triage risks poor clinical outcomes, disgruntled employees, and extra costs.

Author Curtis H. Smith, Executive Vice President, joined Medcor in 1995. He helped develop Medcor’s injury triage system and holds several US and foreign patents on injury assessments methods.  Smith has taught and practiced in EMS as a paramedic and dispatcher.  He currently supports Medcor’s business development and marketing teams. . http://medcor.com. Contact: csmith@medcor.com