What makes a meaningful health advocacy program?

Giving employees access to a top-notch patient-centered health resource can make all the difference in the quality of the care they receive — and the level of savings your organization can realize. But it can be hard to discern a great program from one that falls short. Here’s how to tell the difference.

An employee’s first interaction with their health plan often begins with the 800 number on the back of their insurance card. Trying to understand how their needs square with their coverage, they call to learn:

• What is covered and what is not?
• Where and how can they find the specialists they need?
• What exactly does this EOB statement mean?

Unfortunately, this information can prove hard to find, and the answers people receive on that initial call or chat vary greatly. Some health plans simply redirect callers to the website, leaving them to seek answers on their own. Some offer an AI-driven response that provides a bird’s-eye view of plan information without any personalized explanations.

It doesn’t have to be this way. In the best-case scenario, the employee calls a patient advocacy program provided by their employer to complement its health plan offerings. This support model can offer advice in that initial moment of engagement, tapping specialized nurses and case managers to answer the patient.

By cutting through bureaucracy and delivering critical information quickly, the right advocacy program can counteract the confusion that is endemic to health care — and that can delay care. In fact:

• According to one survey, 56% of people say they feel “completely lost” when it comes to understanding health insurance.¹
• Another study of more than 500 insured adults found that lower health insurance literacy is associated with a greater avoidance of both preventive and non-preventive services.²

Accordingly, the impact of a high-quality advocacy program can be extraordinary. Data gathered by Patient Care Partners reveals that thoughtful direction and advice has a positive impact on patient care, according to 98% of surveyed providers and 92% of patients.³

By evaluating a few key criteria, employers can make sure that they are offering a meaningful patient advocacy program — one that delivers strong health outcomes and compelling savings through a patient-centric lens. Here are the questions worth asking.

Many hurdles can prevent an employee from fully understanding their benefits, such as language barriers and confusing health plan communications. Moreover, a lack of clarity around copays, in-network providers, prior authorizations and other plan details — along with long wait times to speak to a representative — creates further problems.

One study found that almost 90% of patients struggle with health literacy — particularly those who belong to marginalized groups.⁴ Without the support of a patient advocacy program, many employees attempting to utilize their health benefits find themselves adrift, asked to decipher insurance jargon that can feel like an uncrackable code.

Meanwhile, the complexity of an employee’s clinical needs can also make using their healthcare benefits more onerous — so much so that a recent article in JAMA Health Forum called complexity “the enemy of access.”⁵While nearly 6 in 10 Americans say they had trouble using their health insurance in the last year, that figure rises to 8 in 10 for those with conditions that require them to use their healthcare coverage the most.⁶

One of the most common results of these barriers to access is for the patient to simply go without the healthcare they need, often causing not only poorer health outcomes but also the higher-cost conditions that result from delaying essential care. This is the sort of needless gap that a well-crafted advocacy program can close, aiding employees in using the coverage at their disposal and preventing an outcome that hurts employee and employer alike. 

When evaluating a health advocacy program, employers must learn how the program advisors engage with patients:

• Do they compassionately address common barriers to care utilization, such as low English proficiency or health literacy, or a high-complexity condition? 
• Do they give patients the tools they need to take an active role in managing their health? 
• Do they go beyond meeting the patient’s clinical needs to address other non-medical difficulties they may be having as well?

The best advocacy programs go even further, combining claims and clinical data with non-healthcare data (such as lifestyle behaviors and socioeconomic and psychographic factors) to create a comprehensive view of an employee. With this personalized information, advisors can offer relevant, actionable recommendations to increase employee engagement with their benefits.

A study found that 50% of employees think that better understanding their benefits would make them more loyal to their employers.⁷ Meanwhile, personalized benefits navigation services made a top 5 list of high-priority employer offerings in 2023.⁸ And many employers are listening to this advice, with 41% saying they either currently offer or plan to offer such services.⁹

Collectively, these facts tell a clear story: The tide is turning toward patient advocacy solutions that provide a consumer-friendly experience across the benefit ecosystem, connect employees to an array of experienced advisors, create deeper engagement with benefits, and, ultimately, boost employee well-being and productivity.

Consider the case of Cleo, an employee of a large enterprise company, and mother of a 4-month-old who is still in the NICU. As Cleo’s maternity leave nears its end, she calls the advocacy number her employer provided and is assigned a care advisor.

The provider not only helps Cleo find an in-network pediatrician, but conferences in a nurse advisor to answer questions in real time about her baby’s condition. Additionally, the advisor helps Cleo enroll in a Maternity Support Program.

Through the conversation, the advisor learns that Cleo also has 3 other children and needs clothing, a car seat, school supplies and help with utility payments. She connects Cleo with an affiliated coach who researches and provides resources.

Later, the nurse advisor follows up and learns more about Cleo’s stressors and postpartum depression symptoms, which have increased since returning to work. She connects Cleo with additional resources and continues to check in regularly.

As a result of a single call to the advocacy line, Cleo received help finding a pediatrician, enrolled in a support program, accessed care for her own mental health, and connected to assistance programs for working families. Thanks to this proactive, holistic and compassionate care during a difficult time, Cleo is able to manage her own health and maintain her job as her baby continues to get stronger.

What people want from their healthcare is no mystery. In fact, research tells the same story again and again: Today’s employees long for personalized care and customized information.¹⁰

As an employer evaluates a patient advocacy solution, it must look for an approach that’s human, personalized, comprehensive — and able to offer solutions that go beyond a patient’s clinical needs. By checking all these boxes, the right advocacy program can help organizations simplify and improve their benefits experience while increasing engagement and fostering a healthier, more productive workplace.

Learn about Optum Guide, a health advocacy solution that can help guide and empower your employees to engage with their benefits through comprehensive and compassionate support.