By: Katelyn Bush
Think back to the last time you visited the doctor’s office when you were sick. Chances are, you remember your doctor prescribing you a medication before sending you on your way. But here's a question: Did you know, without a shadow of a doubt, how much that prescription would cost before arriving at the pharmacy?
Many of us would answer “no”— because even with modern technology, communication in the healthcare space can be frustratingly opaque. Too often, plan members are left in the dark about their benefits. And for many, this lack of transparency doesn't just make for an unwelcome surprise at the pharmacy; it can mean the difference between getting better and risking more health complications. If, for instance, someone is prescribed medication but later finds out they can't afford the copay— or their health plan doesn't cover it— they may refuse to take the meds at all. This leads to worse health outcomes, more emergency room visits, and lower productivity at work— all factors contributing to ballooning health costs for self-funded employers.
But as many brokers and plan sponsors can attest, solving this issue is far trickier than it first appears. This is because guiding plan members to the best resources requires extensive knowledge about their health needs and histories— information that, without a trusted clinician partner, can feel impossible to piece together.
This is where clinicians like Lauren Roberson, Head of Nurse Advocacy at Connect Healthcare Collaboration, come in. A licensed nurse practitioner, Roberson found her passion for helping plan members after witnessing her father's battle with cancer. “When you’re actually experiencing that personally, you begin to see the gaps in the healthcare system,” she told audience members at this year’s BenefitsPRO Broker Expo. “So what you begin to realize is, ‘What can I do as a clinician to fill these gaps?’”
During her years working at a private practice, Roberson found time and again that clients needed clinicians who could work alongside brokers and plan sponsors to steer members to the best resources. They needed someone members could go to with questions about their plan, who could explain their benefits and resolve any concerns about their medications. In other words, they needed a nurse advocate.
Roberson partnered with Connect Healthcare Collaboration (CHC) to realize this vision of helping plan members receive care. Together, they created a model for nurse advocacy that leveraged both Roberson's clinical expertise and data from their clients' health plans. “What we’ve been able to do is work alongside a data partner," Roberson said. "Every client that we have, we pull in all the plan members, and we have a charting system that we’ve actually built out on our own. And so we have a full picture of who the individual [member] is, and their claims— medical claims, pharmacy claims, everything you need to know. And then we have a full understanding of the benefits.”
This model didn't only succeed because Roberson and CHC had access to plan data; the real game-changer was having a clinician who could interpret those numbers and relay them to members in a way they understood. Another key factor was Roberson's and CHC's ability to engage with less responsive plan members through employee newsletters. “What we do is [make] it very personal,” Roberson explained during the BenefitsPRO panel. “We put videos in the newsletters so that the employees know we’re there, [and] we become a very familiar face in the organization. When an employee sees our picture over and over again, it’s like we become part of their work family.”
The benefits of effective nurse advocacy speak for themselves, according to Roberson. "We had an employee reach out and ask, 'Can you help me with this health condition?' He had been prescribed a medication and wanted to know if it was covered under his plan." Not only was Roberson able to determine the cost of his medication; she also informed him about the other medicines he was taking. One he was taking for neck pain caught her attention. “I noticed in the last year he has had opiate misuse, and he tells me the doctor is now referring him back to pain management," she said. "That's the last place you want him to go. Long story short, we got him into a Center of Excellence program... he's now on a conservative path for his neck pain."
And to think: none of this would have been possible without a trusted clinician onboard to help this employee understand his benefits. By going the extra mile and looking at the man’s previous medical claims, Roberson didn’t just cut costs for the plan sponsor; she made a lasting impact on someone’s life. This, she told audience members, was the power of effective nurse advocacy. “When you have all of that data... and all that visibility that you miss as a provider, you have a moment to really step in and make a difference in someone’s life. And that’s probably one of the most rewarding things you can do as a clinician.”
To learn more about the power of nurse advocacy, visit Connect Healthcare Collaboration's page on the Granite List.
