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New Prescription: Patient Advocates

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By CAROL GENTRY, The Tampa Tribune

Published: October 17, 2007

TAMPA - Ever since his son came within days of having surgery that he didn't need, Tampa employee benefits consultant Rob Pariseau has been calling for a dose of prevention in health care - prevention of mistakes, not just disease.

He frequently cites the findings of a 2003 Rand Corp. study of 7,000 adults: Patients failed to get the most appropriate care almost half the time, and 11 percent were given unnecessary or potentially harmful treatment.

Patients need help to figure out what kind of medical care they need, the best place to get it and how to overcome obstacles, Pariseau said. His prescription: patient advocates.

'Think how much employers would save if employees got the right health care the first time,' said Pariseau, president of Benefits Solutions Group. 'It would be a big number.'

Patient coaching and advocacy vendors are cropping up to fill the niche, contracting with employers or unions to provide advice on getting and paying for top-quality care.

Do Americans - who already pay far more than any other people in the world for health care - really have to pay for muscle to gain access to the right care and get their bills paid?

No, says Mohit Ghose, spokesman for the Washington-based Association of Health Insurance Plans. He agrees that America's health care system is complicated, but says adding more players to the system isn't the answer.

'Our members have done a lot to reduce red tape,' and have improved communication among health care providers, members, and the insurance plan, he said.

The Rand study wasn't an indictment of health insurers, but of physician practice patterns, Ghose said. Health plans' pay-for-performance initiative is correcting that, he said, offering incentives for doctors to avoid mistakes and missed opportunities.

'We're committed to streamlining the system so that patients are getting the right care in the right setting at the right time,' Ghose said.

But coaching and advocacy companies argue it is unrealistic to expect health plans to put the interests of patients first when insurers are bound by their own contracts and financial commitments.

Employers need an independent vendor, consultants say, because employees don't want co-workers or supervisors to know about their private medical issues. New federal health privacy regulations under the Health Insurance Portability and Accountability Act, or HIPAA, have magnified this issue.

Coaching and advocacy companies contract with employers and unions, not individuals or families, because contracting with large groups keeps the fees modest - usually $1 to $5 per employee per month, including family members. The fee can depend on the range of services provided.

The BB&T Experience

One coaching company active in the Tampa Bay area is Peak Health, which counts among its clients banking giant BB&T.

Peak Health screens BB&T's work force at least once a year, including a full blood work-up. It's a condition of employment to have the blood test and fill out a health-risk questionnaire, but it's up to the employee whether to take the next step in the company's wellness program, LifeForce. The program involves going over the questionnaire and blood test results with a nurse coach, and setting goals to improve overall health and fitness.

Employees who actively participate and make progress receive a 20 percent discount on health insurance premiums, a savings of $700 to $800 a year, BB&T benefits analyst Jackie Stoll said.

More than 90 percent of employees participate, Stoll said, and the payoff is that BB&T spends about $1,000 less per worker on medical costs than peer companies.

Denise Mastromarino, a Peak Health nurse who conducts screenings for BB&T offices in the Bay area, sets up appointments, takes blood pressure and checks blood tests results. But she also coaches employees as they struggle to drop bad habits and extra pounds.

Another Tampa BB&T employee, Nancy Ford, said the Peak Health nurse prodded her to get a second opinion when her family doctor didn't seem concerned about abnormalities in her blood screen. It turned out to be a potentially serious problem that is now under control with medicine, Ford said.

'I'm a strong proponent of health coaching,' she said. 'I don't know why everybody doesn't take advantage of it.'

Low-Tech, Personal Approach

Health coaches from Peak Health use a low-tech, face-to-face approach. The new breed of advocacy vendors, however, use technology to locate top-quality practitioners and help patients navigate the bureaucracy to gain access to good care and get medical bills paid.

St. Petersburg-based Delphi of Florida, founded in 2002 to review employers' health expenses, has grown into a patient advocacy company.

Delphi uses a proprietary software to analyze state and federal data to find the best doctors in a geographic area for each type of diagnosis.

Co-owners Edward Dillabough and Jon Wittorff say they've signed 60 employers and union groups in 30 states, charging $3 per employee per month.

At Iowa Lakes Community College, based in Estherville, Executive Vice President Valerie Newhouse said her decision to hire Delphi of Florida paid off.

The college, which self-insures, received an immediate $3,000 reduction on its premium for reinsurance, the stop loss coverage for high-cost cases. That more than covered the cost for a year of Delphi's services, she said.

Even better, medical savings in the first five months of the contract came to $20,000, Newhouse said. That doesn't count the productivity gains that came from having workers diagnosed and treated correctly and returned to work sooner, she said.

When her husband needed prostate surgery, Newhouse said, Delphi got him into the Mayo Clinic in Rochester, Minn., for a mini-incision procedure called da Vinci - a type of surgery that no hospital in northwest Iowa offered.

Instead of the traditional major surgery, which requires a three- to four-day hospital stay and weeks of recovery, he stayed one night and was back at work in nine days, saving the couple from missing a lot of work, she said.

Delphi, whose client companies and union groups cover 60,000 people, is doubling its advocacy business each quarter, Wittorff said. Health Advocate Inc. of Plymouth Meeting, Pa., which says it covers 10 million people, is another fast growing company in the niche.

About 5,000 of those 10 million are workers managed by Tampa-based human resources vendor O2HR, which outsourced the task of dealing with the health care system to Health Advocate about three years ago. It costs less than $1 an employee to cover all their family members, including parents and in-laws, said Aurora Albritton, director of benefits for O2HR.

'Some of these issues can take hours, calling providers, calling insurance companies, filling out paperwork, writing up grievances and appeals for an employee,' Albritton said.

'The benefit far outweighs the cost of what we pay for the service, just in freeing up our staff.'

Pariseau, who urged O2HR to contract with Health Advocate, said he can see the irony of employers hiring an advocacy service so their employees can use the coverage that both are paying for. It's a little like buying a sports car that's so finicky you need a mechanic on retainer.

But he and his wife, Sadie, discovered how difficult the health care system can be to navigate five years ago when their son, Hank, was captain of Tampa Preparatory School's cross-country team. Hank, then 17, began fainting after meets. He had a seizure when heart specialists put him through tests. They prescribed a pacemaker and scheduled surgery.

Navigating The System

For the next four days, Sadie Pariseau scoured the Internet and quizzed friends for information. A cousin put her in touch with a specialist at Duke University in North Carolina, who, after running some tests on Hank, determined that all he needed was a pill each day to retain more fluid. 'You'll outgrow this soon,' he said. And that's what happened.

The Pariseaus said it was a fluke that they found the right specialist, that it's good to have professional advocates.

Carol Fischer, spokeswoman for Health Advocate, said it's important that people feel supported as they confront complex health care and insurance systems.

'For a lay person, it's a very hard system to navigate, and they end up being ping-ponged around. That's where we come in.'

Reporter Carol Gentry can be reached at (813) 259-7624 or cgentry@tampatrib.com.

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