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Published on February 04, 2020

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Why Social Needs Are Part of the Mix in Health Insurance

When it comes to health insurance, many of us don’t think too far beyond the card in our wallet that says we’re covered.

So when health insurance plan members get a call from a member health advocate asking, “how are you doing… is there anything I can help with,” it might come as a bit of a surprise.

“Once people realize they are on the phone with a real person from their health insurance company who cares and wants to help, they are surprised but also open,” said Lauren Clark, Member Health Advocate with Avera Health Plans, who also has a master’s degree in social work.

Involvement of member health advocates has been evolving with Avera Health Plans over the last few years. They are part of a team that also includes nurse case managers, health coaches and pharmacy experts.

This evolution is in line with the concept known as population health – in which the focus is on health and prevention rather than just treating illness or injury. “We’re looking into those determinants that influence a person’s overall health,” Clark said. For insurance companies and employers, it can save on overall health care costs. For individuals, it can save out-of-pocket costs and also result in better quality of life.

“My role is getting members more engaged in their own health,” Clark said.

She encourages members to take full advantage of covered services like an annual wellness visit, vaccinations and recommended cancer screenings, but it goes beyond those traditional expectations.

“Maybe the person has a transportation issue and cannot get to their regular doctor’s appointments. Maybe they need to see a specialist but live far away and don’t have the means to get there. Maybe they need help getting on board with an exercise plan or a healthier diet,” said Clark, who is trained to know what community resources exist and how to help people access those resources.

Currently at Avera Health Plans, the involvement of member health advocates provide support to members who have experienced high medical costs. Such people may have a difficult diagnosis, like cancer. Or they may have multiple chronic conditions.

It could be physical/environmental factors that could be contributing to a member’s overall health, so it’s important to look at those as well.  “We had one member who had experienced numerous falls at home and kept ending up in the ER. We learned that there were a lot of rugs in the home causing that person to trip,” Clark said.

She helps them understand what their plan’s deductible, co-pay and maximum out-of-pocket amounts mean for them.

It’s also important for people to understand the importance of seeing providers that are in-network. “Going to an out-of-network provider can result in a higher out-of-pocket cost to them,” she said.

While she was earning her master’s degree in social work, Clark worked in home and automobile insurance. That background is helpful in her role today, because it’s made her realize that many people don’t understand all the ins and outs of their insurance policy. “I might seem like just a piece of paper.”

Population health as a concept is about keeping a population of people healthier, so that everyone’s costs stay lower. It’s also about helping people get the right type of care at the right time.

Helping people to be more engaged in their own health care and to be better advocates for their own health is an important piece of this puzzle, so Clark expects that roles like hers will become more and more commonplace in the health insurance industry. “For us, this begins with offering our members who are at greater risk an opportunity to have a real conversation with a real person,” Clark said. “As member health advocates we believe in helping our members with their overall health care needs. We want to help coordinate services, provide education and answer questions or concerns that may help them reach their health goals.”

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Avera is a health ministry rooted in the Gospel. Our mission is to make a positive impact in the lives and health of persons and communities by providing quality services guided by Christian values.

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