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The complexity of care has created a new business opportunity

Care navigation services are improving quality of care and reducing costs by assisting patients in their healthcare journeys

Elena Jin

• 9 min read

Healthcare in the US is complicated. With jargon-filled clinical information, administrative nuisances of insurance coverage and billing, and the invisible components of timely care, care coordination, and health literacy, healthcare is a labyrinth to navigate. 

Care navigation is a broad category of solutions that helps patients avoid these obstacles and succeed in achieving health goals. In practice, this can look like assistance with:

  • Administrative matters: understanding health plans and insurance
  • Clinical comprehension: researching and explaining options in prevention, care, and treatment 
  • Patient care experience: advocating for patients, coordinating care, and finding the right care

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With such an expansive repertoire of service points for patients, care navigation really has no clear-cut definition, fittingly, perhaps, because the distinction of where care itself begins and ends is just as blurred. Being able to access and afford care are prerequisites of receiving care, so the services that help patients achieve these conditions, by extension, can also be considered care navigation.

Care navigation companies make up a relatively nascent sector that has seen recent growth in the marketplace, driven by long-standing issues stemming from the notorious fragmentation of the US healthcare system and a more recent crop of complications instigated by the pandemic. Care navigation helps patients untangle the intricacies of the system, but there is also a nagging sentiment that if healthcare weren’t so complicated, these services wouldn’t be necessary. 

This article addresses:

  • The colliding factors that have ripened the market for rising care navigation companies
  • How these companies are a stepping stone to help patients receive better care
  • The types of care navigation services that companies are creating
  • What care navigation looks like in practice

The problem

The US healthcare system lacks a central agency to oversee overall coordination, creating duplication, overlap, inconsistency, inadequacy, and waste. Infamous for its complex healthcare system, the US spends more and ranks worse (last, in fact) in performance among high-income countries. For a benchmark, it spent $812 billion on healthcare administration in 2017, nearly five times the per capita rate in Canada. Behind the dollars is a twisted and perplexing maze of private and governmental health plans and agencies with drastically different plans, coverage, and costs. To name just a few, there are government plans like Medicare, Medicaid, Medigap, the Children’s Health Insurance Plan, and the Veterans Health Administration, in addition to state marketplaces and employer-provided plans.

The existence of multiple payers also makes the system cumbersome and drives administrative costs. Complexity within private and public insurance further exacerbates the problem. Without a universal benefits package, covered services and their costs vary greatly from plan to plan and provider to provider. Private insurance provided by employers covers the majority of Americans, but situational changes, like switching jobs, can alter insurance plans more often than in other countries.

The complexity of the US healthcare system is the main force behind the recent uptick in care navigation startups and related mergers and acquisitions. Beyond these structural complexities, the following issues also contribute to the opaqueness of the system:

  • The fragmentation of the US healthcare system can produce lower quality care and higher costs.
  • Low healthcare literacy, and specifically healthcare navigation literacy, magnifies the issue for patients.
  • The influx of digital health companies fueled by the demand for virtual services during the pandemic has inundated consumers with more options than they can keep track of.
  • Populations historically neglected by the healthcare system are seeking competent providers that specialize in specific health needs, but identifying and accessing these providers can be challenging.

Fragmentation

Healthcare in the US is siloed. This means that there is little communication between departments in one care setting as well as between different care clinics, outpatient facilities, and integrated health systems. The result is episodic patient care rather than holistic treatment. 

To break it down, treating a patient does not simply begin and end with one department. A patient may need to see their primary care physician for an annual checkup, but may need to see a rheumatologist or endocrinologist for specialty care. When healthcare is siloed, it is hard for doctors of different specialties to communicate with each other to gain a complete picture of the patient’s health, which affects their ability to holistically treat the patient. This makes it more likely that the patient is seen as a vessel through which symptoms manifest, rather than as a person with an illness narrative and a disease to manage. Instead of treating the patient, many doctors treat the symptoms.

A greater degree of fragmentation is associated with higher costs and worse quality, including more preventable hospitalizations. With more providers involved in a patient’s care, it is more likely that no one provider holds all the parts to the patient’s narrative, and care becomes, as the name suggests, fragmented into clinical bits and pieces. Poor communication and coordination between providers can snowball into wasted dollars—loss of clinical information from one provider to the next can lead to duplicate or unnecessary tests and services. This can be a frustrating experience for patients who may not easily differentiate between different healthcare entities that do not operate in cleanly distinct domains, such as the health system they received care at and the laboratory where a provider from that health system directed them to complete a diagnostic.

Low healthcare literacy

Low healthcare literacy is another key problem. The fractured system makes things more complicated than they need to be, and Americans have a difficult time even knowing all their options, let alone understanding which one is the most appropriate for their situation. According to the Agency for Healthcare Research and Quality, only 12% of US adults have the healthcare literacy to navigate the complexities of the system. Patients bear the responsibility of advocating for themselves. As reported in this paper, for those with lower health literacy, this can affect their level of engagement in their care as well as nonadherence to medication, leading to poorer outcomes. In addition to having less knowledge in the medical context, patients with low health literacy can also experience further downstream effects including higher mortality rates.

Healthcare waste is another tangible consequence of low healthcare literacy. There are reports that estimate the cost of low healthcare literacy adds up to $106–238 billion dollars annually, which is up to 17% of all healthcare expenditures. This is one sector of the cost of overall healthcare waste, which can add up to $935 billion dollars per year. Healthcare waste includes failure of care delivery and care coordination, administrative complexity, overtreatment or low-value care, and fraud and abuse. 

Pandemic influence

The third driving factor is the pandemic. With increased demands of virtual care, investment in digital health companies reached a record $15 billion in the first half of 2021, including funding in telehealth, wellness, mobile health apps, analytics, and clinical decision support tools. While this is certainly an advantage for innovation in the digital health space, it inundates consumers with too many choices. Similar to the famous Jam Study on consumer psychology (that ruled that consumers were 10 times more likely to purchase jam when the number of jams on display were reduced from 24 to six), too many choices can leave consumers confused and without sufficient guidance. This is also described as decision paralysis. The bottom line is that choice complexity leads to indecision.

And there is an overwhelming abundance of choice in today’s health care system. In addition to navigating primary care and specialty care between health systems, national telehealth providers, and health plan offerings, consumers now also have options for mobile health and wellness apps and more digital health tools to explore. In short, the information available for consumers to make knowledgeable choices hasn’t kept up with the prolific digital health revolution. 

Enter care navigation

The concept of care navigation originated in 1990 following the findings of the American Cancer Society National Hearings on Cancer in the Poor, which stated that poverty affects social determinants of health such that people living in poverty are less able to access healthcare and thus, face poorer health outcomes. In response, patient navigation programs were established with the primary goal of saving lives by eliminating barriers to timely cancer care. 

Today, care navigation extends beyond the scope of cancer care and is meant to support patients at all points in their healthcare experience. It includes a range of different services. A patient needs to know what service they are looking for, who provides it, if they need a referral, how to access it, and how much it costs. A care navigator can help at any of these points. 

Getting the right care at the right time and the right place is an ongoing challenge, and the broad theme of care navigation can be thought of as the glue tying these three pieces together. It simplifies the complexity of healthcare and also addresses healthcare’s triple aim:

  • Improving the healthcare experience for patients
  • Improving quality of care
  • Reducing costs

Improving the healthcare experience

Besides the clinical bulk of healthcare, the overall experience also includes what comes in between visits and what makes the appointment easier for the patient. Care navigation can help ease the difficulties of finding the right in-network provider, work across the board for coordinated care, and advocate for patients at multiple levels. For instance, Accolade helps members at all touchpoints in a clinic visit, including scheduling the appointment, preparing for the visit, following up afterwards, and providing continuous guidance. 

Improving quality of care

Navigation services also facilitate patient-centered care, or care in which the patient is prioritized as an active participant in making their health decisions. This is associated with increased patient satisfaction, better outcomes, and more cost-effective care. It stands in contrast to the more traditional model of a paternalistic doctor-patient relationship, which assumes that healthcare providers are more knowledgeable than the patient about the patient’s clinical condition. Instead, a shift towards a more collaborative doctor-patient relationship is in motion. Following the flood of digital health innovation and increasing access to medical information online, care navigation is equipping patients with more resources to make informed decisions. 

As discussed above, the fragmentation of the healthcare system makes it difficult for doctors to treat patients holistically. Rather than look at a single diagnosis or doctor’s visit, care navigation is involved in the entire process, from finding the right care (that is accessible, covered, and affordable) to receiving care to dealing with post-care issues (billing and follow-up treatment). By doing so, it redistributes the burden of navigating the healthcare system away from patients. This is especially beneficial for older adults, who are more likely to face compounding chronic conditions in an increasingly fragile state, as well as for other populations that are otherwise at a higher risk of not receiving adequate care. This can happen when socioeconomic, cultural, and/or geographic barriers impede access to primary care, which can snowball into more emergency room visits and hospital readmissions for conditions that weren’t caught early on.

Patient advocacy helps in these instances. Advocates are equipped to guide patients through the tricky system to link the patient to the appropriate care. They can help with care management—reviewing and assisting with decision-making for diagnosis and treatment, conducting background research for more information, accompanying the patient to an appointment, and providing support for finding the right resources. 

Reducing costs

A 2019 report found that the prices paid for hospital services varied widely for private health plans versus for Medicare, suggesting that there is room for employers to redesign their health plans and benefits to more appropriately fit with the cost and quality of services provided. Equipped with esoteric knowledge about the healthcare system, care navigators can help in this regard by connecting patients with the appropriate guidance from their first interaction with the healthcare system and then continuously as they move through the system. They can also guide employees away from high-cost, low-value care and toward smarter healthcare decisions. 

For self-insured employers, several companies have reported cost savings after implementing care navigation services:

Care navigation in practice

Care navigation exists as a service that is integrated within an existing system or company. For instance, in the health payer space and in care settings, there are government-funded programs that help people understand insurance coverage in the Affordable Care Act marketplace. Medicaid care management programs are also available for those with chronic conditions. (Care management is a more general term that encompasses disease management and utilization management in addition to care navigation.) In care settings, there are roles for clinicians and non-clinicians alike to help patients understand healthcare, including disease, treatment, and care plan comprehension. 

Care navigation services can also be found integrated within a healthcare-related company, which is the focus of this article. There are general navigation companies that mostly target self-insured employers, verticalized navigation companies that zone in on a specific population or care sector, and embedded navigation companies that exist as services within existing businesses. 

General navigation

These care navigation companies exhibit the most comprehensive suite of services. Some, like Accolade, also vet vendors clinically, financially, and technically, releasing the burden of evaluation from employers. 

Care navigation companies can also help to increase member engagement in underutilized benefits programs. Especially with a shifting business model from per person per month to per engagement, this type of service can help to boost utilization, which is also important for the crop of digital health companies springing up to meet demand for virtual care, such as Omada Health (behavior change) and Lyra (mental health). 

For self-insured employers

Self-insured employers utilize care navigation companies to help them help the employee. Here are how some of those companies are serving patients:

  • Quantum Health works with the self-insured company’s existing benefits programs and brings together member engagement, clinical support, and provider interaction on one platform. It helps members understand their benefits, resolve billing issues, and take advantage of existing point solutions, which are services that a vendor contracted with the company provides to bridge gaps in the healthcare system. These, as mentioned above, can be underutilized simply because of lack of exposure to employees. To cater to specific challenges, Quantum Health also offers a set of personalized care navigation solutions, including incentive management, provider cost and quality search, caregiving support, and benefits navigation for the non-medically enrolled (those who are covered under a spouse’s insurance). 
  • Accolade offers personalized healthcare and benefits solutions. Advocates help patients understand company benefits, including health, dental, and 401(k) plans. This service is one pillar of the company’s foundation, which also works with health professionals to provide members with virtual primary care, mental health care, and video consultations with specialists. With this framework, Accolade boasts a single point of entry for integrated advocacy and care coordination, along with data-driven personalized care.
  • Included Health is a virtual care and navigation company that emerged from the acquisition of Included Health by the Grand Rounds and Doctor on Demand merger (more on this later). It helps patients find in-network providers with proven safety records and also helps book the appointments. A custom-built Engagement Engine and an externally-validated Match Engine are used to assess physicians and generate specific recommendations for members. Similar to Accolade’s, its care navigation service is one piece of its larger healthcare solution, and it also provides services for medical opinions and virtual primary care. 

Direct to consumer

General navigation also encompasses private navigation companies that directly serve patients. Similar to how people may have a personal trainer or a financial advisor, they may also have a care navigator that works with them personally to figure out obstacles at any point in their healthcare journey. For instance, Patient Navigator covers care coordination, medical research, and patient advocacy, and its services span the entirety of the healthcare continuum, from researching medical information and appropriate care facilities to accompanying the patient on their visit to communicating with family members. 

Other

Other care navigation services are embedded into existing businesses. 

  • Bright Healthcare is a health insurance company, selling plans for both individuals and families as well as for those eligible for Medicare Advantage. Their care navigators are trained and funded by the federal government to assist with selecting the appropriate health plan.
  • Docent Health works with healthcare organizations across the board to improve customer engagement, with specific programs ranging in topic from maternity to health equity to Medicaid to member engagement and more. In addition to these established concepts, Docent also offers the option for healthcare organizations to develop their own patient-centered navigation programs catered specifically to their population or line of service.

Vertical navigation

Vertical navigation is an offshoot of general navigation that services a specific population or topic. Growth here parallels the trend in healthcare to specialize and cater to a particular group—once a wide net has been cast, the next target is digging deeper. This applies to care navigation both for specific communities and health sectors. This is important so as to not improve healthcare for only some and not others. 

Here are a couple of companies that are digging into this space. Both of these companies contract with employers as employer-sponsored benefits. 

  • Included Health, in addition to the aforementioned services, also serves the LGBTQ+ community. With 40% of LGBTQ+ members having been discriminated against before, companies that work specifically to ensure that quality care is extended to this population are collectively working to raise the healthcare experience for everyone. 
  • WithMe Health specializes in medication management. Besides access to and cost of medication, varying efficacies and adherence among people make it complicated to handle without guidance. Prescription medication is also a sector in which costs are rising faster than any other medical good or service, with drug prices increasing 33% since 2014. In the opaque prescription drug market that profits off of high medication costs with no incentive to reduce costs for consumers, companies like WithMe Health play a role in lowering costs by matching patients to a pharmacist for guidance.

Trends

In the broader healthcare ecosystem, there has been recent activity to link care navigation services with larger, more general health companies. To name a few,

  • Grand Rounds and Doctor on Demand merged in March of 2021 to combine Grand Rounds’s expertise in healthcare quality and navigation with Doctor on Demand’s services in virtual care. They then acquired Included Health in May to expand their service population. In October 2021, they announced that these companies would be rebranded as Included Health. 
  • Accolade acquired PlushCare, a telehealth startup, and 2nd.MD, a medical second opinions startup.

These mergers and acquisitions that integrate care navigation with other health services follow the trend to provide more care in one location, thus centering the patient as the focus of these companies, rather than the services they provide. Additionally, deals in digital health to unite multiple services under one umbrella totaled $50 billion in 2020. These consolidations make it easier for care coordination to be integrated for the patient, and care navigation services embedded within these consolidated groups also help guide members to maximize benefit in the long run. With the importance of care navigation services recognized in the industry, including them within healthcare companies (through mergers and acquisitions) is also a move to make them an integral part of virtual-first care so that patients are linked to guidance from the very start of their interactions with the healthcare system. This again reinforces the movement toward holistic, patient-centered care. 

Addressing the care navigation existential crisis

This leads us back to our original question of the necessity of these care navigation services. It is a little ironic that the solution to navigating the complexities of US healthcare is to add yet another sector of services to address the compartmentalization of the system. But so long as the healthcare system remains as complex as it is currently, there will be a need for care navigation services that make understanding the labyrinth of choices easier. 

With specialized navigation companies popping up, this also begs the question of whether this additional separation is counterproductive, but as seen with the acquisition of Included Health by Grand Rounds and Doctor on Demand, there is also a space for these vertical navigation companies in the broader landscape.

The verdict: The theme of care navigation is patient-focused. The entire goal is to simplify the healthcare experience for patients to be more manageable. Starting with the integral shift to patient-centered care, the rest of the outcomes—quality and cost—follow easily. It makes sense that when care navigation prioritizes the patient and better links them to care by reducing barriers and smoothing out the road to seeing a provider, the patient experiences better outcomes. Better outcomes also translates to fewer hospital readmissions, saving money for both patients and their employers. Care navigation is a win for everyone.

Elena Jin

Elena is a Research Fellow at HTD interested in both healthcare and public health perspectives of virtual care. She holds a bachelor's degree in biology from Brown University.