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Is Care Navigation the Answer to a Messy U.S. Health System?

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.

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 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.

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.

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

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 the demand for virtual care, such as Omada Health (behavior change) and Lyra (mental health).

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.

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.

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.

Editor’s note: The author affirms that there is no relation between himself and the companies mentioned.

Photo: olaser, Getty Images

Zach is a serial entrepreneur building mission-driven organizations. His first business, The Fresh Corner Cafe, operated for eight years serving hundreds of thousands of fresh and healthy foods in underserved communities in Detroit that are characterized as food deserts. After teaching himself software engineering in order to scale the Fresh Corner Cafe and build its software infrastructure, Zach founded HTD Health, a digital health consultancy focused on strategy, design, and implementation of novel software systems. The company was foundational in the early shift to virtual-first care and supported many care delivery organizations—from startups to enterprises—in building patient and clinician experiences that improve efficiency and efficacy of care. Alongside HTD Health, Zach built a next-generation governance risk and compliance SaaS company called Exos which he sold to a leading compliant cloud provider in 2022. Zach is currently CEO at HTD Health which has broadened its focus to support care delivery organizations, device companies, life sciences organizations, and SaaS for healthcare.

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