Navigating the American Healthcare System
Tl;dr:
The consumer/patient experience of navigating the U.S. healthcare system is abysmal.
Key stakeholders – care delivery organizations and health plans – lack meaningful incentives and capabilities to change this.
Healthcare navigation companies have traditionally sold into employers, and therefore optimize for employers’ desire to reduce healthcare costs, rather than employees’ (patients’) need for an easier experience accessing care.
Selling healthcare navigation services directly to consumers could incentivize the development of more consumer-centric products – but these services are cost-prohibitive for most people.
In 2024, new reimbursement from CMS has made it possible for Medicare beneficiaries to access healthcare navigation services covered by their insurance. This gives consumers choice to select their own healthcare navigators/advocates.
This is the first time navigation is being covered by insurance at scale in the U.S. – and while it doesn’t solve all our healthcare system woes, this new payment structure can incentivize navigation companies to design better experiences for consumers.
If Cartman can’t do it, so can’t you
Stress is bad for health – so we’d do well as a country to make accessing health care a less stressful experience than it is today. Yet in a country that spends 20% of GDP on healthcare, it’s frustrating and confusing for an ordinary person to find answers to basic questions such as:
“I am having x symptom, what should I do?” (Do I need to see a doctor? What kind of doctor? How urgent is it?)
“Where do I go for care?” (How do I find the kind of doctor I need, near me, who has availability, and is in network with my insurance?)
“How do I get an appointment?” (...without having to wait on hold for an eternity, fax in hundreds of pages of medical records, or fight through a labyrinthine insurance prior authorization process?)
South Park summed up the problem well in their 4-minute clip, Navigating The American Healthcare System.
The difficulty of navigating our healthcare system affects us all at one time or another. We expend huge amounts of time, money, and well-being to try to get care when we are at our most exhausted, stressed, and in need of support. This wastes clinicians’ time, too, which could be better spent seeing the patients who they can help the most, at the right time (for example, what cardiologist wants to see a patient with heartburn, which could have been addressed by a PCP, instead of helping the patient with a more complex heart issue?).
In an ideal world, the healthcare system would be much easier to navigate. But there’s little incentive and major barriers for this to change. Health plans benefit from creating what we consumers experience as friction in the system, since paying for less care increases their profits. Provider organizations, which (despite all the talk of value-based care) are still mostly compensated fee-for-service, have little incentive to invest in simplifying navigation. For a health system, a patient who saw the wrong type of specialist for their issue still brings in revenue, and there is no consequence to the system when a patient gets sicker (or dies) because they couldn’t get the right care in a timely manner. Overhauling outmoded IT systems to make tasks like scheduling an appointment a self-service, user-friendly experience can be a sizeable effort requiring capital expenditures that delivery systems can’t or won’t prioritize.
In response, the last decade has seen the rise of healthcare navigation/advocacy companies that say they help patients to have better healthcare experiences. Scaled companies such as Accolade, Quantum Health, and Grand Rounds are sold as an employer benefit to help their employees to “navigate” their care. The ROI these companies offer to employers is reducing their employees’ overall healthcare costs by decreasing unnecessary care and/or routing patients to less expensive care. This approach does not always align with making healthcare easier or more pleasant for patients, and it has not given rise to products that are built with the patient at the forefront. As someone who has used Accolade, I have seen firsthand how unhelpful, or even counterproductive, the product can be from the patient perspective: at best, their navigators have abandoned me to call doctor’s offices using the same outdated, partially accurate list of in-network providers that my insurance company gives me when I need to make an appointment, and at worst, they have tried to stop me from seeking care, even when my physician has recommended it. The one place that Accolade shines is their impressive technology to quickly interpret a patient’s benefits, but this doesn’t seem to be saving the company, which has never turned a profit and currently has a stock price of ~$4 (as of 8/22/24), down from an all-time high of $59.28 in 2020, just a few months after it went public.
Any logical, profit-driven company focuses on delivering value for its paying customers. The employer-facing navigation companies are doing just that. If these companies were being selected and paid by patients, they would have a much stronger incentive to directly solve patients’ healthcare navigation problems. But given the inefficiencies of our healthcare system – such as a reliance on fax and phones to book appointments or authorize care – navigation remains extremely time-consuming, manual, and, as a result, expensive. Direct-to-consumer, cash pay models have not been feasible at scale for such a costly product. So navigation companies have not been incentivized to truly solve patients’ problems.
Navigation Utopia
Can you imagine a world in which you tell someone (or something) your symptom, and within seconds you’re served up not just potential causes of the symptom (hello, LLMs) but also a few options for healthcare providers with appointment availability near you, who are covered by your insurance and have the right skills and expertise for your need? Heavily manual navigation services could become unnecessary for all but the most complex healthcare needs. This may sound simple, but I think it’s unlikely to happen anytime soon given the outmoded state of provider and payer IT and - perhaps more important – these stakeholders’ lack of meaningful incentives and cultural receptivity to change. Until we get to that healthcare utopia, having people who can help us to navigate our care – ideally enabled by technology that automates and expedites as much of the grind as possible – seems like the best option we have.
Until recently, the closest thing I had seen to a truly consumer-first healthcare navigation business was the one my team and I built at Mount Sinai Health System. Observing the significant amounts of employer spend going towards health tech solutions, the health system launched a business unit dedicated to building best-in-class healthcare products for employers. First, the system launched the flagship Health Center at Hudson Yards – a sort of One Medical on steroids, for employers based at Hudson Yards – and several other very nice health centers for local corporations and labor unions. After the first health center launch, Mount Sinai decided they wanted to build a comprehensive navigation product that would earn these (commercially insured) consumers’ loyalty to Mount Sinai, so that they would want to come back to the health system for all of their healthcare needs.
With this mandate, my team was given autonomy to ideate and build the kind of product that optimizes for consumer experience – a rare mission nirvana, made feasible by our unparalleled access to the health system. With a combination of tech + navigators, we developed a healthcare experience that minimized consumers’ administrative burden and unwanted interactions with the healthcare system (i.e., most of them, because who wants to spend time on healthcare when you could be doing…literally anything else?). The product maximized for empathy and efficient problem-solving – more an AmEx than an Aetna customer service experience. Taking the administrative load entirely off the patient’s plate could entail things as “simple” as finding and scheduling appointments with the best-suited doctors (which we were often able to do quickly by accessing Mount Sinai specialist office schedules in Epic, rather than having to call the office and wait on hold to speak to a likely annoyed, and only possibly helpful, rep) or resolving billing questions (expedited by our internal contacts on the Mount Sinai billing team) to anything that involved dealing with insurance (a time-consuming challenge given our lack of meaningful integration with payers, but slightly expedited given our status as representatives of a healthcare provider organization).
But our services were still heavily manual – something that could have been improved upon somewhat, had the health system been willing to invest in more tech build or buy, but not entirely, given the challenges and incentives mentioned previously. This made the team expensive, something that could only make sense financially because we were driving growth in the onsite health center business, bringing downstream specialty referral revenue to the health system, and were to some extent cross-subsidized by a concierge product we sold directly to a comparatively smaller group of high net worth individuals.
This navigation product was – and from what I can tell, continues to be – a phenomenal consumer experience, the kind that I haven’t experienced in healthcare outside of the ZIRP-era, overfunded startups that burned large amounts of venture capital to maintain their near-perfect NPS. Yet at a similar scale to many growth-stage digital health startups, this product serves just tens of thousands of people out of hundreds of millions of Americans who need it – and it is made uniquely possible by the sponsorship of corporations with extra $ to spare for their employee health benefits, and the fortunate circumstances of our positioning and favorable politics within the health system at the time. It showed me that great care navigation is possible – but until recently, not financially scalable.
The New American (Navigation) Dream
In 2023, as part of the Cancer Moonshot, the Biden administration announced it would be incorporating navigation services into Medicare. Since this went into effect in 2024, Americans over 65 with chronic or acute medical needs (not just those with cancer) can get the help of a healthcare navigator reimbursed by their insurance. While this doesn’t cover every American, it makes navigation accessible to a huge portion of the population.
Because of the historical incentive structure, the incumbent navigation companies weren’t built in a way that would make consumers want to interact with them (if anything, after experiencing Accolade, I wish I could go back to dealing directly with my health plan – said no one, ever). With the new CMS reimbursement, with which patients can choose their own navigators, navigation companies are for the first time financially incentivized to build truly consumer-centric products to compete for patients’ business.
This is why I was excited to come across Solace Health, a healthcare advocacy marketplace that enables consumers to search for an advocate and connect with them for help (disclaimer: I am personally an investor in Solace). Solace is a deeply mission-driven company with a product that is built entirely with the consumer in mind – an approach that has become scalable through insurance coverage (though Solace still accepts cash pay for people whose insurance doesn’t [yet] cover healthcare advocacy). The company came out of stealth this week, with a story in the Wall Street Journal.
In a world where it has become easy to get the most inessential things with one click, it’s incredibly backwards that we make it difficult and unpleasant to access the most essential – good health. With the government now investing behind this, we’re one step closer to making healthcare easier.
PSA: Solace is hiring - check out open roles here!
If you’re building a product that makes healthcare not suck for people, I’d love to hear from you!