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The Business Case for Patient Navigation - A Necessary Tool for Healthcare Reform and the Bottom Line

by Dr. Hillary Lin

The Current Healthcare Sh!tshow

Maya's ordeal with metastatic colon cancer began not with her diagnosis, but with a series of healthcare system failures. Despite knowing the importance of early screening due to her family history, life's upheavals – a divorce and job loss leading to a lapse in health insurance – derailed her plans. When she finally obtained insurance, bureaucratic delays in getting a primary care appointment and subsequent referral for a colonoscopy allowed critical years to slip by. By the time of her diagnosis, she was well beyond her recommended screening age and now facing a formidable health challenge.

(Names and details have been changed for privacy.)

This is a *simplified* version of what a person goes through in upon receiving a cancer diagnosis.

Maya's struggle highlights a critical gap: the urgent need for efficient patient navigation in healthcare. Patients like Maya, facing complex medical conditions, are expected to navigate a labyrinth of medical appointments, insurance policies, and treatment options, often without guidance. This lack of direction not only leads to patient frustration and confusion but also has tangible, detrimental impacts on health outcomes such as higher rates of ED visits and hospitalizations (Commonwealth Fund Study 2018).

What is Healthcare Navigation?

The concept of health navigation originated in the 1990s with Dr. Harold Freeman's work in Harlem, New York, primarily to assist cancer patients. Since then, the role of patient navigation has expanded to encompass a variety of healthcare scenarios, addressing not only clinical needs but also the psychosocial aspects of healthcare.

Healthcare navigation is an essential service designed to guide patients through the complexities of the healthcare system. Think of a navigator as a sherpa, GPS, or co-pilot. At its core, it involves personalized assistance provided to patients to help overcome healthcare system barriers and facilitate timely access to quality medical and psychosocial care from pre-diagnosis through all phases of the disease continuum.

The role of a health navigator often includes, but is not limited to:

  1. Assisting with Appointment Scheduling: Navigators help patients schedule appointments, ensuring they receive timely care without the stress of managing a complex healthcare calendar.
  2. Coordinating Treatment Plans: They play a crucial role in coordinating among various healthcare providers to ensure that the patient's treatment plan is comprehensive, coherent, and timely.
  3. Insurance Navigation: Understanding and utilizing health insurance can be daunting for many. Navigators assist in deciphering insurance plans, benefits, and facilitate communication between insurance companies and patients.
  4. Providing Emotional and Social Support: Beyond logistical assistance, navigators offer emotional support to patients, helping them cope with the stress and emotional burden of their healthcare journey.
  5. Educational Resources: They provide valuable information and resources to patients, helping them understand their condition, treatment options, and what to expect throughout their care journey.
  6. Community Resource Linkage: Navigators connect patients with community resources, which may include transportation services, financial assistance programs, or support groups.

Today, the jobs of navigation are haphazardly covered by caregivers, nurses, care coordinators, doctors, social workers, volunteers, advocates, and many others inside and outside the formal healthcare system. This leads to the problems of ownership and fragmentation, leaving a patient often still overwhelmed and frustrated. I have spoken to countless patients who are rockstars and leaders in their workplace and are stumped by the simple problem of figuring out how much their prescribed medications will cost. I can relate - after all, I am a physician and have exactly the same problem!

A health navigator is often described as the healthcare version of a Sherpa, or a group of people known for their skills in mountaineering and who often guide others on treacherous expeditions.

Innovation is Happening…but It’s Been Slow So Far

I’m far from the first person to realize this gap - or opportunity - to innovate. The patient navigation landscape is young but already buzzing with companies ranging from teams of humans to full technology solutions.

Accolade, Rightway, and Grand Rounds (now Included Health) have made names for themselves by offering personalized health assistance. They focus on providing individualized support to patients, helping them navigate treatment options, understand their health benefits, and find the right providers. However, their solutions are teams of humans enabled with a thin layer of technology for note-taking and basic population segmentation, meaning their services scale linearly with their hires.

TailorMed specializes in addressing the financial side of healthcare, which makes sense because finances are the #1 barrier for most patients. Castlight Health - the original healthtech IPO and darling - started out tackling pricing transparency as well. (Sadly, after over a decade I’m not convinced we’ve even come close to solving the financial toxicity despite all efforts.)

Levey, N. (2022, July 9). In America, Cancer Patients Endure Debt on Top of Disease. KFF Health News. https://kffhealthnews.org/news/article/in-america-cancer-patients-endure-debt-on-top-of-disease/

Virgin Pulse and Healthee emphasize wellness and preventive care alongside navigation. They integrate tools and resources for maintaining health and preventing illness into their navigation platforms, highlighting the trend towards a more holistic approach to patient health.

Besides these and other companies dedicated to health navigation, there are patient advocacy groups providing some of the best, unbiased, and free information to support patients. To highlight a few, TriageCancer focuses on legal and financial navigation for people with cancer, and NeedyMeds offers support for anyone needing help to pay for their medications.

Health navigation and advocacy are game-changers in patient care and innovative organizations are making strides with diverse approaches. Navigation mirrors roles like marketing, sales, and customer success in other industries, yet they stand apart in healthcare’s complex landscape. The sector’s unique challenges demand a dedicated, specialized approach, highlighting the critical need for healthcare-specific solutions. It’s time that every healthcare organization dedicates just as much to health navigation as they do toward radio ads (they still exist!) and highway billboards.

Not Just the Right Thing To Do

Investing in patient navigation isn’t just beneficial for healthcare outcomes; it also helps the bottom line. Truly. This approach offers tangible advantages for the healthcare industry:

Cost Reduction through Efficient Care: Let’s start with the overly obvious one. Effective patient navigation can significantly cut healthcare costs by reducing unnecessary hospital readmissions and emergency room visits, and saving on average $781.29 per navigated patient (JAMA Oncology 2017). Efficient coordination and streamlined care pathways mean fewer resources are expended on avoidable treatments, translating to savings for healthcare providers and insurers.

Boosting Patient Satisfaction and Retention: Patient satisfaction is a key differentiator that matters not just for the dreaded CAHPS scores, but also for adherence to treatment plans (pay attention here, health systems and pharma companies). A seamless navigation experience also enhances patient loyalty, driving retention and improving the provider’s market reputation.

Adapting to Policy and Reimbursement Shifts: With healthcare moving towards value-based care models, patient navigation aligns well with the focus on patient outcomes and satisfaction, potentially influencing reimbursement rates and financial incentives. Also, there is a new set of CMS billing codes for navigation coming soon in 2024! That’s right — effective January 1, 2024, healthcare providers can HCPCS codes G0023 and G0024 for Medicare payment of Principal Illness Navigation (PIN) services. (Other payers, outside of Medicare, will likely adopt similar reimbursement plans at a later date.)

Expanding Patient Access and Diversity: Navigation services can attract a broader patient base by making healthcare more accessible and less daunting, particularly for those who might be overwhelmed by the complexity of the healthcare system. One study showed that adding navigation increased cancer screening percentage of Hispanic and African American patients by over 200%! This is important for health equity, obviously, but also for adhering to requirements for diversity in clinical drug trials and similar initiatives.

Data-Driven Insights for Strategic Decisions: Data has been and always will be a treasure trove for any healthcare organization. One estimate noted that healthcare generates 30% of the world’s data volume! Digital patient navigation platforms offer valuable data, providing insights that can inform healthcare organizations’ strategic planning, service optimization, and identification of improvement areas. In other words, Data = $$$$.

Navigating to Brighter Horizons

Efficient patient navigation isn’t a luxury; it’s a lifeline. It’s about transforming healthcare from a bewildering puzzle into a navigable journey. The evolving landscape highlights a clear trend: a shift towards holistic, patient-empowered healthcare, where effective navigation and advocacy are central to every patient’s journey.

The real game changer? The upcoming 2024 CMS billing codes for navigation. This isn’t just a policy update; it’s a seismic shift, aligning healthcare’s financial incentives with the actual needs of patients.

The business logic behind patient navigation is compelling and straightforward. It slashes unnecessary costs, ramps up patient satisfaction, adapts seamlessly to evolving policies, and broadens access to care. It’s a strategy that not only pays off financially but also paves the way for a more inclusive and intelligent healthcare system.

The trick is to make activation and implementation of navigation more reliable, scalable, and effective. We have seen the first generation of innovative companies to attempt digitization of healthcare navigation. However, existing solutions still mainly rely on human labor to tackle the complexity of the healthcare system. We have reached a technological era where we can now augment humans with a digital system as comprehensive and helpful as the GPS in our phones.

For more on that topic, stay tuned…


Dr. Hillary Lin is a Stanford-trained physician and Co-Founder and CEO of Curio, an AI-augmented navigation platform dedicated to improving health equity and empowerment. With a deep-rooted passion for marrying technological advancement with compassionate care, Dr. Lin’s mission is to revolutionize the healthcare landscape by making it more personalized, efficient, and accessible.

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