Advocate Spotlight - Clara Lambert
1.) What brought you down your current career path?
This is actually a bit of a long story. But I have to start at the beginning so you know where I come from. When my husband and I were 32, he was diagnosed with Non-hodgkin's Lymphoma. We had 3 kids between the ages of 5 and 12, it was actually my youngest son’s first day of kindergarten when Joe had his biopsy. Right after he started his treatment, I lost my job because my boss’s wife decided she wanted to come back to work, and Joe wasn’t feeling well enough on chemo to work a full week. We were really financially struggling. Then to top it all off, his treatment crossed over into the next benefit year. So we got the double whammy of meeting our Out of Pocket Max twice. In my time off, I was juggling taking care of 3 kids, a sick husband, job hunting, and researching to find any help I could find. I found a handful of things, and my kids actually had a pretty decent Christmas.
“In my time off, I was juggling taking care of 3 kids, a sick husband, job hunting, and researching to find any help I could find.”
I remember sitting beside Joe while he was getting his treatment one day feeling proud of myself, hoping that I could find a way one day to help others the way that i helped our family. A few months later, I got my first job working in our hospital's Emergency Department, registering patients. It was a step by step process from there. It took me 10 years, and really I had almost forgotten about that little wish until I talked to an MS patient who was super frustrated about a bill on the phone. Then it all came flooding back to me. A few weeks later, the manager of our Social Work department called me to tell me about a job opening she thought I would be great at, and I think you all know the rest.
2.) What do you think is the most frustrating aspect of health care that patients are facing today? What has changed over the last 50 years or so?
Oh wow! My first reaction to this question is Health Insurance! So, that is going to be my answer. Health Insurance has changed so much from when it first came to be. Just in my time working in healthcare it has changed. I am talking about from the patient perspective.
First, I have found that more and more people truly do not understand how their coverage works for them, and it is getting more and more complicated in the oncology and chronic/rare disease world when some treatments are being paid for out of medical benefits and some treatments are paid for out of pharmacy benefits.
Second, I am finding they don’t know what plans to pick. Many times they just select the plan that costs the least amount per month. Not realizing how much more it might cost when they factor in the cost of treatment. There are also too many bad choices out there, like short term plans.
Third, the authorizations, appeals, and denials. This is something that really slows down the treatment path for the patients. I have seen that commercial insurance and Medicare advantage plans actually have higher denial rates than traditional Medicare. So this tells me that this is something significant that is evolving.
3.) As patient advocates, what can we be doing to ensure a better experience for the patient across the board?
Since we have been talking about insurance, I am going to say that one of the first things we need to do is to help our patients understand their current coverage. Then also help them to optimize their coverage. So, if something is available to them right now that they can get into that will lower their out of pocket costs, help them enroll. If they have better options at the next enrollment, counsel them. You can do this in an encouraging way. They didn’t make a mistake if they didn’t know better. You can help them know more and make better decisions to help themselves.
Next, they have a lot on their plates. Remember my story? I was job hunting, I was raising a family, I was caring for a sick spouse, I was doing a lot. I found a lot for my family, but looking back, I really didn’t do that well as a financial navigator. There were some major things I did not find that would have really helped my family a lot, and I am still paying for that today. I found things to help with our living expenses and to get our kids Christmas presents. But, I had not worked in healthcare and I really did not know much about the copay programs. All I knew was that I couldn’t pay my hospital bills. We applied for Medicaid, and even though I wasn’t working, Joe was working just enough to take us over the Federal Poverty Level, and we both had some money in 401Ks. The kids were put on Medicaid, but that did not help with Joe’s chemo and radiation bills. I called the hospital and asked for help. A really nice financial counselor gave me a 5 page application to fill out for the hospital financial assistance program, they also needed bank statements and tax returns and pay stubs and lots of paperwork. It was daunting! Remember - I was overwhelmed with everything else in my life? The reason I say that - Help your patients. Help them fill out those applications, help them gather all those documents they need. Be their go to person. I have heard places say that the patient needs to have some skin in the game. They do, believe me, they do, they have a lot of skin in the game. It is OK to facilitate these applications, it is OK to do some hand holding.
“During this study we assisted 74% of the patients we reviewed, with over $3.5 million in approved savings and $1.5 million in community benefit.”
4.) How can HIT innovations ensure patients get the medication they need?
HIT innovations are amazing. When I started as a Financial Navigator in 2013. We were pulling information out of our EMRs(notice the plural on EMRs), schedules, accounting software, insurance verification, and several other places. It took us several hours every afternoon just to plan for the next day. We had an Excel spreadsheet with about 14 tabs to track everything. Don’t get me wrong, that spreadsheet was amazing. I got it from my mentor, and I adjusted it and optimized it to make it my own. The thing is, we were tracking in the spreadsheet, we were putting notes in the EMR, we were putting notes in the accounting software. So we were double/triple documenting. Essentially we were wasting a lot of time. I knew there had to be a way. But I was so busy getting the info to do my job, doing my job, and tracking my job. Some of my degree is in Computer Information Systems, and I didn’t even have the time to put into figuring out how to solve this situation. Then I met Srulik Dvorsky, and he shared his idea of TailorMed with me.
I had the opportunity to pilot the program for 8 months. During this study we assisted 74% of the patients we reviewed, with over $3.5 million in approved savings and $1.5 million in community benefit. Our revenue increased over $250,000. But those are just numbers. TailorMed was getting all the info we needed for us. We came in to work in the morning and our worklist was ready for us. The patient list was there, the insurance benefits were verified, there were out of pocket estimates, including travel and missed work, and there were valid suggestions. We got back probably between 2-4 hours of the day, which meant we could work with almost double the patients we had been able to work with, or we could work on special projects and studies to further financial navigation. At first it was almost exhausting, but it was also exhilarating.
The medication world is changing, there are regular FDA approvals of new drugs, there are biosimilars, there is a lot going on with how insurances are paying for the medications. I think with HIT innovations, it will be a lot easier for a navigator to keep up. HIT innovations are able to scrub the internet and find things before a human can. Most of the time humans are reactive rather than proactive, and in Financial Navigation it is truly of a benefit to be proactive. If we can help prevent the dangerous side effects of a patient stopping treatment because they cannot pay for it by proactively working with them because of a HIT innovation, then we have succeeded.
Clara Lambert
TailorMed
Director of Financial Navigator, Former Advocate Good Samaritan Hospital - Bhorade Cancer Center