The Patient Protection and Affordable Care Act (ACA),
Public Law 111-148, formalized and strengthenedthe role of patient navigators in the health care system: every state health insurance exchangeis required to establish a “navigator program” to help individuals and businesses make informed decisionsabout enrolling in healthinsurance through the exchange.
The American Medical Association believes that the primary role of a patient navigator should be to foster patient autonomy and provide patients with information that enhances their ability to make appropriate health care choices and/or receive medicalcare with an enhanced sense ofconfidence about risks, benefits and responsibilities. Patient navigators can provide patients with guidance in the health insurance marketplace, which is especially critical for patients who have low health literacy skills. As such, it is important to define the appropriate role of a patient navigator as part of a patient’s health care team— with the ultimate responsibility for patient care residing with physicians.
Patient Protection and Affordable Care Act provisions
• The ACA requires that each state health insurance exchange establisha navigator program to help individuals and businesses make informed decisions about enrollingin health insurance through the exchange (see “Health insurance exchanges” in this series).
• The ACA outlined the following responsibilities of
- Provide expertise on eligibility, enrollment and coverage details for each plan
- Provide information in a fair, accurate and impartial manner
- Facilitate the enrollment process
- Provide referrals for conflict resolutionservices for
enrolleeswith complaints orconcerns
• The ACA outlined eligible entities to serve as patient navigators, including community groups, trade or professional associations, chambers of commerce, and licensed agents or brokers. Notably, health insurers and their representatives are not eligible to participate inthe navigator program.
Organizations of patient advocates have developed ethical standards that stress that the primary role ofa patient navigator should be to foster patient autonomy, and to provide patients with information that enhances their ability to make appropriate healthcare choices, or to receive medical care with an enhanced sense of confidence about risks, benefits and responsibilities.
A patient navigator is someone whose primary responsibility is to provide personalized guidance to patients as they move through the health care system. The term patient navigator is often used interchangeably with the term “patient advocate,” and the role may be filled formally or informally
by individuals with clinical, legal, financial or administrative experience, or by someone who has personal experience facing health care-related challenges. Navigators can be employed by community groups, hospitals or insurance companies, or they may be independent consultants who offer fee-based services to people who are unwilling or unable to manage complex medical issues on their own.
Patient navigator or patient advocacy services can be categorized as having one of the following goals:
• Reducing health care disparities and increasing access to care
• Improving patient outcomes for a specific illness or chronic disease
• Helping patients effectively negotiate the complex web of administrative and clinicaldecisions associated with the health care system