The Healthcare Navigation Challenge: Helping Employees Find the Right Care

Employers invest heavily in healthcare benefits, but those benefits create the most value when employees know where to start, which resources to use, and how to find the right care at the right time.

Healthcare Has a Navigation Problem

Employers invest significantly in healthcare benefits designed to improve access, support employee health, and manage long-term costs. But offering strong benefits is only part of the equation. Those benefits create the most value when employees understand how and when to use them.

Today, employees are expected to navigate provider networks, referral requirements, care settings, costs, coverage, and an increasingly complex mix of healthcare resources, often while they’re sick, concerned about a family member, or trying to make a decision quickly. Even with a robust benefits package, figuring out where to start can be difficult.

The challenge becomes even greater once multiple providers are involved. The Centers for Medicare & Medicaid Services (CMS) notes that fragmented care can contribute to unnecessary repeat testing, conflicting treatment plans, increased emergency care, medication errors, and poor transitions between healthcare settings.

Without clear direction, employees may seek care in a higher-cost setting than necessary, bypass primary care for specialty services, delay treatment because they aren’t sure where to go, or move between disconnected providers with little coordination. The result can be a frustrating employee experience and healthcare spending that doesn’t deliver the value employers intended.

That’s where healthcare navigation becomes an important part of a benefits strategy. By helping employees understand where to start, which resources fit their needs, and what should happen next, employers can make healthcare easier to use while encouraging more appropriate utilization of the benefits they’re already funding.

The goal isn’t simply lower-cost care. It’s helping employees get the right care, in the right setting, at the right time.

More Healthcare Options Can Mean More Confusion

Depending on their benefits, today’s employees may have access to traditional primary care, employer-sponsored health centers, virtual care, retail clinics, urgent care centers, emergency departments, nurse lines, specialists, behavioral health services, and other healthcare resources.

These alternatives are widely used. According to the CDC’s National Center for Health Statistics, 27.6% of Americans used an urgent care center at least once in 2024, while 19% used a retail health clinic. Among adults ages 18–64, those percentages were 28.9% and 20.1%, respectively.

Having options is valuable. Understanding those options is another matter. An employee experiencing a new health concern may have to determine whether it can wait for primary care, whether virtual care is appropriate, whether they need urgent treatment, or whether their symptoms warrant emergency care. If testing or specialty services are recommended, another series of questions begins: Where should they go? Is the provider in-network? Is there a more cost-effective option? Is a referral required? Who schedules it?

For employers, this creates an important distinction: Access to healthcare resources isn’t the same as access to understandable healthcare. A strong navigation strategy helps bridge that gap.

Choosing the Wrong Door Can Have Real Consequences

Healthcare navigation shouldn’t be viewed simply as a strategy for directing employees toward the least expensive option. Sometimes urgent care is appropriate. Sometimes a specialist is necessary. And when someone is experiencing a potentially life-threatening emergency, the emergency department is exactly where they belong. The objective is appropriate utilization.

Emergency care remains a significant component of healthcare utilization. The CDC’s National Center for Health Statistics reported approximately 155 million emergency department visits in the United States in 2022, equivalent to about 47 visits per 100 people. Problems arise when employees use a higher level of care because they don’t know another option exists, or when they enter a fragmented pathway that results in unnecessary referrals, duplicated testing, repeated appointments, or delayed treatment.

Where a service is performed can also have a significant effect on what it costs. The nonprofit Health Care Cost Institute (HCCI) examined 57 services that could be provided in either hospital outpatient departments or physician offices for people with employer-sponsored insurance. In 2022, every service studied was more expensive in the hospital outpatient setting, with prices ranging from 1.27 to 13.5 times those in physician offices. That doesn’t mean the lower-cost setting is always the clinically appropriate choice. It demonstrates why knowing the options matters.

Each healthcare decision may seem small in isolation. Across an employee population, those decisions can influence healthcare utilization, employee out-of-pocket expenses, and overall health plan spending. Better navigation helps employees make those decisions with more information.

Primary Care Should Be the Front Door

For many non-emergency healthcare needs, primary care provides employees with a logical place to start. The National Academy describes high-quality primary care as whole-person, integrated, accessible care delivered through sustained relationships. It also positions primary care as foundational to improving population health, patient experience, and healthcare costs. A primary care provider can evaluate symptoms, consider a patient’s medical history, provide treatment, order appropriate testing, manage medications, monitor chronic conditions, and determine when additional expertise is necessary.

That makes primary care more than another care setting. It can serve as the hub that connects the rest of the healthcare journey. Consider an employee experiencing persistent knee pain. Without guidance, that employee might schedule directly with an orthopedic specialist, visit urgent care, or simply continue living with discomfort. Starting with primary care creates another pathway. The provider can evaluate the problem, determine whether conservative treatment is appropriate, order imaging if necessary, recommend physical therapy, or coordinate specialty care when the condition warrants it.

Not every rash requires a dermatologist. Not every headache requires a neurologist. Not every musculoskeletal concern requires an orthopedic specialist. But some do. The value of primary care is having someone who can help determine the difference. When employees establish an ongoing relationship with a primary care team, those decisions can also be made with knowledge of previous diagnoses, medications, test results, family history, and changes over time rather than treating every concern as an isolated event.

Help Employees Understand Where to Go

Employers don’t need employees to become healthcare experts. They need to make the basic pathways easy to understand.

Primary Care / Employer Health Center

For many non-emergency concerns, start here. Primary care can address preventive care, annual physicals, common illnesses, minor injuries, new or persistent symptoms, chronic disease management, medication questions, routine laboratory testing, and follow-up care. It can also determine whether another level of care is necessary.

Virtual Care

Virtual appointments can provide convenient access for appropriate non-emergency concerns, questions, follow-up conversations, and situations where a physical examination or onsite testing may not be necessary. Whenever possible, virtual care should remain connected to the patient’s broader medical record rather than becoming another isolated encounter.

Urgent Care

Urgent care can be appropriate for concerns requiring prompt attention that aren’t life-threatening, particularly when primary care isn’t available. The goal should be for urgent care to supplement primary care rather than replace it for needs that benefit from continuity and ongoing management.

Emergency Department

Emergency departments are designed for serious or potentially life-threatening conditions requiring immediate evaluation and resources unavailable in other settings. Employees should never delay emergency treatment because of concerns about cost or uncertainty about their benefits. Navigation should make the distinction between emergency and non-emergency care clearer, not create another barrier when emergency treatment is necessary.

Specialty Care

Specialists provide essential expertise when a condition requires evaluation or treatment beyond primary care. Whenever possible, specialty care should be coordinated with primary care so referrals are appropriate, relevant medical information follows the patient, results return to the primary care team, and someone continues looking at the patient’s health as a whole.

Navigation Doesn’t End When a Referral Is Made

Choosing the appropriate care setting is only the beginning. Once additional services are recommended, patients can face an entirely new set of decisions involving specialists, imaging centers, physical therapy, diagnostic testing, and other healthcare facilities.

The Agency for Healthcare Research and Quality (AHRQ) recommends making referrals easier for patients, including helping with appointments and ensuring information flows between primary care and the clinicians receiving the referral. AHRQ notes that making the referral process easier can increase the likelihood that patients follow through.

Simply telling a patient, “You need an MRI,” doesn’t answer where that MRI should happen. Likewise, saying, “You should see a specialist,” doesn’t help an employee determine which specialist is appropriate, whether that provider participates in the health plan, how quickly they can be seen, or whether another pathway might be available.

And communication doesn’t always happen seamlessly once outside care begins. A Commonwealth Fund analysis found that fewer than four in 10 U.S. primary care physicians surveyed reported adequate coordination with specialists and hospitals regarding changes to their patients’ care. Effective navigation continues through these transitions. A care team can help employees understand their next steps, identify appropriate providers and facilities, coordinate referrals, assist with scheduling, and make sure results return to the patient’s medical record.

Sometimes, specialty expertise may even be available without immediately sending the patient to another office. Secure consultation partnerships can allow primary care providers to obtain guidance from specialists on complex cases, helping confirm treatment approaches or determine whether an in-person referral is necessary. When primary care can safely continue managing the condition, the patient may avoid another appointment. When specialty care is needed, the referral becomes more purposeful. This is where navigation and care coordination begin to overlap.

Location Matters

Where a service is performed can produce striking price differences. HCCI’s analysis found that in 2022, Level 1 imaging without contrast averaged $227 in hospital outpatient departments compared with $61 in physician offices, a 3.7-times difference. Across the imaging categories studied, hospital outpatient prices were between 2.62 and 3.7 times physician-office prices. The pattern extends beyond imaging. Another HCCI analysis examining facility fees and healthcare prices found that the median price of a laboratory test in a hospital outpatient department was more than 3.5 times the price at an independent laboratory and 3.3 times the price in a physician office.

These differences are especially relevant for employers funding health benefits. HCCI’s Health Care Cost and Utilization Report shows that hospital inpatient and outpatient services account for more than half of per-person spending among people with employer-sponsored insurance. Yet simply making price information available doesn’t eliminate the navigation challenge.

The U.S. Government Accountability Office (GAO) has previously identified several factors that make it difficult for consumers to obtain meaningful healthcare price information, including complex billing, multiple providers contributing to a single episode of care, and variations in insurance benefits.

Employees need context. Is this service necessary? → Where can it appropriately be performed? → Which options work with the employee’s benefits? → What are the quality, access, and cost considerations? Instead of simply telling employees to “shop around,” employers can give them access to people and resources that help identify appropriate options based on clinical needs and available benefits. That’s an opportunity to address unnecessary healthcare spending before the service occurs.

Better Benefits Need Better Directions

Adding another healthcare resource isn’t always the answer. Sometimes the bigger opportunity is making existing resources easier to understand and use. Employers can start by creating a clear “start here” message. When an employee needs healthcare, they shouldn’t have to dig through an enrollment guide or remember a presentation they attended months earlier to determine what to do.

Benefits education should also continue throughout the year. Open enrollment may introduce employees to their options, but healthcare decisions happen every day. Regular reminders about primary care, virtual care, navigation resources, preventive services, and other benefits can keep those resources familiar when employees actually need them.

Communication should also be practical. “Where should I go if…?” is often easier to understand and remember than lengthy descriptions of plan features. Employers can strengthen navigation by:

• Establishing a clear first point of contact for healthcare questions.
• Educating employees about when to use primary, virtual, urgent, emergency, and specialty care.
• Communicating healthcare resources throughout the year.
• Using real-world examples to explain benefits.
• Helping employees identify quality, in-network, and cost-effective services.
• Providing human navigation support for complicated healthcare journeys.
• Reviewing utilization patterns to identify opportunities for better education and navigation.

Most importantly, navigation should include access to human support. Digital tools, provider directories, and price-transparency platforms can provide useful information, but employees are still left to interpret that information and decide what to do with it. A knowledgeable care team can turn information into action.

A New “Where to Go” Resource for WeCare tlc Clients

Making healthcare navigation easier also means giving employees something they can reference before they need care. WeCare tlc has developed a “Where to Go” pathway graphic designed to help patients quickly understand which care setting may be appropriate for different healthcare needs. It reinforces the health center as a convenient starting point for many non-emergency concerns while helping distinguish when virtual, urgent, or emergency care may be appropriate.

The goal is simple: make healthcare navigation visual, approachable, and easier to remember. WeCare tlc clients can access the “Where to Go” pathway through their patient microsite or contact their Client Services representative for a copy. Employers can incorporate the resource into benefits communications, onboarding, employee education, digital resources, and year-round outreach to continually reinforce appropriate care pathways.

Turning the Health Center Into a Healthcare Navigation Hub

At WeCare tlc, we believe an employer-sponsored health center can do much more than provide convenient primary care. It can become an employee’s home base for navigating healthcare.

Our onsite, near-site, shared-site, and virtual care models give eligible employees and dependents easier access to a primary care team that can evaluate concerns, provide treatment, monitor ongoing health needs, and help determine what should happen next. When outside care is necessary, that relationship doesn’t end.

Care navigators and RN health coaches can help patients understand next steps and coordinate outside services. Referrals can be directed toward quality providers that align with the client’s health plan or other available arrangements. Relationships with community providers can also help improve access and affordability for services such as imaging, physical therapy, musculoskeletal care, and sleep studies. WeCare tlc can work directly with employers and their consultants to identify additional community partners that support the needs of their specific workforce and health plan.

Our care model can also provide clinicians with access to secure specialist consultation support. Primary care providers can obtain specialist insight on appropriate cases, refine treatment plans, and determine whether an outside referral is necessary. When specialty care is required, patients move forward with a clearer clinical pathway. When it isn’t, care may be able to continue within primary care without adding another appointment, delay, or expense.

Diagnostic findings and outside results can then be incorporated into the patient’s ongoing medical record, helping the primary care team maintain visibility into the broader healthcare journey. Importantly, WeCare tlc isn’t owned by a hospital system and doesn’t depend on downstream referrals to generate revenue. We aren’t obligated to direct patients to a particular hospital, imaging facility, or specialist simply because it belongs to an affiliated network.

That independence allows our care teams to focus on what is appropriate for the patient while also considering the client’s health plan, available benefits, quality, access, and cost. That’s an important distinction between simply providing primary care and creating a true healthcare navigation hub.

The Right Care. The Right Setting. The Right Time.

Employers have made significant investments in giving employees more ways to access healthcare. The next opportunity is helping employees make sense of those choices. Better navigation can help employees know where to start, avoid unnecessary detours, access appropriate care sooner, and remain connected as their healthcare needs become more complex.

For employers, that can mean a better employee experience, more effective use of existing benefits, stronger continuity of care, and greater opportunities to address unnecessary healthcare spending. For employees, it means something much simpler: They don’t have to figure out healthcare alone. Because sometimes the most valuable healthcare benefit isn’t another option. It’s knowing which option to use.

References

Centers for Medicare & Medicaid Services (CMS)
Care Coordination

Centers for Medicare & Medicaid Services (CMS)
Primary Care

National Academies of Sciences, Engineering, and Medicine
Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care

Centers for Disease Control and Prevention, National Center for Health Statistics (CDC/NCHS)
Urgent Care Center and Retail Health Clinic Use Among Adults: United States, 2024

Centers for Disease Control and Prevention, National Center for Health Statistics (CDC/NCHS)
Emergency Department Visit Rates by Selected Characteristics: United States, 2022

Agency for Healthcare Research and Quality (AHRQ)
Make Referrals Easy: Health Literacy Universal Precautions Toolkit

The Commonwealth Fund
Finger on the Pulse: Primary Care in U.S. and Nine Other Countries

Health Care Cost Institute (HCCI)
Trends in Utilization and Prices for Site-Neutral Services in Hospital Outpatient and Physician Office Settings

Health Care Cost Institute (HCCI)
Facility Fees: What Are They and How Do They Impact Health Care Prices?

Health Care Cost Institute (HCCI)
Health Care Cost and Utilization Reports

U.S. Government Accountability Office (GAO)
Health Care Price Transparency: Meaningful Price Information Is Difficult for Consumers to Obtain Prior to Receiving Care