“We’d been looking for the right person for about a year,” recalls Tommy White, LIUNA Local Union 872’s Business Manager, reflecting on how the union’s health and welfare fund came to hire its Patient Advocate. “Meanwhile, the fund’s total program costs were topping one million dollars a month, and it was iffy from month to month.”

“The data showed that 80 percent of the fund’s costs were associated with only 20 percent of its participants,” says Health Strategies President Patricia Allen, who serves as the fund’s consultant. “We needed to find an intervention that would keep participants from sliding into that group. We tried health newsletters and the phone, but that wasn’t working. That’s when Tommy said, ‘We need our own person.’”

In December, 2006, White made the move, hiring Doug Twilligear, a registered nurse who had been a Laborer before he left construction for nursing school. “We were pretty sure we’d see results,” says White, “but Doug did a lot more than we expected.” In his first full year on the job (2007), total payouts declined by more than $700,000, a savings of just over $58,000 per month. In comparison, the monthly cost of the PA program is less than $13,000.

Those savings are dramatic and show the cost benefits of including more direct patient support in the union’s health care program. According to White and Twilligear, the Patient Advocate is part medical professional, part investigator, part educator and part coach. Basically, Twilligear’s job is to help the local’s membership and their families get healthy, stay healthy and, if sick or injured, get better as quickly as possible.

His cell phone should be attached to his ear because it is ringing all the time. “I want the members to call me, anytime,” says Twilligear. “My job is to help them solve their health problems. If they’ve got a question or concern, I need to know about it.”

Patient Advocate Doug Twilligear


Twilligear is constantly on the go, driving across Las Vegas from the fund’s offices to a home visit with a diabetic member, to the union’s training center to speak to an apprenticeship class, to a hospital where a member’s daughter is recovering from surgery, to the local’s new, free, convenient care clinic and back to his office where he teaches an evening class on nutrition.  He constantly preaches wellness and urges members to take more responsibility for their health.

At the same time, he monitors their health. For Twilligear, the participant base divides into three large groups. “About 20 percent are our youngest, healthiest members. They are having babies and rearing families. This group needs only gentle persuasion and guidance to embrace a healthier lifestyle.” Another 20 percent are chronically ill and the most expensive participants. “They are very sick and, in all likelihood, will never get well. Education, in and out of the hospital and at home, case management, securing timely medications and an attitude of caring and going the extra mile is all that can be done for them.”

His greatest challenge is the remaining 60 percent. “They’re not now sick, but without attention, many will slip into the chronically ill category.” This group has established lifestyle habits that are difficult to break. It needs education and other services in every aspect of health. “If we can keep this group healthy, our future is assured. If not, our fund will not be able to keep up with ever-rising costs.”

Keeping the membership focused on health and wellness is a constant battle. Twilligear relies upon health classes, regular presentations at local union meetings, a participant newsletter, picnics and health fairs. He is able to direct more focused attention to PPO participants, due to a daily census from all area hospitals and a utilization print-out from the PPO network providers. “Knowing our membership more intimately has created a trusting relationship that our members count on. I think they are empowered when they have someone to help them navigate their health plan and their care decisions. They know help is just a phone call away.”

In contrast to the PPO, the HMO will not share individual medical records with the Patient Advocate, so Twilligear must get word from the family or a business agent when someone is sick. “Every day, I consult the PPO database and make an assessment as to if, when and how I should intervene. Every situation is unique.” Services provided through the HMO are set by the HMO, but the fund itself controls the benefit plan of the PPO. A variety of better-focused benefits – including a podiatry program with free orthotics and a diabetic program with free strips and syringes – has encouraged 300 participants to switch to the PPO during the last year. “We expect the free services for PPO members at the new clinic to accelerate this trend,” says Twilligear.

A comparison of 2007 and 2008 data indicates that the Patient Advocate position makes a difference. During the interval, local union membership increased by more than 300, but inpatient admissions per 1000 lives increased only slightly (two percent). Meanwhile, inpatient days declined 22.6 percent, and the average length of stay dropped from 5.17 to 3.92 days. Twilligear’s early interventions with members also led to increases in outpatient procedures (38.6 percent) and surgeries (22.7 percent). According to Twilligear, “Those outpatient interventions addressed problems that, in many cases, would have eventually turned into hospital admissions.”

Twilligear points out that there is no way to measure the additional savings that were realized because members never went to the hospital in the first place. “When I started,” Twilligear says, “I talked to 40 participants who had heart problems, but only 16 were under the care of a cardiologist.” He brought the rest under cardiological care, likely saving the cost of catastrophic care avoided by the more specialized monitoring of these seriously ill individuals. “You only have to avoid one serious heart attack to save the cost of Doug’s salary,” says White.

Asked whether Las Vegas has exceptional characteristics that enable the Patient Advocate position to show such a positive return, Allen, the consultant, says that while every situation is unique, each should be assessed on its own merits. “An alternative to hiring a Patient Advocate is for the utilization review group to assign a local nurse to follow up on cases or to hire a full-time vendor to provide Patient Advocate-type services.”

White acknowledges that Twilligear, as a former Laborer, is ideal for the Patient Advocate position. “He has the right personality, and he understands our work. We’re fortunate, but another fund could also find the right person for the job,” he explains. “For instance, a member’s spouse, who is a nurse, might be ideal.

“Whoever is selected,” he continues, “has got to report regularly to the members to let them know what’s going on with the health and welfare fund.” He says he or Twilligear reports to the membership at every union meeting.

Through the Patient Advocate program, the Local 872 health and welfare fund maintains close, personal touch with every participant who endures serious illness. “It provides something that all our newsletters and mail-outs just can’t do,” says Bonnie Payson, the fund’s administrator.  “Here, there’s a feeling of family in the union, and Doug has a lot to do with that.”

[Steve Clark]