Today, four condition categories — cancer, musculoskeletal, cardiology and kidney — drive a quarter of all health care spending, accounting for $455 billion annually.1 A large majority of employers (87%) are concerned with costs related to these conditions.2
Likewise, these conditions are overwhelming for individuals and their families. They don’t understand what their insurance covers or where to go for treatment, especially within the first six months of receiving their diagnosis.
Complex, costly conditions and related needs are complicated and profound, and employers are responding by adopting more nuanced strategies. By leveraging advocacy services and working with Centers of Excellence (COEs), employers can help better guide their employees through the health care system.
Advocacy services help people access their benefits, understand their treatment options and find the services they need, including network providers. Oftentimes, this means referring them to a COE.
COEs are those organizations that have been shown to have:
- High-quality providers
- Less likelihood of complications
- Better patient recovery and stronger outcomes
- Bundled payments for certain procedures
- Greater cost transparency to benefit plan sponsors
- Better patient experience and satisfaction
COE providers have strong, demonstrated outcomes for specific high-cost, high-risk surgeries and conditions, such as hip and knee replacements or cardiac care. In most cases, these COEs focus on cardiology, radiology, oncology and musculoskeletal conditions.
How to identify a COE
Ultimately, employers want to help their employees answer the question, “Where should I go for the best quality of care at the most appropriate price?”
To determine a COE, Optum looks at the variation of care, quality and cost. Through sophisticated analytics, we identify those centers, health systems and providers that are considered the best and provide high-quality care. We then contract with them and try to direct people to those centers.
We want people to go to the doctor who has decades of experience in performing successful knee replacements over the doctor who is new to them.
We want people to get the best possible treatment at the lowest possible price.
We want people in and out without complications.
COEs can help ensure that success.
Achieving the quadruple aim with COEs
As with advocacy, the success of COEs can be measured by considering the quadruple aim of cost, quality, member experience and provider experience. Consider the following questions.
Cost: Did the COE use a bundled payment plan to better manage the cost of treatment? Was there greater cost transparency?
Quality: Did the individual experience any complications? How was their recovery?
Member experience: Would they recommend the COE to others facing a similar condition? Would the individual recommend the provider who helped them?
Provider experience: Did the provider have a successful experience with the patient?
COEs today and in the future
An Optum study, “Ten Years of Health and Well-being at Work,” includes responses from more than 500 U.S.-based employers, related to workplace well-being. This research features a section on COEs.
We learned that COEs have gained remarkable traction as a strategy to provide better outcomes and address the high costs associated with complex, costly conditions. Over the past two years, employer use of COEs has grown from 45% to 78%.3
Moving forward, the challenge with COEs is both operational and cultural. By navigating metrics and the payment structure, providers can channel individuals and their families to these services via communication, benefit design and strong referrals. On the cultural side, providers need to shift their mindset to quality and outcomes orientation rather than driving revenue through billing for multiple services.
How you can help your employees avoid complex, costly conditions
While not every complex, costly condition is 100% preventable, there’s a lot we can do to decrease the likelihood of getting one. The following are things people can do across the board to better avoid these sometimes devastating conditions:
- Maintain a healthy diet
- Exercise regularly
- Manage weight within a healthy range
- Manage stress
- Get enough sleep
- Get proper health screenings, such as a mammography for breast cancer or blood pressure check for heart disease
- Quit smoking
Consider utilizing a COE to help your employees get the best possible care for complex, costly conditions. Visit optum.com to learn more.
To learn about other well-being at work topics, including behavioral health, women’s health and complex, costly conditions, download the e-book.
About the Author
Seth Serxner, PhD, MPH
Chief Health Officer, Optum
Seth Serxner, a national expert on behavior change, program design and measurement, brings the breadth of his experience in academia, industry and consulting to his role as chief health officer at Optum.
His versatile skill set ensures processes and outcomes that improve health for clients in all markets. His deep knowledge of behavior change, population health and measurement allows him to visualize and deliver on program innovation.
He is a published author with over 25 years of experience in health and productivity management. He holds a master’s in public health and a doctorate from the University of California, where his research focused on health promotion and disease prevention in social ecology.
1. Optum. “Complex, costly conditions” white paper. 2019.
2. Optum. “Ten Years of Health and Well-Being at Work” e-book. 2019.
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