COE As The Path To Value – ONEcare Population Health Academy

Payers and health plans are looking for increased “value” from provider organizations—but the parameters that define that “value” are changing. Their focus is increasingly shifting to reducing re-hospitalization and unnecessary use of emergency rooms, low total cost of care per member, HEDIS and CMS Stars scores, and consumer satisfaction and member retention (see It’s About The Customer…).

But success with these new value measures is more than a generic “one-size-fits-all” approach. Five percent of the population accounts for nearly half of all health care spending in any given year and 50% of the population accounts for only 3% (see How Do Health Expenditures Vary Across Population). Among the 5% of consumers using most of the resources are a high prevalence of chronic health conditions like stroke, emphysema or asthma, diabetes, high blood pressure, and high cholesterol—and even more highly concentrated in consumers with more than one chronic condition. And if you look at the consumers with any chronic health condition along with behavioral health and cognitive conditions, the spending numbers jump. Add to that, the fact that consumers in need of social support have even greater resource needs (see What, When & How To Share Data – Innovating For Social Needs & Population Health Strategies and Total Health Care Costs Twice As High For Commercially Insured Consumers With Behavioral Health Conditions).

Given this bimodal health care utilization landscape, the question for specialty provider organization executive teams is how to position their services in a way that provides the “value” that health plans are seeking. For the 50% of the population with relatively low utilization, retail clinic organizations and digital first provider organizations have made significant investments in low cost, fast access, service delivery models (see The Retail Health Effect). But because most health care resources are used by consumers with more serious illnesses and complex management needs, there are many opportunities to provide care coordination, health management, and treatment programs for specific complex consumer populations.

While there are many models for bringing these specialized services to the market, one that is gaining traction is the center of excellence (COE) approach. From a health plan perspective, COEs are health care programs that provide clinically superior, cost-effective health care for a specific type of consumer (see Centers Of Excellence Networks). These programs are considered to provide “high value,” with good performance on both quality and cost, and are often compensated using some value-based model. COEs are being developed for a wide number of acute or complex conditions like orthopedics (see Norton Healthcare Named Country’s First Advanced Orthopedic And Spine Center Of Excellence), kidney disease (see UC San Diego Named Health Center Of Excellence For Polycystic Kidney Disease), and skin cancer (see Center Of Excellence For Mohs Surgery Is Now In-Network For AETNA-CVS ACA Individual Marketplace Plans).

The opportunities and challenges of establishing a COE were the focus of the December 15 Circle Elite Executive Roundtable, Center Of Excellence In Addiction Treatment — The Hazelden Betty Ford Foundation Case Study, featuring Kim Albers, Director of Recovery Management, and Jennifer Duncan-Sanford, National and Strategic Account Director, from the Hazelden Betty Ford Foundation. Hazelden Betty Ford is a $187 million, multi-modal provider of addiction treatment, mental health care, education, prevention and support services. Their treatment program models range from residential and outpatient treatment programs, aftercare services, and sober living options for women and men, serving approximately 25,000 consumers annually at 15 locations and online across eight states. Hazelden betty Ford currently has more than 60 health plan contracts across the country, including relationships with Optum, Cigna, Aetna, and Blue Cross Blue Shield. And, 10 of these contracts are based on a value-based or COE model.

In the session, Ms. Albers and Ms. Duncan-Sanford reviewed the new data on the performance of addiction treatment COE initiatives. From a performance perspective, recent health plan claims studies have found that COE programs cost 19% less than the average in-network provider treatment programs—and have a readmission rate that is 22% lower.

They also discussed some of the differentiating factors of the Hazelden Betty Ford approach to addiction treatment COE models. One key differentiator is their Connection® recovery coaching and monitoring program, designed for consumers who are in early recovery or recently discharged from an addiction treatment program. The model is based on one-on-one coaching for the consumer, as well as the consumer’s family—and includes substance use monitoring and care coordination. While service duration varies based on clinical appropriateness, average length of engagement in the program is 11 to 12 months. (While included as part of their COE model, the Connection® program is available on a direct-to-consumer basis and through health plans—either on a case rate or fee-for-service basis.)

For executives of specialty provider organizations considering developing their own COE initiatives, the speakers had some advice. One recommendation was to focus on consumer engagement. Successful programs will combine evidence-based practices with best-in-practice clinical professionals—with a ‘whole person’ approach that offers opportunities for consumers to stay highly engaged. Ms. Duncan-Sanford emphasized that engagement in care is especially important with chronic health conditions such as SUD because symptoms often return. She said it’s important to remember that the user experience is everything—that consumers engage in care they trust, and establishing trust is a key part of providing a good user experience.

Ms. Albers highlighted the importance of a positive brand reputation in building a successful COE. She noted that American consumers’ trust in institutions such as government and large industries, including health care, has eroded dramatically over the past decade. Her take is that partnerships between trusted entities and known brands enhance the value and validity of both organizations and provide a foundation for good user experiences and successful outcomes.

For more information on COEs, as well as the latest in SUD treatment, check out these resources in the OPEN MINDS Industry Library:

For even more on innovative approaches to addiction treatment, join us in New Orleans on June 15 at The OPEN MINDS 2023 Strategy & Innovation Institute for the session, “Innovation In Substance Use & Suicide Prevention – The Elevance Health Approach”, featuring David Lederman, Senior Product Manager at Anthem/Elevance.