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COEs Deliver Quality Care and Cost Savings for UnitedHealthcare Complex Medical Conditions Programs

August 1, 2017

UnitedHealthcare is one of the leaders in identifying Centers of Excellence (COEs) that use evidence-based, quality-of-care protocols to help deliver cost-effective care for complex medical procedures at leading treatment centers. Members who seek care from a COE may benefit from:

  • A rigorous review process and criteria
  • Deep contractual savings
  • Improved outcomes that may contribute to cost savings
  • Effective benefit design
  • Dedicated member support by specialized clinicians
  • Lower rates of readmission and post-surgical complications, than other hospitals and surgery centers

Consider these program savings from COEs:

COEs supporting UnitedHealthcare’s Complex Medical Conditions programs, include:

Bariatric Resource Services (BRS):
Our BRS COEs yield proven results at reducing the long-term personal, clinical and economic costs of obesity. UnitedHealthcare’s Bariatric COEs network have fewer complications and readmissions based on superior surgery programs with COE surgeons and centers to help minimize mortality rate, initial procedure rates, reoperation rate, readmission rate, catastrophic surgical outcomes complication cost and length of stay. The solution is also designed to provide an improved member experience, supporting care coordination, and promoting improved surgical outcomes. Dedicated nurse case managers have expertise and insights into bariatric patients and their comorbid conditions. Furthermore, the clinical team promotes lifelong behavioral and dietary changes. Consider these program results achieved at a bariatric COE:

  • 15 percent lower mortality compared to non-COE providers5
  • 16 percent lower inpatient hospital readmission5
  • 12 percent lower reoperation rate for bariatric procedures5
  • $4,239 lower average cost per surgical episode6

For additional information, review our BRS customer presentation.

Cancer Resource Services (CRS):
CRS is a network access solution available for newly diagnosed members with any kind of cancer but primarily for those with an uncommon, complex or hard to treat cancer. Cancer Nurse Consultants provide personalized support and resources to:

  • Help guide members to local community providers as appropriate
  • Help guide members to cancer COE facilities for treatment or for a medical second opinion
  • Provide travel and lodging benefits
  • Provide support and education during initial stages of care

Program results include COE savings between 35 and 45 percent off a standard billed rate.7 For additional information, review our CRS customer presentation. Also, see a map and listing of the Cancer COE Network.

Cancer Support Program (CSP):
CSP is network access and cancer case management solution available to proactively manage members in order to avoid unnecessary hospitalizations and chemotherapy treatment. Ongoing management helps ensure that evidence-based medicine is being practiced, COEs are utilized when appropriate, cost-effective and quality care setting is being utilized. Reduced use of inpatient care and emergency room visits, increased hospice utilization, disease and treatment education, treatment decision support and intensive case management help ensure improved quality-of-care and mitigation of cancer costs. Experienced nurses support members and caregivers throughout treatment, recovery or at end-of-life, helping prevent and reduce symptoms and side effects. When using health care providers that participate in COE network, payers receive:

  • National Committee for Quality Assurance (NCQA) accredited program
  • CSP participants have a 10 – 20 percent lower cost than non-participants7
  • CSP saves $29,000 more per participant vs. patients managed by a general case management team7
  • Per diem rates that save 30 – 45 percent on inpatient charges7
  • Procedure case rates for major surgical procedures in some contracts
  • Discounts of 17 – 35 percent for outpatient and physician services7
  • Lower case costs due to shorter length of stay
  • Cost avoidance by helping reduce unnecessary and inappropriate treatment and avoiding complications

Congenital Heart Disease Resource Services (CHDRS):
Congential heart disease (CHD), which includes numerous conditions that vary in complexity, is the leading cause of birth defect-related deaths in the U.S.8 CHDRS provides access to some of the nation’s leading CHD programs, using nurse consulting and clinical expertise. Program results include average savings between 20 and 40 percent off standard billed charges per case and 35 percent lower COE average length of stay versus non-COE.8,9 See a map and listing of the Commercial CHD COE Network.

Neonatal Resource Services (NRS):
NRS provides onsite and telephonic case management to help manage NICU cases both inpatient and post-discharge. NRS possesses a dedicated team of specialized and experienced NICU nurse case managers as well as full-time medical directors capable of caring for fragile neonates. The NRS program can help reduce the average length of stay by 16 percent.10 In addition, the program has lowered readmission rates on average by 39 percent and received a 95 percent member satisfaction rating.10,11 See a map and listing of the NRS Onsite Facilities.

Fertility Solutions (formerly Reproductive Resource Services):
Fertility Solutions helps deliver uniquely personal, effective support during all stages of the infertility treatment. The program is made up of education, counseling and access to national COEs of qualified infertility treatment clinics to help achieve better health outcomes and more cost-effective treatment paths. Fertility Solutions drive significant results:

  • 25 percent reduction in costs with use of Fertility Solutions COE providers12
  • Unmanaged fertility treatments have a significantly higher amount of multiple births. Multiple births are 5–20 times more expensive than single births.13
    • 20 percent multiple births vs. 4.7 percent with no fertility treatments13
    • 6 percent reduction in multiple births with access to the solution12
    • Reduction in multiple births* with mandatory enrollment12

For additional information, review our program flier. See a map and listing of the Fertility COE Network.

Spine and Joint Solution (SJS):
SJS helps manage the rapidly rising costs of spinal surgeries and knee and hip replacements by offering a network of surgeons and hospitals that qualify for orthopedic and spine COE designation in more than 30 markets. SJS benefit design helps to reduce out-of-pocket costs by using bundled payments for in-scope procedures, achieving 25 percent lower costs, on average, when compared with median costs in the same metropolitan areas and $10,000 or more average cost savings per operation.14 The program has also achieved 17 percent fewer complications and 22 percent fewer readmissions.14

Transplant Resource Services (TRS):
TRS provides access to the nation’s leading transplant network, managing 16,000+ referrals annually. Comprehensive contracts provide an average of 54 percent off standard charges per episode.1 TRS has also resulted in a 17 percent lower hospital length of stay than the national benchmark as well as a 10 percent lower than expected transplant incidence in population with high COE utilization.15,16 See a map and listing of the Commercial Adult and Pediatric Transplant COE Networks.

For more information about our COEs or UnitedHealthcare’s Complex Medical Conditions programs, please contact your UnitedHealthcare representative.

 

*Multiple births — particularly triplets or more — can lead to increased risk for mother and babies.13
1 McGillis. Optum repriced claims (Facets 2014-2015). Reconciled cases of 8/2015.
2 Chen, Optum CHD contrast comparison data 2014-2014, November 2015.
3 Derosa, A., average discounts for Optum clients when they access Optum COE programs. Data assessed May 12, 2016.
4 Optum 2014 COE qualification analysis results, Schrader, 2015. Actual savings depend on illness burden, final program adoption and any customization. Results shown are not a guarantee of future performance.
5 2014 Center of Excellence qualification analysis results. Compared to non-COE providers. Schrader 2015.
6 2015 Optum claims book of business analysis. Haig 2015.
7 Optum data analytics.
8 Complex is defined as those cases that undergo a procedure that falls within the RACHS risk scoring system, RACHS 1-6.
9 Tao. UnitedHealthcare commercial population 2011-2014. November 2015. Outlier cases exclusions based upon LOS for all RACHS categories except RACHS 6 in order to show performance of center and to eliminate skews from high-acuity cases.
10 LOS>2 from 1/1/2015 through 12/31/2015 vs. telephonic/onsite model using 2016 book of business trend report; LOS Savings uses a cost per day amount of $3,736, based on 2015 NRS book of business.
11 Baseline readmission rate = 3.6% of Unmanaged discharged cases from 1/1/2015 through 12/31/2015 while NRS rate averaged 2.2%. Readmissions Savings uses a cost per day amount of $2,916, based on 2015 NRS book of business. Average readmit LOS of 6.8 days based on unmanaged readmissions from 1/1/2015 through 12/31/2015.
12 Book of Business analysis clients having three years’ program experience. Completed 2014.
13 Lemos EV, Zhang D, Van Voorhis BJ, et al. Healthcare expenses associated with multiple vs. singleton pregnancies in the United States. Am J Obstet Gynecol 2013;209:586.e1-11.
14 Optum analysis – joint replacement, book of business, July 2012-June 2015, Aug. 8, 2016.
15 McGillis and Ruppert. 2015 CMC Internal Claims Data for UHC FI (Facets). Accessed August 23, 2016.
16 Hanson S., Bentley T. 2014 U.S. organ and tissue transplant cost estimates and discussion. Milliman, Inc. http://www.milliman.com/uploadedFiles/insight/Research/health-rr/1938HDP_20141230.pdf. Published December 30, 2014. Accessed January 20, 2015.