At Employer Direct Healthcare (EDH), clients that mandate utilization for certain procedures see the highest engagement—80%+. And high utilization pays off for everyone: patients who receive high-quality surgical care are less likely to experience complications and save several thousand dollars on out-of-pocket costs. Thanks to improved outcomes and negotiated rates, employers see significant savings, too.
Of course, the more employees use a Center of Excellence (COE) for their care, the better for all involved. But employers who require employees to only see providers within a COE for certain procedures often run into pushback and member dissatisfaction.
The reasons tend to be straightforward: most people dislike having their options limited, especially if their primary care provider or a loved one already made a recommendation.
While mandatory plan designs are an option for some employers, there are other ways to incentive utilization while maintaining a sense of choice. Benefits leaders shared strategies for addressing barriers to utilization that employers can consider as they search for a COE partner or build out a new program.
Meeting members where they are: Best practices for any plan design
While mandatory plan designs are likely to deliver the most clinical impact and savings, employers have other options for steering employees to high-quality care.
Educate early and highlight incentives. Ideally, employers will reach employees about their COE before they learn they’ll need surgery. Communications should make any benefits of using the program, such as cost waiving, as clear as possible. Since just 17% of Americans know how much their healthcare will cost before receiving it, providing clarity and cost savings here can be impactful. If it’s likely employees will need to travel for care, highlight what support they receive, like coverage for gas, flights, and hotel stays.
Emphasize quality. Messaging should also include, at a high level, why employees should use the COE from a care quality perspective. For example, EDH delivers best-in-class outcomes with complication rates nearing zero (0.6%) across all plannable surgeries. Needing surgery is stressful and can be a significant interruption to daily life. Knowing they could have a shorter recovery time by using a COE is appealing and important to highlight.
Leverage integrations with related vendors. Partnerships and integrations with relevant programs can also help catch employees at the right moment and, in some cases, guide employees to surgery alternatives. At EDH, we partner with digital musculoskeletal pain programs Hinge Health and Sword Health to help guide members to physical therapy when appropriate.
Missing employees? Try these approaches to increase utilization
Reaching employees before they start their journey isn’t always easy—after all, most of us don’t pay much attention to our benefits package before we need it. To help, employers can consider inserting a required “check” that requires member receive a level of education on your COE before they proceed with surgery.
Harness the power of second opinions. Requiring employees to get a second opinion before surgery is both an impactful moment to educate them about your COE solution and about their overall care options.
“At Honeywell, we provided incentives for employees to participate in a surgical decision support process for major surgeries such as joint and spine to ensure members understood all their treatment options,” said Brian Marcotte, former president of Business Group on Health and VP of Compensation and Benefits at Honeywell, at a client event. “If surgery was elected, we used the opportunity to educate employees on the benefits of the COE solution.”
Guiding employees to high-quality surgeons makes it more likely they’ll avoid inappropriate surgeries and pursue less invasive care, like physical therapy. For example, research shows that 60% of spine surgeries shouldn’t happen. Physical therapy is less invasive, has a shorter recovery time, and is just as effective in many cases.
“The first thing I was taught in residency was, ‘The most important decision you’re going to make is to decide who doesn’t need surgery,” said Alan Davis, MD, Emeritus Staff at the Cleveland Clinic.
Require surgeon review from your COE. Another option is to require your COE to review your employee’s surgeon before their procedure. This is another way to potentially prevent employees from receiving lower-quality care, avoid unnecessary surgery when possible, and educate them on your COE solution.
Require that employees engage with your COE before moving forward. Rather than requiring that employees use a COE, a softer option is to require they call and learn about their options first. Most companies that offer a COE include incentives like cost waiving and travel support. When employees learn more about their costs, why their employer is partnering with COE, and the care quality they can receive, many will voluntarily choose to get care from your COE.
Mandatory plan designs: Pros, cons, and engagement tools
For employers that decide to mandate a COE for certain procedures, some requirements will be easier to swallow than others. Requiring employees to use a COE is most common for fertility and bariatric procedures. Because employees generally don’t expect their plan to cover these procedures at all, there tends to be less pushback here.
Requiring a COE for joint and spine procedures, on the other hand, can be a tougher sell because they’re accustomed to being able to pursue referrals from their primary care providers and friends and family.
For employers that decide to mandate utilization, making sure these pieces are in place can help create a better member experience:
Ensure members have options close to home. Requiring care through a COE may be particularly burdensome if your employees must get on a plane for surgery. Finding a COE with local access makes a difference here.
“The goal of our network design is to provide three high quality choices within 50 miles of the employee’s home,” said John Zutter, CEO of EDH. “The only reason we’d ever recommend someone get on a plane is if they have a highly complex case that requires treatment at a national institution, but the vast majority of people can receive great care close to home.”
Look for a COE partner that includes options close to home. At EDH, 98%+ of members are within driving distance of their providers.
Allow exceptions when members would need to travel more than 50 miles for care, in addition to providing a travel benefit. If employees are pushing back on your COE solution because they don’t want to travel for care, consider allowing exceptions to a mandatory plan when a provider is more than 50 miles away. These exceptions can still be paired with incentives to use your COE, such as cost waiving and travel assistance.
Leverage word-of-mouth and employee testimonials. One client shared that while mandating EDH for joint and spine surgery received pushback from employees, positive word-of-mouth experiences have helped—and their savings have been significant. Identify employee champions and find ways for them to share their experiences, such as through lunch-and-learn presentations, quotes in your company newsletter, and referral programs.
Change is always challenging, especially if employees are also feeling emotional about needing surgery in the first place. But making sure employees get quality care couldn’t be more important to outcomes.
“Some of these changes are going to be disruptive but the upside in terms of health outcomes and savings is so big it’s worth it,” said Marcotte. “The risk reward calculation bears out.”
