Whether employees require a knee replacement, face a cancer diagnosis or need some other form of specialty care, the cost and quality of that healthcare can vary widely. But higher costs don’t always signal better care, leaving employers and employees vulnerable to overpaying without a guarantee of quality.
In a recent Lantern webinar, we uncovered how benefits and HR leaders can successfully redefine their approach to healthcare benefits by selecting a surgical Center of Excellence (COE) based on proven quality metrics.
The webinar participants included:
– Erin Tater, SVP, Consultant Relations, Lantern
– Jason Tibbels, Chief Medical Officer, Lantern
– Ryan McCracken, Director, Benefits, Edward Jones
Read on to learn:
– Quality metrics that matter most for impactful benefits
– How to improve care quality while reducing costs
– How Edwards Jones assessed quality while choosing its surgical COE
Cost and Quality Don’t Necessarily Correlate
As medical costs reach decade-high levels, top cost-drivers for large employers include musculoskeletal conditions, cancer and high-cost prescription therapies. Despite rising costs, there hasn’t been an increase in quality outcomes.
The Business Group on Health lists COEs as the No. 1 delivery approach to reform healthcare, but many employers utilizing carrier COEs haven’t seen the engagement or outcome they desire.
“There’s a huge variation in costs for procedures like joint replacements depending on where patients get care, which would be understandable if outcomes at pricier locations were predictably better, but they’re not,” Tater said. “However, this means it’s possible to secure higher quality care at a lower cost.”
The Institute of Medicine Quality Framework
Tibbels introduced the Institute of Medicine Quality Framework as a way to measure benefit solutions. The Framework, which is adopted broadly among leading health organizations, offers six quality metrics:
- Safe
- Effective
- Patient-centered
- Timely
- Efficient
- Equitable
“Most people think about two of these domains in relation to quality: patient safety and effectiveness,” Tibbels said. “But our North Star, which is to deliver the highest quality care, should be the goal of every stakeholder, whether we’re talking about providers, purchasers, payers, or most importantly, our patients. Any solution being considered has to address all of these domains, and not think about quality in a narrow way.”
When searching for a center of excellence or specialty care program that improves care quality and reduces costs, it’s crucial to consider all six domains.
1. Safe
The care that is intended to help patients shouldn’t cause harm.
“Unfortunately, we know this happens way too often,” Tater said. “Nationally, there’s an 8% to 15% complication rate for surgery, for example. When you look at infusion therapy, patients are getting infusions in hospital settings with a very high nurse-to-patient ratio, so monitoring can be limited. Improving patient safety and quality care reduces cost by reducing hospital readmissions and making sure your employees get back to work sooner.”
When evaluating solutions, look for a demonstrated understanding of the importance of safety and a commitment to ensuring safety.
For example, many traditional centers of excellence build their networks based on facility evaluations.
“Study after study has demonstrated that there’s a ton of variation in quality and outcomes within a given institution,” Tibbels said. “It’s more important to evaluate the who. Is there a rigorous evaluation at the individual surgeon level, and more specifically of that surgeon’s performance for the procedure that we’re talking about?”
For example, a surgeon who mainly performs hip procedures isn’t the best option for a shoulder procedure.
“At Lantern, we want to know the credentials and performance for every physician we contract with,” Tibbels said. “We spend a lot of time vetting that. That’s the reason why we have an absurdly low complication rate when you benchmark ours against national averages. You want to be sure the center of excellence is providing your employees the right procedure at the right place with the best surgeon for that surgery.”
After reviewing analysis of medical cost-drivers and seeing MSK in their top three, Edward Jones sought a solution that would connect their employees with high-quality care. Lantern stood out for its robust vetting process for surgeons.
“We keep our associates and their family members with us for their whole career in most cases,” McCracken said. “Having effective and safe outcomes was really important to us, because that’s what allows us to help bend the long-term cost curve — reducing complications, reducing readmittance and reducing repaired surgeries.”
2. Effective
Inappropriate and unnecessary surgery is unfortunately common. Effective care avoids misuse or underuse.
“A surgeon can be the very best technician on the planet with the lowest complication rate, no infections and no readmissions,” Tibbels said. “But if they’re operating on people who would be better off without surgery or with a less invasive or more conservative treatment, that’s poor quality.”
Lantern diligently evaluates providers for appropriateness. As a result, Lantern surgeons recommend against surgery 22% of the time.
“We follow surgical avoidance so closely and include it in our savings methodology with our clients, because many times the most important care you’re getting is what you’re not getting,” Tibbels said.
Care Advocates and nurse oncologists also provide treatment plan reviews and second opinion referrals, which prove especially impactful in cancer care, of which 40% of treatment plans aren’t consistent with current guidelines.
3. Patient-centered
The Medicine Quality Framework defines patient-centered care as providing care that is respectful of and responsive to individual patient preferences, needs and values. This means ensuring patient values guide all clinical decisions.
“Medicine has such a history of being paternalistic and directing the patient on what to do, and that’s not the right approach,” Tibbels said. “It’s important that patients’ own goals and preferences are considered. Sometimes those preferences are in the treatment, which can be the how, the who and the where, and we should care about that. We shouldn’t assume we know what a patient’s goals are.”
Lantern’s Care Advocates provide one-on-one support through each step of the member’s healthcare journey. This contributes to Lantern’s 85 Net Promoter Score, compared to the health insurance NPS average of 30.
“When patients rate their experience higher, they actually have better functional status,” Tibbels said. “They have less complications and lower mortality. We want to know our providers are putting patients at the center of their care, both to optimize their experience and their outcomes. And if you’re doing both of those things, you also get the benefit of saving money, because you’ll have fewer complications.”
Patient-centered care was an important consideration for Edward Jones.
“We pride ourselves on taking great care of our clients. Because of that, our associates have very high expectations on what service looks like for the people who take care of them,” McCracken said. “It was very important for us to be able to easily link our members with providers who were going to give them the best possible care in the location that worked best for them.”
4. Timely
For cancer patients, a one-month delay can increase mortality risks by 13%. Lantern’s Accelerated Access program ensures members are seen in less than 10 days, whereas people going to National Cancer Institute-designated centers may normally wait 50 days to be seen.
“Time for treatment is an incredibly key metric and has a direct impact on mortality and morbidity, and can make the difference in staging and survival,” Tibbels said.
While timely care is obvious for cancer, access to faster care is always beneficial.
“The more quickly you can get someone functional, you’ll see benefits,” Tibbels said. “Their functional status is going to improve, their mental health is better. They’ll be in less pain. You’ll see higher productivity and less absenteeism.”
5. Efficient
Overall, employers and private health plans pay, on average, 254% of Medicare prices. Within a given market, surgery prices may vary by up to 313%.
“Paying more for care doesn’t mean you’re getting better quality,” Tater said. “At Lantern, we negotiated prospective bundles that are 50% to 60% less than commercial carrier rates, which delivers hard dollar savings directly to the plan sponsor.”
In addition, Lantern steers patients to a subset of facilities, which are willing to accept rates at 120% of Medicare.
“Site of care also has a tremendous impact on cost and efficiency, especially in surgery,” Tater added.
For example, a routine knee replacement surgery is generally safer and more affordable at an ambulatory surgery center versus an academic medical center.
“But sometimes you might need to be in a hospital-based facility,” Tibbels said. “That’s why we contract with the most reputable acute care centers, like Cleveland Clinic, Mayo and Johns Hopkins, and also the safest ambulatory care centers. We don’t want to be bound to a facility. We contract in a way that allows us to put our members in the hands of the best surgeon and best facility for their unique clinical situation.”
The same applies for cancer care.
“For some things, you really do need to be in an NCI-designated cancer center. That’s why we contract with them,” Tibbels added. “But there are also situations where you can get
great care closer to home in a much more convenient and lower cost setting.”
6. Equitable
Because Lantern clients significantly reduce their overall costs, they’re able to pass savings on to their employees.
“Most of our clients waive 100% of cost share when folks use the Lantern benefit for surgical procedures, or everything after the minimum required deductible in an HSA plan,” Tater said. “This means our members save $2,000 to $4,000 on out-of-pocket costs, on average. For a lot of people, that’s the difference between being able to get a procedure or not being able to afford it.”
Geographic access also has a significant impact on equity.
“Most people aren’t financially or logistically able to travel for care, even with a travel benefit. Those who are most impacted by affordability concerns are least able to travel due to things like caregiving responsibilities at home or a second job,” Tater said.
By building a surgeon-first network of excellence, members can receive care wherever excellent surgeons operate, including ambulatory surgical centers, community hospitals and teaching institutions. This increases access, placing 99% of members within driving distance of care.
This network was a huge plus for Edward Jones, which has 80,000 plan members spread across nearly every U.S. county.
“Being able to provide resources to connect people with surgeons all across the country was huge for us,” McCracken said. “Healthcare navigation is a constant struggle, and it’s really challenging to help educate members on how to find the care that’s right for them. We needed a solution that would be easy for our members to use. We needed it to be both highly effective at a competitive cost to incentivize members to engage with it.
“This was one of those rare win-win type of scenarios where we can provide our members with the best possible care and also pass on savings,” McCracken added. “Honestly, the hardest part was getting people to believe they could have both lower costs and higher quality.”
