Developing a benefits strategy that balances high-quality care with cost control is one of the biggest challenges for payers and employers. This challenge is particularly difficult for complex, high-cost conditions with treatment and recovery journeys that require access to Centers of Excellence (COEs) for innovative specialty care.
A benefits strategy that combines a strong clinical foundation, proven protocols, and deep market expertise can deliver quality care more efficiently and cost-effectively. This balance is sustainably achievable when a plan has a proven clinical structure and governance framework.
A proven clinical structure and governance framework can help a benefits strategy deliver whole-person, evidence-based care that improves health outcomes, coordinates care effectively, manages costs, and maximizes ROI. It also means establishing value-based incentives with clear, measurable expectations.
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Value-based care programs reward providers for improving patient outcomes, unlike traditional fee-for-service programs that reimburse providers largely based on the quantity of care delivered. A proven clinical structure can deliver healthier members, better care experiences, and more predictable costs and ROI.
Payers and employers are increasingly feeling the impact of fertility care through the direct costs of treatment and maternal and infant health outcomes. An estimated 17% of women use fertility services, and the number is growing, driven by women ages 35 and older who are at greater risk for complications.
Without evidence-based clinical pathways, care inefficiencies can drive unnecessary costs and delays. A benefits strategy with structured clinical protocols can improve outcomes, reduce unnecessary interventions, and help families achieve pregnancy more safely and efficiently.
Women ages 35 and older are at greater risk for complications, including gestational diabetes, high blood pressure, miscarriage, multiple births, premature babies, and chromosomal abnormalities. A well-designed benefits strategy can help guide members to the whole-person care they need within an ecosystem that integrates pharmacy, medical, and behavioral care.
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A well-designed benefits strategy informed by deep market and industry expertise can help simplify access and navigation, emphasize early intervention to prevent escalation, and deliver the right level of care as close to home as possible. It can also leverage analytics and trusted services to streamline clinical, administrative, and financial processes.
Complex medical and behavioral health conditions each require a distinct clinical model and member journey. A benefits strategy must be flexible enough to accommodate these differences, while meeting members where they are and offering them high-quality, cost-effective access to the specialty care they may need.
Enlisting a partner with market and industry expertise can help a strategy leverage COEs, providing members with advanced, evidence-based care for conditions ranging from cancer and congenital heart disease to musculoskeletal disorders and infertility. Members with complex conditions who seek care from a COE often benefit from a rigorous review process and criteria, improved health outcomes, and dedicated member support by specialized clinicians.
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Before adding COEs to a benefits strategy, these specialty centers should undergo a rigorous qualification process that evaluates ongoing program effectiveness, analyzes outcomes and cost data, follows established best practices, and identifies cost-effective methods of care. By integrating COEs into benefits plans, payers and employers can help members access evidence-based care, support better health outcomes, and promote efficient use of healthcare resources.
One of the key benefits of working with COEs is the ability to manage complex and high-cost conditions, such as congenital heart disease, more effectively. About 40,000 children are born with congenital heart defects every year in the United States, many requiring multiple surgeries and a lifetime of medications. Contracting with a specialized network of leading congenital heart disease COEs can help manage this risk, while providing members and case managers with access to cost-effective, high-quality healthcare.
Combining a proven clinical structure with market expertise can deliver healthier members, better care experiences, and more predictable costs and ROI for everyday needs and complex conditions. This approach can help payers and employers balance the need for high-quality care with the need for cost control, ultimately leading to better health outcomes and more efficient use of healthcare resources. They can find more information on congenital heart defects and other complex conditions from the Centers for Disease Control and Prevention.