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By Cory Thornton, MS

In health plan contracting, the center of excellence (CoE) concept is on the rise (see Mercy Care Plan and Mercy Maricopa Launch Medicaid Centers Of Excellence For Autism For All Ages and Walmart Selects Covera Health As National Radiology Centers of Excellence). My colleague, OPEN MINDS Chief Executive Officer Monica E. Oss, recently spoke about this trend that seems to be driven by convenience, better outcomes, lower costs, and a need for different provider organization performance (see The Changing Face Of Integration). But in the current market, this model of contracting isn’t like “centers of excellence” in years past.

The emerging trends in the CoE model was the focus of the session, What Does It Take To Be A Center Of Excellence? The Changing Market Role For Specialty Provider Organizations with Erin Boyd, Behavioral Network Strategy, Solutions & Program Director, Cigna; Pablo McCabe, LCSW, Director, National & Strategic Accounts Team, Hazelden Betty Ford; and Debra Nussbaum, Ph.D., LCSW, Senior Director, Behavioral Product, Optum, at last week’s 2020 OPEN MINDS Performance Management Institute.

The session started with a definition of the new CoE—a selected narrow network of provider organizations that demonstrate excellence in serving a particular consumer need. These organizations are “high value,” with good performance on both quality and cost, and are often compensated using some value-based model. From a consumer perspective, the value of using a CoE is often reduced cost sharing. From a provider organization perspective, the benefits of CoE recognition include enhanced rates, additional referrals, and special status with the health plan (see What Does ‘Center Of Excellence’ Mean Now? and Health Plans Take A New Approach To Centers Of Excellence – OPEN MINDS Releases New Guide To COEs For The Complex Consumer Market).

Ms. Boyd shared the work being done at Cigna in developing CoEs for mental health, addiction treatment, and opioid-specific addiction treatment. Cigna reviews facility clinical outcomes such as readmission rates, seven-day ambulatory follow-up and discharging to other in-network providers. Cigna’s mental health network consists of 228 access points nationwide. Other in-network mental health facilities have a 37%higher readmission rate than the CoEs. The substance use treatment network has 337 access points across the country. Out-of-network substance use treatment facilities cost 240% more per admission and have a 71% higher readmission rate.

Ms. Nussbaum talked about Optum’s CoE program, Achievements in Clinical Excellence (ACE), which includes specializations in general mental health, substance use disorder (alcohol), substance use disorder (all other substances), and eating disorders. The goals of Optum’s ACE program include increasing use of evidence-based services, improving continuity of care, and increasing the adoption of ambulatory treatment, medication-assisted treatment, and more robust recovery support services.

Organizations that are selected by the ACE become part of Optum’s Platinum/Preferred provider network. Advantages of the Platinum/Preferred designation include a streamlined review process for the consumers admitted under the recognized program; inclusion in Optum’s provider search tools; and consumer incentives and benefit design strategies to promote Platinum/Preferred Programs.

Mr. McCabe shared his experience at Hazelden Betty Ford, which is a CoE for Cigna, Optum, Aetna, Beacon, and the Blues plans. To help meet payer CoE requirements, Hazelden built its own “Patient Care Network” in 2017. The Hazelden Patient Care Network is “a multi-level network of like-minded and ethical providers” that shares “most-effective, evidence-based treatment for substance use disorders and a commitment to improving the patient experience” through “collaborative affiliations designed to increase patient engagement, therapeutic alliance, self-efficacy and treatment outcomes” (see Hazelden Betty Ford Patient Care Network).

An additional takeaway from the session was the interest in different forms of bundled rates. (For more on the increase in bundled rates, see VBR – Where’s The Beef?) Both Ms. Boyd and Ms. Nussbaum said they are exploring episode-of-care rates, which would provide the ability to report and manage clinical utilization, cost, and performance in a different way. For more on CoEs, check out these resources from The OPEN MINDS Industry Library:

  1. Walmart Employee Health Plan Expands ‘Centers Of Excellence’ Program To Cover Kidney Transplants In 2020
  2. Addiction By The Numbers
  3. New Jersey Medicaid To Cover Office-Based Addiction Treatment
  4. Health Plans Take A New Approach To Centers Of Excellence – OPEN MINDS Releases New Guide To COEs For The Complex Consumer Market
  5. The Moving Medicaid Addiction Treatment Market
  6. Delaware Awards Addictions Center Of Excellence Contracts To Brandywine Counseling & Connections Community Support
  7. Vermont Care Partners Designates Two Centers Of Excellence
  8. What Does ‘Center Of Excellence’ Mean Now?
  9. Health Plans Take A New Approach To Centers Of Excellence – OPEN MINDS Releases New Guide To COEs For The Complex Consumer Market
  10. Pennsylvania Medicaid Moving To Value-Based Reimbursement For Behavioral Health

For more coverage from the 2020 OPEN MINDS Performance Management Institute (hashtag #OMPerformance) on social media channels and follow us @openmindscircle.


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