Despite COE care usually requiring travel, many Walmart enrollees jumped at the option, for which Walmart covered all out-of-pocket costs and travel expenses for the patient and a caregiver, said Amanda Deegan, director of global public policy for Walmart.
"When they came back, they told us they had no idea that healthcare could look like this," Woods said. "They asked, how can you help us change healthcare in our community?"
The company classifies specified surgeries performed outside of a COE facility as out- of-network care and covers only 50% of the cost in most cases.
The company found striking results from the care provided at the COEs, including:
- Reduced average length of stay (LOS) by half a day for spine surgery and joint replacement
- Reduced spine surgery discharges to SNFs to 6/1000 compared to 49/1000 at non-COE providers
- Shortened time off for spine surgery by almost three weeks
- Shortened time off for joint surgery by a week and half
"We’re seeing all of this data and we know that quality matters," Woods said. "It absolutely matters. And so that’s the mission that we’re on. And it is our North Star, ensuring that our associates get the very best care."
That quality focus extended to individual physicians at the COEs. Walmart partnered with a vendor who visited each practice in person to analyze data and interview surgeons. The vetting process included selecting which surgeons at the COEs could operate on their enrollees.
But some of the biggest benefits of the COE initiative came before any surgery. Any patient diagnosed as needing spine or joint surgery by local providers was reassessed at the COE with new imaging and new readings. More than 50% of plan enrollees who had been told by local providers that they needed spine surgery, and 20% previously told they needed hip or knee surgery were found by the COEs not to require those costly, invasive procedures and instead were provided with alternative treatments.
"We were seeing where the associates would go to a COE and the COE would repeat an image or CTs or MRIs and realize [local diagnostics] probably weren’t the right read or not good quality," Woods said.
The findings led Walmart to focus in 2019 on improving its enrollees’ imaging and the reads of images, which are commonly viewed as not having any variation in quality. That year, Walmart partnered with a vendor to launch imaging COEs for CT and MRIs.
"I can tell you that we are already seeing positive data in six months; we’re seeing a decrease in misdiagnosis, so we are so excited," Woods said.
Pricing not a focus
The retailer negotiated bundled payments with each of the health systems it selected as COEs and identified 2015-18 cost outcomes in a 2019 Harvard Business Review column, which included:
- 8% higher cost for spine surgery at COEs
- 15% lower cost for joint replacement at COEs
But the company has found longer-term costs for both types of care were lowered by reduced readmissions and shorter LOS.
"Pricing has not been our focus," Woods said. "Our focus has always been on the quality of care. We always felt that if we had quality of care then we would see downstream savings, which is absolutely what we have seen. So, we don’t go in and try to negotiate deeper discounts. That’s not what this is about. This is about negotiating for the right care."
The three-market curated network aims to build on the COE experience by assessing quality outcomes for local physicians in eight specialties:
- Primary care
Walmart contracted with Embold Health, which has access to de-identified claims data on more than 150 million lives and has developed evidence-based guidelines of care in consultation with academic physicians from leading universities. The local physicians are then screened based on their performance and its effect on appropriateness, effectiveness and costs of care.
The vendor’s analyses are provided to Walmart, which has the final say on who to include in its curated network.
"What we’re looking at is that they have a demonstrated track record of providing consistent, appropriate and high-quality care," Deegan said.
Key metrics tracked by Walmart’s quality analyses include obstetricians’ rates of performing c-sections on low-risk patients, which were found to vary by 300% in one local market, Deegan said.
The coming networks were previewed in employees’ 2020 coverage, which included quality information for "featured providers," Deegan said.
However, the 2021 networks could change as Walmart and its vendor plan ongoing data reviews and changing selections based on the latest results.
"The reality is that we want all of the doctors, if we can, to be on our network list," Woods said.
Striving for that goal has meant providing the quality assessments to all physicians in the targeted specialties in those three markets, so that they can see how they compare with others and can engage in a dialogue with Walmart and its vendor.
"Part of the reason we like working with [the quality data vendors] is because they are committed to working with providers to be better," Woods said.
Deegan said the physician discussions have included some pushback on the data.
On the data, we hear, "Well, I don’t believe this data," Deegan said. Walmart’s response has been, "Well, OK, let’s walk through it," Deegan said. "This is what we’ve seen."
Although the quality reporting program has been well-received by Walmart’s enrollees, Deegan said the physician response has been "a mixed bag."
The narrow network challenge
Getting enrollees to select the narrower network, instead of the traditional, broad Blue Network the company also will offer in those markets, may prove Walmart’s biggest challenge.
"I recognize that employers are concerned about that," Woods said about employee resistance to narrow networks. "From a communication perspective, when we share that we are focused on quality and that’s what’s most important here, most associates — as we’ve seen from the experience in our [COE] program — are very appreciative of the opportunity," Woods said.
The challenge stems from the common perception of U.S. healthcare consumers that more care is equivalent to high-quality care, but growing amounts of evidence indicate quality results often decrease with more — and more aggressive — medical interventions, Woods said.
"I truly believe that we are on the tipping point of seeing a movement where quality will become very much more a focus," Woods said. "And we’re seeing it within our own company."
The company is now formulating the way that it will pitch the new network to its enrollees. And a key part of its potential appeal will lay in its ease of use, which Walmart hopes to help, in part, with an app that provides ongoing communication based on the enrollee’s changing healthcare needs.
"We are trying to create change, we are trying to get our associates to the highest quality, but I will not tell you that we have everything figured out, and we’re still working on it," Woods said. "That’s exactly what I would have told you when we started COEs."
The Walmart network pilot