| Treatment for congenital heart disease (CHD) can be overwhelmingly expensive for self-funded medical plans. Fortunately, Symetra and our partners at OptumHealth can help mitigate these expenses for employers and deliver superior outcomes for employees.
Congenital heart disease (CHD) is the most common birth defect and is the number one cause of death during the first year of life. CHD incidence is estimated to be 55 to 60 per million lives, and the most complex CHD conditions occur at a rate of 33 incidences per million lives.1 This small incidence, however, drives a significant amount of spending. Average billed charges for a CHD case are $250,000, and can exceed $3.6 million. This amounts to an expected $13.56 million in billed charges annually per million lives.2
For self-funded plan providers, conditions such as CHD can become overwhelmingly expensive. Fortunately, stop loss medical insurance providers like Symetra and our partners can help mitigate these expenses by steering patients to Centers of Excellence (COEs), where quality service and superior outcomes greatly benefit the clients of our partners.
For many years, OptumHealth (formerly United Resource Networks) has helped Symetra manage the costs of transplants through their Transplant Resource Services program. Like transplants, CHD presents opportunities to steer cases to the best facilities in the country to help achieve the best clinical outcomes for patients and reduce costs for clients. Based on their successful transplant partnership, Symetra now also utilizes OptumHealth’s Congenital Heart Disease Resource Services (CHDRS) program to manage CHD cases.
What is CHD?
The term congenital heart disease includes approximately 40 specific conditions. These conditions can be highly complex, such as Hypoplastic Left Heart Syndrome which requires a Norwood or Fontan procedure.
The condition’s high complexity and low incidence result in significant quality and cost variation among facilities. Furthermore, there is little publicly available information to identify the best facilities. This presents a challenge for both patients and payers. Between 2005 and June 2008, there were just over 130 facilities that had treated a complex CHD case,3 and there were only about 50 facilities that had treated the most complex category of CHD patients.4 This leaves patients and payers with only a handful of hospitals in the country that treat enough patients to build the expertise and can demonstrate a COE level of quality. The challenge is to find them!
Congenital Heart Disease Centers of Excellence
OptumHealth’s Congenital Heart Disease Resource Services (CHDRS) program has been identifying and qualifying Centers of Excellence for Congenital Heart Disease since 2003. To qualify as a Center of Excellence, the facility and its staff surgeons undergo a rigorous qualification process executed by OptumHealth’s Clinical Sciences Institute. Qualification requirements are established by an advisory panel made up of the nation’s leading cardiothoracic surgeons and cardiologists. There are three fundamental criteria for achieving COE status. First, there is a facility case volume requirement for both the total number of CHD procedures and highly complex CHD procedures. Outcomes are the second performance measure. Outcomes are measured by in-patient mortality and morbidity. Finally, individual staff surgeons must also make the grade. Qualification requires staff surgeons have a minimum of five years experience, in addition to an annual case volume requirement.
The Value of Centers of Excellence
Qualified COEs are proven to have shown significant value to both the payer and the patient. For starters, COE survival rates for complex CHD conditions are 15-30 percent better than those that are not COE qualified.5 Secondly, the average length of stay at a COE is 18 percent – or three days – shorter than unqualified COEs. For the most complex cases, the average length of stay at a COE is eight days shorter.6 And finally, OptumHealth leverages its leading market position to negotiate the best possible rates for payers utilizing the CHDRS Centers of Excellence network. CHDRS’ paid rates as a percentage of billed charges are 7 percent lower than cases at the same facilities but not utilizing CHDRS contracts.7 At $250,000 per case, this savings alone adds up to an average of $17,000 per case.
Take Advantage
Together, Symetra and OptumHealth can provide significant cost savings and improved medical care for complex conditions such as CHD, transplants and more. To learn more, contact your regional Symetra claims office  or call our home office toll free at 1-800-426-7784.
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