| January 22, 2026
| 9:00 AM
Photo: Morsa Images/Getty Images
A competitive benefits strategy connects members with complex conditions to Centers of Excellence (COEs) for advanced therapies and specialized care. Yet, every condition is different — with unique pathways and measures of success. For payers and employers, this raises three critical questions:
- Value: How can we be confident in the quality of care?
- Timing: When should members access specialty care?
- Sustainability: How can we balance high-cost interventions with members’ everyday needs and program longevity?
Three key components can help organizations address these challenges and integrate COEs into their benefits strategies efficiently and cost-effectively. Specifically, scale and scalable solutions, the ability to evolve with industry changes, and enterprise-wide resources can help improve outcomes and deliver long-term value.
Scale and scalable solutions
As the prevalence of complex conditions grows and new treatments emerge, COEs should be integrated into a benefits strategy that combines proven scale with scalable solutions. This will help organizations adapt to the evolving needs of members, manufacturers and providers.
Solutions that are both large-scale and scalable can help enable organizations efficiently manage clinical and administrative resources through strategies such as vertical integration, extensive provider networks, comprehensive plans and modular offerings to help:
- Create care pathways tailored to each member that are informed by analytics and evidence-based clinical practices and designed to improve outcomes and satisfaction
- Address urgent gaps, such as responding to request for proposal requirements, emerging treatments or shifting market demands
- Implement digital strategies, manage complex utilization reviews and provide access to regional and national provider networks to reduce travel burdens and enhance convenience
- Give targeted support where it’s needed most by offering end-to-end solutions or modular options for key functions — such as claims management, provider networks and service expansion — to streamline operations and accelerate growth
- Maintain consistent quality and outcomes across diverse geographies
Leveraging partners with established scale also drives cost efficiency. Large-scale networks, vertical integration and volume-based contracts can help provide access to high-quality care at a lower total cost. Built-in discounts, guarantees and quality measures can help make the financial impact more predictable across the short-, mid- and long-term through:
- Driving discounts with purchasing power
- Ensuring value through robust qualification processes and value-drive contracting
- Improving decision-making via online cost, quality and access tools
- Structuring contracts around case rates to optimize risk management
- Negotiating across all lines of business, including specialty care for complex conditions
- Offering flexible pricing models, including fee-based arrangements
- Repricing claims
This approach also can help save payers and employers significant time and resources they might otherwise spend building capabilities in-house or coordinating with multiple external partners to meet evolving needs. By combining existing scale with scalable solutions, organizations can respond quickly to change while driving to sustain consistent, high-quality care, that can help mitigate financial risk and deliver improved ROI.
Ability to evolve with changing industry needs
As emerging treatments, clinical innovations and real-world data continue to reshape healthcare, benefits strategies must meet current needs and be positioned for the future. One of the most significant shifts is the move from traditional fee-for-service payment models to value-based contracting.
The targeted therapies for complex conditions often carry high price tags, but they can still be cost-effective when value-based agreements are carefully negotiated and managed. While results vary, value-based care models can save payers 3% to 20%, depending on the assumed risk.1 At Optum, for instance, COEs have delivered 38% lower bariatric inpatient hospital readmissions.2
Because these agreements require specialized expertise and strong relationships, employers and payers benefit from a partner that has experience designing and implementing these contracts — and can negotiate on their behalf. To be successful, the parties must:
- Define endpoints that are measurable and relevant to all stakeholders
- Build trust and alignment across multiple perspectives
- Use real-world data and analytics to monitor and measure outcomes
When value-based contracts are combined with a simpler, more connected care experience, they can help expand patient access, improve outcomes, enhance productivity and mitigate financial risk.
Broad capabilities — including interoperable platforms and technology, a scalable operating model and a comprehensive — are the keys to ensuring a benefits strategy can adapt to evolving needs while supporting financial goals.
Fee-for-service versus value-based care
| Fee-for-service | Value-based care | |
| Provider reimbursement | Providers are paid based on the quantity or volume of healthcare services or procedures performed. | Providers are paid based on certain criteria, including care quality, outcomes and affordability. |
| Provider incentives | Providers may be incentivized to provide more services, regardless of the outcome, which may lead to overutilization and higher costs. | Providers are incentivized to focus on patient outcomes, care coordination and population health management, which may lead to better outcomes and lower costs. |
| Benefits for providers | Maintains the status quo and may offer providers more perceived financial stability and less administrative burden. | Financially incentivizes providers to deliver quality, cost-effective care — with the goal of better experiences, outcomes and lower costs for their patients. |
| Impact on employees and their families | They may receive unnecessary services or procedures because providers are paid by volume. | They may receive more appropriate, quality care, leading to better health outcomes and lower costs. |
| Impact on payers and employers | Often can lead to overutilization and higher costs as a result of more services being provided with less controllable costs and less predictable care pathways and outcomes. | Often can lead to better outcomes and lower costs as a result of improved access to high-quality care and more predictable financials. |
Access to enterprise-wide assets and resources
Enterprise-wide assets and resources bring together clinical expertise, advanced analytical and proven administrative systems to deliver scale and insights that optimize a benefits strategy, maximizing value and ROI.
When the primary priority is mitigating stand-alone catastrophic claims, the clinical needs of members and financial realities of the continuum of care including complex conditions and routine ones can be shortchanged. This can often lead to a costly, time-consuming cycle of pursuing the lowest price rather than achieving the greatest long-term value and ROI. As a result, member care can be disrupted, and more time and resources may be spent hiring consultants, soliciting proposals, negotiating contracts and implementing programs than on realizing the intended savings.
Importantly, a benefits strategy with scale and scalable solutions that leverages enterprise-wide assets and resources can generate savings through value-based contracts and discounts while also delivering data-enabled clinical programs that connect members to the right level of care at the right time. These programs can help prevent symptom escalation and reduce unnecessary emergency department visits, hospital stays and readmissions.
At the same time, this approach can enhance member satisfaction and productivity, improve clinical outcomes and strengthen program resilience.
Learn more about Optum programs that work with COEs to improve outcomes for members while lowering total cost of care and maximizing ROI.
References
1. McKinsey & Company. Dec. 20, 2022.Investing in the new era of value-based care. https://www.mckinsey.com/industries/healthcare/our-insights/investing-in-the-new-era-of-value-based-care.
2. Chen, M. 2019 Centers of Excellence qualification analysis results, analyzed 2020. Individual results will vary and historical aggregated lower admission rate is not a guarantee of individual future results.
