| January 15, 2026
| 9:20 AM
Photo: Morsa Images/Getty Images
One of the biggest challenges for payers and employers is developing a benefits strategy that balances high-quality care with cost control. For complex, high-cost conditions with multifaceted treatment and recovery journeys, this challenge is particularly difficult, especially when members need access to Centers of Excellence (COEs) for innovative specialty care.
This balance is sustainably achievable when your plan combines a strong clinical foundation, proven protocols and deep market expertise. These components and evidence-based methods can help deliver quality care more efficiently and cost-effectively.
Why clinical structure matters
A proven clinical structure and governance framework can help your benefits strategy deliver whole-person, evidence-based care that can help improve health outcomes, coordinate care effectively, manage costs and maximize ROI.
It also means establishing value-based incentives with clear, measurable expectations. This can help members receive the right care at the right time, helping improve outcomes and manage costs. Additionally, built-in mechanisms can assess the value, such as engaging independent experts to regularly review select patient cases. These experts evaluate clinical appropriateness, provide second opinions and offer independent evaluation of appealed decisions, that can help improve access to high-quality, cost-effective care.
Value-based care programs reward providers for improving patient outcomes. In contrast, traditional fee-for-service programs 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 for everyday needs and complex conditions.
Fertility: A case for structured clinical protocols
For example, 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,1 driven by women ages 35 and older who are inherently at greater risk for complications, including:2
- Gestational diabetes
- High blood pressure
- Miscarriage
- Multiple births
- Premature babies
- Chromosomal abnormalities
Without evidence-based clinical pathways, care inefficiencies can drive unnecessary costs and delays:3
- Multiple cycles of ineffective treatment
- Treatment continued despite poor prognosis
- Use of expensive drugs with inconsistent dosing guidelines
- Misaligned medical and pharmacy protocols
- Waste and abuse
A comprehensive benefits strategy with structured clinical protocols can improve outcomes, reduce unnecessary interventions and help families achieve pregnancy more safely and efficiently.
Why deep market and industry expertise matters
A well-designed benefits strategy informed by deep market and industry expertise can help:
- Guide members to the whole-person care they need within an ecosystem that integrates pharmacy, medical and behavioral care
- Simplify access and navigation
- Emphasize early intervention to prevent escalation
- Deliver the right level of care as close to home as possible
- 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. Your 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 along the way.
Enlisting a partner with market and industry expertise also helps your 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
- Dedicated member support by specialized clinicians
- Better care coordination and/or case management support
- Fewer emergency room visits, hospital stays and other adverse events
Driving cost efficiency
Strategically contracting with COEs expands access to high-quality care and can help generate significant cost savings while delivering ROI by improving outcomes and leveraging negotiated discounts. For example:
- Cancer COEs that adopt multidisciplinary approaches to care, treatment planning and coordination, and high-quality clinical research can reduce costs through shorter hospital stays and avoiding unnecessary procedures.4
- Orthopedic COEs have been shown to save an average of $13,000 per operation for participating members and have 37% fewer complications for joint replacement surgeries.5
- Bariatric COEs have been shown to reduce:5
- Average surgical episode cost by $4,900
- Length of stay by 31%
- Admission rates by 39%
- Re-operation rate by 60%
- Mortality rate by 60%
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.
The key is to enlist a partner with market insights to guide this process, ensuring only the most experienced and statistically successful COEs are selected.
Congenital heart defects: A case for market expertise
For payers and self-funded employers, congenital heart disease is a low-incidence but high-cost and clinically complex condition.
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.6 These rare but high-cost cases drive more than $4 million in annual charges per 100,000 members, averaging $493,000 in billed charges per case.7
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.
Thus, 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.
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. Centers for Disease Control and Prevention. Oct 13, 2017. Key statistics from the National Survey of Family Growth. https://www.cdc.gov/nchs/nsfg/keystatistics.htm.
2. Mayo Clinic. June 7, 2025. Pregnancy after 35: healthy moms, healthy babies. https://www.mayoclinic.org/healthy-lifestyle/getting-pregnant/in-depth/pregnancy/art-20045756.
3. Optum internal analytics, 2021.
4. Optum book of business, 2023.
5. Chen, M. 2019 Centers of Excellence qualification analysis results, analyzed 2020.
6. Centers for Disease Control and Prevention. Oct. 21, 2024.Congenital heart defects (CHDs): Data and statistics. https://www.cdc.gov/heart-defects/data/.
7. Internal commercial population January 2011–December 2018. June 2020. n = 11,098.
