Two Surgeries, Two Outcomes

Two fictional Walmart associates, Sean and Carla, have struggled with back pain for years. Both associates (as the company refers to its employees) recently had MRIs that came back abnormal. Sean opts to go to a surgeon affiliated with a local health system, using his traditional insurance coverage. Carla chooses Walmart’s Centers of Excellence (COE) program for spine surgeries.

A COE program circumvents traditional insurance companies, connecting employers directly to health care providers. With the help of a third-party administrator (TPA), the two groups negotiate a bundled payment that entirely covers the cost of care — all the procedures, devices, tests, drugs, and services a person will need. The program also picks up the cost of travel, lodging, and meals for both the associate and a caregiver.

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One of the best ways to understand the differences between traditional insurance and the COE program is to compare Sean’s and Carla’s experiences from start to finish. All the data included on the timeline is based on Walmart associate averages from 2018, and each patient’s journey is representative of what associates experience with that health care option.

Step 1: Scheduling Surgery

PATIENT ONE

Sean sees a surgeon. A date for surgery is set.

PATIENT TWO

Carla contacts her traditional insurance carrier, where a health care adviser connects her with a TPA. The TPA team handles her intake, and a nurse gathers her relevant health history.

Next, a hospital that is part of Walmart’s COE program is selected based on Carla’s location.

A team at the hospital, comprising coordinators, doctors, nurses, and administrators, collects and reviews her MRI images and medical records. Carla is connected to the nurse navigator who will guide her through the care process.

Step 2: Heading to the Hospital

PATIENT ONE

Sean wakes up early and his brother drives him to the hospital.

PATIENT TWO

Carla and her sister, who serves as her caregiver, fly to an airport near the hospital, where they are picked up by a sedan service. (There are eight spine centers in the U.S., so air travel is common for Walmart associates seeking treatment.) Carla then meets with her spine care specialists — surgeons, rehabilitation medicine physicians, psychologists, and an internist — along with her nurse navigator.

Doctors determine that spine surgery is the best option for Carla. This isn’t always the case; 54% of her colleagues who are referred to a COE for spine surgery don’t need it due to better treatment options — or because surgery wouldn’t fix their problem. Carla’s surgery is scheduled for the next day.

Step 3: Surgery

PATIENT ONE

Sean has surgery. He stays in the hospital for 2.9 days, the average for associates using traditional insurance.

PATIENT TWO

Carla has surgery. She stays in the hospital for 2.5 days, the average for associates using the COE program. Half a day in a hospital can cost anywhere from $1,000 to $5,000, based on national averages.

Step 4: Recovery

PATIENT ONE

Sean is discharged from the hospital. His brother picks him up and he recovers at home. He’s lucky — 4.9% of associates who have non-COE spine surgery are discharged to a skilled nursing facility because they require additional rehabilitation.

PATIENT TWO

Carla is transferred to a local hotel with her sister. A nurse navigator stays in close contact with them during their stay. They are given a benefits card, paid for by Walmart, that allows them a daily stipend for meals and other expenses.

After postoperative visits with her surgeon, Carla is cleared to travel. (A mere 0.6% of Walmart associates who use the COE for spine surgery are discharged to a skilled nursing facility for rehab.) She and her sister are driven to the airport by a sedan service and fly home.

The nurse navigator reaches out to Carla’s primary care physician to communicate about the surgery, share a summary report, and confirm Carla’s first follow-up appointment. The nurse navigator checks in regularly in case there are unexpected complications. (Patients who need to return to the COE for additional care do so at no charge.)

Step 5: Returning to Work

PATIENT ONE

Sean returns to work after 90 days. In total, Sean pays 50% of his spine surgery costs, which for Walmart associates average around $15,000. As of January 2019, however, the surgery would cost him 100%, or around $30,000; Walmart has changed its health benefits to encourage associates to use the COE program.

PATIENT TWO

Carla returns to work after 75 days. To help Walmart and the COE program assess her experiences and recovery, she completes surveys three, 12, and 24 months after surgery.

In total, and including travel, Carla’s surgery costs her $0. The cost for Walmart is a little over $30,000 — more than Sean’s and Walmart’s payments combined in his case. But the COE is an overall cost saver for the company and its associates, because so many unnecessary surgeries are avoided and outcomes are better at program sites.