EviCore SOC Solution
Jun 21st 2023

EviCore's Site of Care Solution: Same Quality Care, Lower Costs, Satisfied Patients

Significant Opportunities in Musculoskeletal, Gastroenterology and Radiology

EviCore healthcare by Evernorth’s mission is to help patients get evidence-based care that meets their individual clinical needs in order to optimize health outcomes and lower costs.

A natural extension of that work is making sure the location where patients get that care is appropriate. Why? Because when it comes to the location of care, “costs can vary widely, but the outcomes are often as good or better at a lower-cost site of care,” shares Dr. Robert Westergan, EviCore’s Associate Chief Medical Officer of Connected Musculoskeletal (MSK) Solutions. “What’s more, patients typically prefer the experience at a non-hospital setting.”

While there are situations when hospital care is necessary, alternative sites like ambulatory surgery centers, freestanding imaging centers and clinics are often the smarter choice. And you may be surprised by just how much they can save.

Wide Cost Variations Across Sites of Care

MSK, gastroenterology and radiology are three fields with significant opportunities to help guide patients to high-quality, more affordable sites of care.

For example, research indicates cost savings of 30-40% for knee and hip procedures performed in an outpatient vs. inpatient setting — with no increased risk of 90-day complication rates or readmission rates. Despite these findings, less than 15% of knee and hip procedures are performed in outpatient settings.

In radiology, the average national cost of hospital-based imaging services is almost three times the cost of receiving those same services at freestanding imaging centers or physicians’ offices. However, 60% of imaging is still performed in a hospital setting — typically with no clinical reason the patient couldn’t go to the lower-acuity setting.

Guiding Patients to High-Quality, Lower-Cost Facilities

EviCore’s Site of Care solution offers three levels of management to ensure the right care at the right cost:

1. SmartChoice® proactively educates patients about facility options for approved procedures based on cost, quality, and convenience. Available for EviCore’s Radiology Solution, this educational program empowers patients to choose the option that works best for them. Once a procedure (like an MRI, CT or PET scan) is approved, our highly trained SmartChoice team acts as a concierge to the patient by providing information like same-quality facility availability, the cost of services at each facility, and appointment coordination. We also send reminders to help ensure the patient follows through with their appointment. Additionally, EviCore’s team makes sure the referring provider is informed of any decision the patient makes to ensure continuity of care.

2. Site of Care utilizes medical necessity review to ensure the appropriateness of a particular site of care, applying evidence-based clinical guidelines. It requires a medical reason when a higher-acuity setting like a hospital is requested in certain cases, such as large joint or spine surgeries. The request is reviewed against evidence-based guidelines to help ensure the patient gets the procedure in the most appropriate setting for their needs. Site of Care medical necessity review is available for EviCore’s Radiology, Gastroenterology, Medical Oncology and MSK solutions.

3. Site-Only Review manages only the facility selection when there would be value in having the procedure performed in a lower-cost setting, but no authorization is required for a procedure itself. For example, surgery to treat carpal tunnel syndrome doesn’t require medical necessity review, but the procedure is more cost-effective in an office setting without sacrificing patient safety. Site-Only Review ensures that patients get the care they need at an appropriate, affordable location.

“Our work is centered on ensuring members and providers are selecting a clinically appropriate and economical place to deliver care,” said Christa Gassler, Senior Director of Affordability at EviCore. “Patients’ safety and well-being is always our top priority, and cost is only considered once we ensure a site of care is appropriate for the patient’s needs and offers quality service.”

For more information about EviCore’s Site of Care solutions, email sales@evicore.com.