Rush University Medical Center launched a partnership with United Airlines to provide hip and knee replacement and spine-fusion surgeries to all 80,000 of the carrier’s workers and their dependents across the U.S. They’ll receive care at a fixed cost, waving any deductible or coinsurance, and United will even cover the travel costs.

What have been the biggest challenges to making this run as planned so far?

ESTES: Capacity is always a concern, but I think we’ve worked that out pretty well. We have a schedule where, as patients come through the program, we rotate them across a panel of physicians so we’re not overburdening any particular doctor, and we have set aside and have a requirement internally for access. Once we deem a patient appropriate for surgery, we have a time frame that we’ve agreed to in order to get them in. We do have a shuffling-of-the-deck process internally to make sure that we can receive patients in a timely fashion. If the program really grows, that could become more of a challenge over time, but that would be a good problem to have to solve. I think the other issue we’ll have to focus on is collecting longer-term outcomes data to then present back to United Airlines to show the ongoing value of the program.

Why isn’t this type of arrangement more common in Chicago and elsewhere?

ESTES: Well, you have to have a pretty robust infrastructure to make it work from an operational perspective, and then there’s obviously the reputational aspect of it as well. Part of what makes Rush an attractive partner for people in orthopedics and spine is because we’re nationally ranked for those programs and have been for a number of years. We have the reputation behind us that is a door-opener, but then when you do bundled payments, you have to have a lot of processes to make sure that the physicians and the hospitals don’t bill in their normal course of business. Otherwise, it’s a mess for the customer on the back end. We’ve put together a whole process where we are responsible for aggregating all the billings of the providers and we package it into one single bill, send it to a third-party administrator that United Airlines has contracted to administer the centers of excellence program exclusively. They’ve carved that out of their normal health insurer relationship, and we have another organization with whom we work for these cases, and then that third-party administrator adjudicates the benefits on the cases. We get the single payment to our organization and have relationships in place with all the clinicians who provide care to the patient, and we make the distributions ourselves. It really simplifies the process for the employer, as well as their third-party administrator. For most organizations, unless they employ all the doctors, it’s difficult to begin to do that.

What does the future hold for these sorts of contracts with employers?

ESTES: I actually think that these direct-contracting relationships are going to grow. Centers of excellence and bundled payments are a good place for many employers to start because it’s not upsetting their whole benefits strategy. National employers are more willing now than they ever have been to entertain options like this, or even narrow networks, either through their carrier partner or with health systems on a local basis. We don’t have any of those emerging yet in Chicago, but I know that, in other parts of the country, employers are more interested in talking with health systems directly about so-called ACO arrangements or narrow networks. Locally, we do have an opportunity to provide a center of excellence program to more than just employers like United. I think there are opportunities in the municipal space, the labor space and even with smaller employers, as well. It’s probably going to take a couple more years before this becomes pretty common. United is a little more progressive in its thinking than a lot of other employers, but once it starts to happen, it will happen pretty quickly.