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Cami Dobrin
Health and behavioral science
The Big Idea Series /
Transforming Health Care


HOW EMPLOYERS ARE FIXING HEALTH CARE

Walmart has embraced a new approach to improve the quality of care and lower
costs. The results have been dramatic.
by
 * Lisa Woods,
 * Jonathan R. Slotkin,
   and
 * M. Ruth Coleman

by
 * Lisa Woods,
 * Jonathan R. Slotkin,
   and
 * M. Ruth Coleman

March 13, 2019 · Long read
The Big Idea Series / Transforming Health Care

01
How Employers Are Fixing Health Care
02
Inside Employers’ New Health Care Playbook
03
Why Do Employers Provide Health Care in the First Place?
04
Two Surgeries, Two Outcomes
05
What Makes Geisinger’s Destination Care Program Tick

 * Post
 * Post
 * Share
 * Annotate
 * Save
 * Get PDF
 * Buy Copies
 * Print

A 56-year-old man who works at Walmart — we’ll call him Bill — had been
suffering from mild neck pain for years. Recently the pain had worsened, and his
wife noticed a subtle tremor in his hands. An MRI showed some narrowing of the
spinal column along with disc degeneration. A local surgeon explained that
Bill’s best option was spine surgery.

Bill had two choices. He could have the surgery at his community hospital and
absorb deductibles and co-pays. Or he could enter Walmart’s travel surgery
program and fly with his wife to a top spine center in another state, all costs
covered. Bill opted for the travel plan.



 * LW
   Lisa Woods is the senior director of strategy and design for U.S. benefits at
   Walmart.
 * Jonathan R. Slotkin, MD, is the director of spine surgery at Geisinger
   Neuroscience Institute and the associate chief medical informatics officer at
   Geisinger Health.
 * MC
   M. Ruth Coleman is the founder of Health Design Plus and the principal at
   ValTrans Health.

Two weeks later the couple headed to Danville, Pennsylvania, for an evaluation
at Geisinger Medical Center. The team there immediately noticed Bill’s tremor
and some shuffling as he walked. They suspected the problem wasn’t his neck. A
neurologist saw him that day and confirmed the team’s suspicions: Bill had
Parkinson’s disease.

The team conferred with Bill’s local doctors to map out a plan of care. The next
morning Bill and his wife flew home, and he began treatment, which was covered
under Walmart’s standard plan. He paid exactly zero for a correct diagnosis and
avoided potentially dangerous surgery that wouldn’t have helped — and Walmart
saved about $30,000 by averting the unnecessary procedure. Bill’s symptoms have
dramatically improved, and he’s returned with new energy to his hobbies and
work.


. . .

For competitive companies, providing quality coverage is good business. It helps
attract and retain employees (good health plans are a sought-after benefit), and
workers who receive good, affordable care are more satisfied and productive. But
that coverage is expensive, and costs are rising. Employer spending on health
care services increased by 44% per enrollee from 2007 to 2016, reaching an
annual amount of nearly $700 billion in 2017 — roughly what the Pentagon spends
on defense. Walmart alone spends billions of dollars a year on health care for
its associates (as the company refers to its employees).

Much is at stake: Various actors in the health care ecosystem, some large
insurers and providers among them, benefit from an arrangement that layers on
administrative costs and rewards volume, not value. Yet business as usual is
unsustainable for those absorbing the costs and experiencing the uneven quality
of care. Pioneering employers and providers are in a position to upend the
status quo and change expectations about what affordable, quality care can and
should be. What follows is an account of our experience with one important
effort, among several being tried, to find a better way.

Walmart and other innovative companies, including Lowe’s, McKesson, GE, and
Boeing, are disrupting how employers pay for care by taking insurers out of the
equation and contracting directly with leading health systems. Working closely
with providers such as Geisinger, the Mayo Clinic, Johns Hopkins, and Virginia
Mason, and with the help of specialized consultants, they are crafting bundled
payment arrangements that cover the cost of an employee’s care for certain
episodes from start to finish — all the procedures, devices, tests, drugs, and
services needed for, say, a knee replacement or a back surgery. They’re also, in
most instances, picking up the tab for any necessary travel, lodging, and meals
for the employee and a caregiver, thus democratizing destination care programs
that have historically been reserved as an executive perk. Bill is one of many
notable successes of Walmart’s six-year-old Centers of Excellence program, which
covers several common surgeries, cancer evaluations (to confirm the diagnosis
and treatment), and, through the integration of an earlier initiative, organ
transplants.

COE programs are at the vanguard of U.S. companies’ efforts to control health
care costs while providing employees with superior care, and results have been
dramatic. Working with teams at our respective organizations, we have played key
roles in crafting Walmart’s initiatives with Geisinger and other clinical
partners: Lisa as the senior director of strategy and design for U.S. benefits
at Walmart, Jonathan as the director of spine surgery at Geisinger’s
Neuroscience Institute, and Ruth as the founder of the third-party administrator
Health Design Plus. As we’ll show, the resulting bundled care programs have
saved the company and its associates tens of millions of dollars and produced
better outcomes than conventional care has. To the best of our knowledge, the
data we provide below is the most thorough and transparent on employer-purchased
care ever published. Drawing on this experience and that of other companies and
providers, we offer guidance that many employers, even midsize companies, can
apply.


WHAT’S DRIVING COMPANIES

Employers provide the lion’s share of health care coverage in the United States.
They insure 49% of Americans, while government entities (principally Medicare
and Medicaid) cover another 35%. (The remaining population is self-insured or
uninsured.) Walmart itself, the largest private employer in the world, provides
coverage to more than 1.1 million U.S. associates and their families under its
self-funded plan.

Expense isn’t the only problem employers face. Like other health care
purchasers, companies struggle with tremendous variation in cost and quality
from one provider to the next. Walmart associates live in every state, and costs
for the same service can vary by more than 50% from region to region and
sometimes even within a community — and they often have little relation to
quality. At the extreme end, costs vary more than tenfold; a 2011–2012 survey,
for example, found that hip replacements ranged from $11,100 to almost $126,000
nationwide.



Transforming Health Care: Get the reprint
download PDF buy copies

Such variation makes it hard for companies to accurately budget their health
care expenses. And although employers shoulder much of the growing cost,
employees are absorbing a large and increasing burden too. Nationally, workers’
out-of-pocket expenses (beyond premiums) have increased in parallel with
employers’ costs; according to the Health Care Cost Institute, they topped
$5,600 per person, on average, in 2017.

At the same time Walmart, like most other employers, has had limited control
over the quality of care workers get, given the wide variation in outcomes for
common procedures among different providers. This isn’t a new problem. Nearly 30
years ago Walmart founder Sam Walton was taped at a meeting of his senior
leadership, excoriating the health care industry for gouging payers like Walmart
and, by extension, their employees, himself included. Walton challenged his team
to do something about it. “These people are skinnin’ us alive,” he said. “Not
just here in Bentonville but everywhere else, too….They’re charging us five and
six times what they ought to charge us….So we need to work on a program where
we’ve got hospitals and doctors…saving our customers money and our employees
money. We haven’t even started to do that. And if we don’t get it done this
year, I’m gonna get real upset. I mean real upset.”

That impassioned speech is still talked about as a defining moment for the
company — the point where Walmart turned its formidable procurement capabilities
to the challenge of buying affordable, quality health care. The company didn’t
get it done that year, of course, but it did start on a decades-long project.
There’s a direct line from Walton’s 1991 call to arms to Walmart’s Centers of
Excellence program today.

Companies have long used traditional measures, such as increasing employees’
share of expenses and limiting their access to specialists, with mixed success,
and to workers’ frustration. Only recently have growing numbers taken a more
active role in the development of their health plans, applying their purchasing
power and procurement smarts to do an end run around insurers and negotiate
directly with providers. According to a Willis Towers Watson survey, although
just 6% of employers had such relationships in 2017, 22% said they either
planned to contract directly or would consider doing so by 2019.

These relationships can take many forms, and they use a variety of payment
schemes, including payment of a set amount per enrollee over a defined period
(so-called person-year arrangements); shared-risk contracts, such as an
accountable care organization (ACO) model, which commonly reward hitting quality
and cost targets, penalize missing them, and split any savings or additional
expense between payer and provider; and bundled payments — the single-price,
soup-to-nuts coverage Walmart has negotiated with providers for specific,
defined episodes of care.



WALMART’S ACO INITIATIVES

Accountable care organizations, or ACOs, are clinically integrated
collaborations among doctors, hospitals, and other providers. They seek to
decrease costs and improve outcomes through careful coordination aimed at
eliminating duplication and errors, by applying best practices to reduce
unwarranted variation, and by emphasizing preventive care. They often involve
shared-risk contracts, which pay a set amount per enrollee for a specified
period of time. These contracts may also reward good performance on clinical and
cost goals and penalize falling short.

Beginning in 2016 Walmart has added accountable care plans, or ACPs, to the
medical benefits associates can choose from. It currently has 11 ACOs in select
markets, including Mercy, in Missouri, Oklahoma, and Arkansas; Memorial Hermann
Health System, in Houston; and Ochsner Health System, in the New Orleans area.
Some of these are also Walmart Centers of Excellence providers. ACPs cover many
medical services with a co-pay ($35 for primary care and behavioral health, $75
for specialist and urgent care) and no deductible. Members choose an ACO
provider for all routine primary care. They are covered for out-of-network
medical emergencies but pay the full cost of any nonurgent out-of-network care.
ACP members also have access to Walmart’s Centers of Excellence program.

Walmart has developed not just bundled coverage but also ACO arrangements with
selected providers. In each case the driving principle has been to secure the
highest-quality care at the best price. Bundles, as we’ve seen, are well suited
to travel surgery programs; ACOs work well for broader coverage, including
primary care for associates in a local market — say, the community within a
45-minute drive of a given provider.

In this article we’ll focus on how the travel surgery program works and the
results it has obtained so far.


GETTING STARTED

All employers are trying to control health care costs, but a single-minded focus
on cost containment would be shortsighted. From the start Walmart, like the
providers it partners with, has explicitly pursued health care value — lowered
costs coupled with better outcomes. It would do little good to secure
bargain-priced care if that didn’t help people resume their lives and return to
work.

Walmart had traditionally used various insurance carriers to manage its health
benefits, but those companies were huge and often had limited ability to
innovate and to negotiate on Walmart’s behalf for high-value deals. In 2012,
building on its experience with a long-term relationship with the Mayo Clinic
for organ transplants, the company set out to develop similar arrangements with
other providers for an expanded set of conditions. Early in the discussions its
benefits plan leadership zeroed in on the procedures with the greatest
opportunity for improvement: common and expensive surgeries (those costing more
than $20,000, on average) with high variation in cost and clinical outcomes
across providers. Heart and spine surgeries meet those criteria. What’s more,
they’re risky procedures that, done poorly, can have a devastating impact on a
patient’s health and well-being; in the case of spine surgeries, evidence
suggests that a large number aren’t even necessary. Walmart launched its heart
and spine surgery programs in 2013. It went live with joint replacements (hip
and knee) in 2014, certain cancer evaluations in 2015, and bariatric, or weight
loss, surgery in 2016.

The benefits team knew that crafting and administering these complex contracts
and running the travel program’s ongoing operations would require specialized
expertise — a third-party administrator. TPAs provide care management, claims
administration, and benefits structuring, generally at a fee of 2% to 4% of the
cost of the total plan management, depending on their exact role. Although they
offer full benefits administration, they generally don’t take on insurance risk,
and they are small and flexible enough to craft customized programs for single
employers.

Health Design Plus, or HDP — a TPA founded in 1988 by coauthor Ruth Coleman —
was instrumental in developing and managing Walmart’s program, including its
bundled care contracts.


SELECTING PROVIDERS

Companies that rely on traditional insurance generally view doctors’ offices and
hospitals as mere vendors of care. It’s different with the COE providers Walmart
associates use. Walmart and the HDP team sought true partners — providers that
would share the company’s vision for the program, take a team approach to care,
and include patients and their families in decisions.

The process started with a review of health benefits data to identify providers
that had delivered significant amounts of high-quality service to Walmart
associates. Publicly available information on the quality of care from these and
other providers was also evaluated. On the basis of this analysis, Walmart
reached out to potential hospital partners. Medical centers in targeted regions
throughout the country were selected according to the distribution and needs of
associates. The company focused on integrated systems, in which care is closely
coordinated across constituent provider organizations and clinicians. The
assumption (which has largely been borne out) was that the hospitals in such
systems would be better aligned than others, would resonate more fully with
Walmart’s health care mission, and would be better equipped to take on bundled
rate contracts. Providers participate in bundled pricing much more readily now
than in 2012, but many health systems had to be eliminated from consideration
because they were unwilling or unable to commit to the model.



THE VALUE TO PROVIDERS

As one of the physicians leading Geisinger’s destination care program, I’m
sometimes asked by other health care providers why a health system would enter
into an agreement with employers in which it is paid less for services than it
would be in a conventional fee-for-service arrangement. The answer, in short, is
that clinicians, patients, and the business itself can benefit.

On the clinical side, the exercise of creating and running efficient,
high-touch, multidisciplinary bundled-care programs leads to process
improvements that diffuse to clinicians and patients throughout the organization
and to patients outside of the programs — an important “halo effect.” What’s
more, frequent scheduled collaborations (including an annual in-person summit)
with the other health systems providing care to participating employers
encourages valuable sharing of outcomes data and best practices, improving
everyone’s performance. The data clearly shows that patients win too.

On the business side, travel care contracts with employers, particularly big
ones like Walmart, bring in new patients, usually from far beyond a system’s
local population. These patients represent true business growth. In addition,
direct partnerships with employers generally establish stable, set payments for
services, in contrast to Medicare and conventional fee-for-service arrangements,
where reimbursements can shift — often downward. Finally, participating in these
programs can increase a system’s visibility to other employers, helping attract
new business.

For more on the impact of these programs on systems such as Geisinger, see the
HBR.org article “Why GE, Boeing, Lowe’s, and Walmart Are Directly Buying Health
Care for Employees.”
— Jonathan R. Slotkin, MD

We’ve found that good integration and a willingness to build bundles are
necessary but not sufficient. Becoming a COE provider can suddenly increase
patient volume. Some providers have assumed that the main challenge would be
ensuring adequate surgical capacity. In fact it has to do with the support team
— having enough nurse practitioners, navigators, and other staff members to
manage patients throughout the process. We’ve had to pause referrals to some
medical centers so that they could better prepare for an influx of patients.

Success with bundled contracts turns out to be a good indicator of the
capabilities and character of a hospital and its providers; it shows that a
provider is motivated and able to integrate the work of a diverse clinical team
around a patient’s needs, align incentives to improve value, and track outcomes
to inform continued improvement. Walmart and HDP found that providers with those
capabilities were more likely than others to meet key selection criteria,
including:



 * strong quality indicators, such as low complication rates, good performance
   on patient safety metrics, and systems for measuring quality, including at
   the individual physician level
 * evidence-based, integrated care delivery
 * patient-centered, collaborative, team-based decision making
 * a willingness to construct competitive bundled prices

Although bundled pricing is critical to the program, we intentionally put it
last on our list. Walmart decided that no center would be selected if the first
three criteria weren’t met, no matter how attractive the price.


BUILDING BUNDLES

By defining and pricing all the elements in an episode of care, prospective
bundles (which are defined in advance and paid for soon after the end of each
episode of care) cap costs and can improve quality. They should appeal to
employers for those reasons alone. But they have other advantages, too. They
encourage integrated care, reduce incentives to perform unnecessary care, and
make it easier for employers to accurately predict their health care costs. And
once the initial employer-provider negotiation is concluded, price discussions
are largely off the table. This lets all involved focus on what’s best for the
patient.

As mentioned, employers rarely have the in-house expertise to negotiate bundled
care contracts, and Walmart enlisted the help of Health Design Plus. In
developing a bundle for, say, hip replacements, HDP identifies the procedure’s
standard billable components (which include imaging, tests, devices, and pre-
and postsurgical inpatient care) and negotiates a total price with the provider.
The negotiated rates typically average 10% to 15% less than prices paid under
conventional insurance and traditional fee-for-service reimbursement. In some
cases a bundle may cost slightly more than FFS, because it provides
higher-quality care; unit cost reduction is far from the biggest driver of the
COE program’s financial success. High-quality, ethical providers have lower
complication rates and provide less unnecessary care.

The transparency of the process means that all parties know precisely what is
being bought and paid for. In the spine surgery bundled care program that
Geisinger and other centers provide for Walmart associates, for instance, all
episode-related inpatient care is included, but postdischarge skilled nursing
and rehabilitation isn’t. Bundles might include a second visit, depending on the
type of care (weight loss surgery always involves two visits, for example). And
although providers engage with associates far in advance of travel, the bundled
payment starts when a patient arrives at the hospital and typically ends upon
discharge for the trip home.

Being clear about the arrangement from the start prevents disputes later on
about what’s covered and what’s not — the bane of providers when dealing with
insurers. Of course, it’s impossible to predict every contingency, so contracts
need some flexibility. Patients might require unanticipated tests or have
unforeseen complications, such as a previously undiagnosed cancer or a fall
after arrival but before care. Provisions in the contracts address surprise
costs and assure fair compensation for the provider (without shifting those
surprise costs to the patient) — a feature that reinforces the sense that the
employer and the provider are partners in patients’ care, not adversaries
jockeying to minimize their own costs. All procedures include a warranty: If a
patient has complications and needs to return for further treatment within 30
days, the provider does not receive additional compensation for that care.

When managing bundled arrangements for employers, HDP oversees the entire
process, from initial employee referral to discharge home and payment of claims.
Although the provider ultimately decides what care is needed, if there are
anticipated or actual charges outside the bundle, HDP approves payment on a
case-by-case basis. Because the COEs are so carefully vetted and are regarded as
team members, conflicts about charges are rare. The various clinical sites,
along with HDP and Walmart, have frequent calls; during them, clinical feedback
from the sites is occasionally used to expand (and more rarely to remove)
covered services.

A known risk of bundled payment strategies is that they can create incentives
for providers to perform more episodes of care. This can be mitigated in various
ways, including having strict treatment criteria defined by the provider
organization and selecting only providers with a track record of sound clinical
decision making and integrity.


THE PROGRAM IN ACTION

Most Walmart health care benefits are covered by traditional self-funded plans
managed by a major carrier, but associates are encouraged through incentives and
various communications to use the COE program for the surgeries we’ve described.
Promotions across the company intranet, open enrollment materials, testimonial
videos, benefits portals, and other channels tout the program’s upsides: access
to superior providers; all travel, lodging, and meals covered for the associate
and a caregiver companion (except in the case of weight loss surgery); and (with
a few other exceptions) no co-payments, coinsurance, or deductibles.

Associates who are eligible for the program can choose not to use it — but at a
cost. Beginning in 2017, those opting for spine surgery outside of the COE
network (to avoid travel, for example) had to pick up half the total cost; the
amount climbed to 100% in 2019. The same applies to associates who want surgery
even though the COE concludes it’s not needed. In 2018 Walmart instituted a 50%
co-pay for non-COE joint replacements. (These charges are always waived for
emergent and urgent conditions.) The co-pays have driven a dramatic increase in
utilization: After Walmart introduced the one for joint replacements, the number
of patients choosing to have their surgery at a COE site increased by 113%.

Associates typically start to engage with the program when they are clearly on a
path to surgery. The first step is to connect with HDP. A customer service team
there conducts an initial triage; if the associate meets the basic criteria for
the program, she is put in touch with a dedicated nurse-management team.
Continuity of care is critical for good outcomes, so associates are accepted
into the program only if a local physician — usually a primary care doctor — has
agreed to provide follow-up care after the patient’s return. The nursing team
educates the associate about the process, evaluates her self-reported clinical
status and symptoms, and, if she meets more-detailed program criteria, refers
her to the appropriate provider. Program coordinators and specialist physicians
at the COE take over at this point. They review the patient’s records to
determine whether surgery or a medical evaluation visit (in the cases of spine
and bariatric surgeries) is appropriate; if so, the provider submits a plan of
care to HDP and schedules a surgery or a nonoperative visit.

HDP handles all logistical and financial arrangements and communicates the
details with the associate and her caregiver. The caregiver is much more than a
companion; he or she must be an able adult who can meet specific support
requirements and assist the patient after leaving the hospital and with travel
home. HDP verifies that the caregiver has agreed to this role before the
associate receives final approval.

Unless they choose to drive themselves, the associate and her caregiver board a
flight a day or two before the surgery. They are picked up by a hired sedan at
the airport in the provider’s city and brought to a hotel experienced in hosting
postsurgical patients. The next day they make a short trip to the hospital,
where they connect with the navigators and nurse coordinators who will shepherd
them throughout their stay. The associate also meets the treatment team for a
medical evaluation; barring the unexpected, the surgery is performed the
following day. Inpatient stays vary according to procedure and patient status
but are generally a few days. The associate is discharged to the hotel, and
after the medical team issues an all-clear, she and her caregiver are driven to
the airport for their flight home.

The medical team communicates with the associate’s local physician about her
experience, clinical status, and follow-up care, and the COE provider remains
available as needed. Most centers check in frequently with the patient and her
local doctor to track her recovery. Payments now revert to the associate’s
standard benefits. A dedicated HDP nurse relays her status and care needs to a
nurse at her insurance carrier, who arranges any additional care related to the
episode in the rare cases when that’s needed.

More than 5,000 associates have participated in Walmart’s travel program, and
the overwhelming majority give it high marks. Despite the disruption inherent in
travel, HDP surveys find that more than 95% of patients are “satisfied” or “very
satisfied” with the care and the overall experience. One associate said, “This
has been the best medical experience of my life. This is the most important
benefit of working at Walmart.” The company and its COE clinical sites have
received scores of similar, unsolicited testimonials.

Of course, some patients have been less thrilled; complaints from the small
percentage who are “dissatisfied” tend to center on the decision not to move
forward with surgery. In most cases these patients have been told by their local
doctor that surgery can heal them; learning otherwise can be frustrating and
disappointing. In other cases COE surgery isn’t an option because of health
issues such as obesity and tobacco use. Although we work with these patients on
necessary lifestyle changes, the experience of being denied surgery and advised
to lose weight or quit smoking doesn’t always sit well.

Other challenges range from the merely inconvenient — travel patients have
missed pre-op appointments because they were sightseeing — to the serious: One
year we had to divert patients from several locations because of hurricanes and
wildfires. Preparing for the unexpected is a less obvious but critical part of
running the program.


POSITIVE OUTCOMES

The happiness most participants report with their COE experience stems in part
from its concierge aspect. But good outcomes and affordability also boost
satisfaction. Patients receiving their care at the centers do better, on
average, than other patients on a host of clinical measures — and recall that in
most cases they pay nothing. We’ll look now at data for three of the travel
programs in turn. (Unless otherwise specified, the statistics given for them
represent averages.)

 

1. SPINE SURGERY

Almost half of the Walmart associates who had spine surgery or a medical
evaluation without surgery from 2015 to 2018 did so at a COE site. That group,
totaling 2,300 patients, was divided equally between men and women, and most
were 50 to 64 years old.

One reason for the good outcomes is the fact that, as we’ve discussed, the
program heads off unnecessary or inappropriate surgeries in favor of
more-effective, less dangerous, and less expensive treatments. It prevented more
than half of the surgeries recommended by non-COE providers.




Among associates who did undergo surgery, those at COE sites spent 14% less time
in the hospital than those who went outside the program…




…and their likelihood of readmission was 95% lower.




Because of the relatively good health status of COE patients postsurgery, only
0.6% of them had to be discharged to a skilled nursing facility for monitoring
and rehabilitation, compared with 4.9% of patients receiving surgery outside of
the program.




Patients at COE sites returned to work sooner than non-COE patients, shaving 20%
off their time away.




The cost to Walmart for surgery at a COE site is about $2,400 (8%) higher than
that at a non-COE site, but as we’ve just seen, the payoffs are considerable:
earlier discharge, lower readmission rates, far less utilization of skilled
nursing facilities, and faster return to work. And the slightly higher cost per
case is more than offset by the hundreds of surgeries that are appropriately
avoided and by improved outcomes.




 

2. JOINT REPLACEMENT SURGERY

Eighteen percent of the Walmart associates who had joint replacement surgery
from 2015 to 2018 had it at a COE site. Roughly two-thirds of these 1,836
patients were women, and most were 50 to 64 years old.

Here, too, COE specialists headed off unnecessary procedures, having determined
that many patients would not benefit more from surgery than from
more-conservative treatments, such as physical therapy, or had health reasons
that rendered surgery inadvisable.




Among the associates who had surgery, those at COE sites spent 32% less time in
the hospital than those who went outside the program.




Because COE patients experienced fewer postsurgical complications, they were 70%
less likely than non-COE patients to be readmitted.




Given their relatively good health status postsurgery, none of the COE patients
needed a skilled nursing facility after discharge, compared with more than 5% of
the patients treated outside the program.




And because they were discharged sooner and recovered more quickly, the COE
patients returned to work a week and a half sooner than their non-COE
counterparts.




Walmart’s cost per case is about 15% less at COE sites than at non-COE
hospitals, and the savings from avoiding inappropriate surgeries and from better
outcomes are great.




 

3. BARIATRIC SURGERY

As we’ve discussed, obesity can cause or exacerbate medical problems such as
diabetes and high blood pressure. It can be expensive for employers and
employees alike: Medical and pharmaceutical costs can exceed $10,000 per member
per month. Bariatric surgery — which reduces the size of the stomach, routes
food past it, or limits the amount that can be eaten — can help people lose
weight and keep it off. Walmart covers 75% of the procedure’s cost; patients pay
the rest, along with their travel expenses. The surgery is offered only through
the travel program, so we lack data comparing it with non-COE care. Still, early
results are promising.

To date more than 300 associates have had the surgery. Three-quarters were
women; the average age was 46. Before surgery the group’s average body mass
index was just over 50. (For reference, a 5’4” woman with a BMI of 50 would
weigh 291 pounds; a 5’9” man with a BMI of 50 would weigh 338 pounds.) Six
months after surgery the women had lost an average of 39 pounds, the men 45.

It’s too soon to know definitively whether this weight loss reduces absenteeism
or so-called presenteeism (working while sick), but preliminary data suggests
so. We do know that it dramatically cuts pharmacy and medical costs. Those
decreases reflect the profound impact of the surgery on patients’ health:
Complications of obesity drop sharply, as does the need for medication.




Sources of savings. To understand exactly how the COE programs save money, HDP
has analyzed direct cost reductions, the effects of care quality and decreased
complications on cost, and the impact of avoided costs, including surgeries
recommended outside the COE program but not performed along with reductions in
hospital readmissions, additional operations, and the use of skilled nursing
facilities. For the 2017 benefits year we estimate that Walmart, Lowe’s, and
McKesson together saved $19.4 million through their spine and joint surgery
programs (Walmart associates made up a majority of those patients). About
one-third of the savings resulted from direct cost reductions; the rest came
from the avoidance of unnecessary care and a decrease in complications.


WHAT’S NEXT FOR WALMART — AND FOR U.S. HEALTH CARE

We’ve focused here on Walmart, but a growing number of other companies have
launched or are developing similar value-based, direct-to-provider programs,
sometimes sharing models, partners, and resources, in conjunction with HDP or
one of the several other capable TPAs operating nationally.

Next In
Transforming Health Care
Inside Employers’ New Health Care Playbook



Organizations big and small are contracting directly with providers for bundled
care and other services. Here’s how to get started.






A BRIEF (AND INCOMPLETE) HISTORY OF VALUE-BASED PURCHASING BY EMPLOYERS

1997 Walmart contracts directly with the Mayo Clinic as its exclusive provider
for organ transplant surgeries.

2010 Lowe’s begins a program with the Cleveland Clinic to provide eligible
full-time employees and their covered dependents with enhanced benefits coverage
for qualifying cardiac procedures.

2010 Lowe’s engages Health Design Plus to assist in designing and managing a
Centers of Excellence program for heart surgery.

2013 Walmart launches COE cardiac and spine surgery programs at five hospitals
and health systems.

2013 Intel and Presbyterian Healthcare Services debut Connected Care, an
initiative with novel risk-sharing arrangements and a value-centered payment
structure that includes bonuses for hitting certain quality and financial
targets.

2014 Walmart launches COE hip and knee replacement programs.

2015 Boeing starts offering employees access to narrow-network local care
delivery initiatives in several cities. This direct employer-purchasing
arrangement has provided more than 15,000 employees with benefits, including low
or no co-pays, same-day appointments, and access to expanded digital-health
tools.

2015 Walmart launches a COE cancer evaluations program.

2016 Walmart launches a COE bariatric surgery program.

2018 Dallas Area Rapid Transit launches an accountable care organization
offering with the Baylor Scott & White Quality Alliance. It emphasizes
preventive care, measurable outcomes, and the involvement of providers with a
population health-management perspective.



In tandem with the rise of these programs is the emergence of business
coalitions that help employers connect with superior providers and advocate for
value-based contracts. To that end Walmart has partnered with HDP and the
Pacific Business Group on Health, a San Francisco–based not-for-profit
employer-advocacy organization, to create the Employers Centers of Excellence
Network, or ECEN. The state of Washington, through its Health Care Authority,
has selected two hospital systems to cover hip and knee replacements and spine
care for its employees, with clinical standards and bundled pricing informed in
part by the Bree Collaborative. Dozens of purchaser coalitions exist in the
United States, providing a smorgasbord of resources and services; nearly 40 can
be found within the National Alliance of Healthcare Purchaser Coalitions, which
serves 12,000 purchasers. What they broadly have in common is a focus on helping
employers use their clout to improve the value of care for their employees.
These employers’ combined scale (NAHPC members alone cover 45 million Americans)
strongly suggests that companies will become an increasingly powerful force in
the transformation of U.S. health care — and providers and commercial insurers
should pay heed.

All this may look very complex — and when first approached, it is. We advise
employers and providers contemplating direct employer-purchased care not to wait
while they assess the feasibility, clinical benefits, and return on investment;
we, and coalitions such as ECEN, have already done that work. As legacy
insurance companies assume less and less insurance risk (while often operating
at a notable surplus), it makes sense for health care purchasers and providers
to connect directly, and many validated approaches for doing so exist. The right
providers and an experienced third-party administrator can lift the burden from
the employer. Although there will be demanding work up front, once programs are
established the work becomes less complex, and even more of the burden is borne
by the TPA and the providers. The return in both dollars and employee wellness
and satisfaction is high.

Walmart CEO Doug McMillon has publicly stated that health care now represents
one of the company’s two most significant areas of innovation focus (digital
transformation is the other). So, what does the future hold? Walmart’s COE
program ensures that associates get high-quality care; however, it is not
realistic to think that employers can ask employees to travel for all types of
care, or that travel is always the best approach. By design Walmart’s program
has focused on acute episodic surgical care. General medical and chronic
conditions such as diabetes, high blood pressure, and heart disease are more
common and, in aggregate, more costly in both dollars and employee health and
well-being. Care for them is often best done by the top providers in patients’
own communities. Walmart’s ultimate goal is to bring a COE-level experience to
the communities where its associates live, offering convenience, quality, and
transparent, fair pricing. This will also allow the company to measure and
continuously improve the impact of its programs on health.

Employers will shoulder a substantial portion of the cost of U.S. health care
for the foreseeable future. Until recently they’ve had few options but to shift
some of the growing cost to employees and fight for rate decreases. Those
tactics have not stemmed rising costs and have done little to address quality.
But as we and others have found, higher-quality care is reliably the most
cost-efficient. The success of Walmart and other employers in improving health
care value through direct partnerships can be a model for others, helping them
address the cost-and-quality dilemma and drive change nationally. We urge other
companies to act on Sam Walton’s call to arms.The Big Idea

Read more on Health and behavioral science or related topic Personnel policies
 * LW
   Lisa Woods is the senior director of strategy and design for U.S. benefits at
   Walmart.
 * Jonathan R. Slotkin, MD, is the director of spine surgery at Geisinger
   Neuroscience Institute and the associate chief medical informatics officer at
   Geisinger Health.
 * MC
   M. Ruth Coleman is the founder of Health Design Plus and the principal at
   ValTrans Health.

 * Post
 * Post
 * Share
 * Annotate
 * Save
 * Get PDF
 * Buy Copies
 * Print

The Big Idea Series / Transforming Health Care
01
How Employers Are Fixing Health Care
02
Inside Employers’ New Health Care Playbook
03
Why Do Employers Provide Health Care in the First Place?
04
Two Surgeries, Two Outcomes
05
What Makes Geisinger’s Destination Care Program Tick
Read more on Health and behavioral science or related topic Personnel policies


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MAGNITE, INC.

Cookie duration: 365 (days).

Data collected and processed: Device characteristics, Probabilistic identifiers,
Browsing and interaction data, IP addresses, Privacy choices, Device
identifiers, Non-precise location data, Precise location data

more

Uses other forms of storage.


View details | Storage details | Privacy policylaunch
ConsentLegitimate interesthelp_outline


RATEGAIN ADARA INC

Cookie duration: 730 (days).

Data collected and processed: Device characteristics, Users’ profiles,
Authentication-derived identifiers, Browsing and interaction data, IP addresses,
Privacy choices, Device identifiers, Non-precise location data, User-provided
data

more




View details | Storage details | Privacy policylaunch
Consent


SIFT MEDIA, INC

Doesn't use cookies.

Data collected and processed: Device characteristics, IP addresses, Device
identifiers, Non-precise location data, Precise location data

more




View details | Privacy policylaunch
Consent


RAKUTEN MARKETING LLC

Cookie duration: 730 (days).

Data collected and processed: Device characteristics, Probabilistic identifiers,
Users’ profiles, Authentication-derived identifiers, Browsing and interaction
data, IP addresses, Privacy choices, Device identifiers, Non-precise location
data, User-provided data

more

Cookie duration resets each session. Uses other forms of storage.


View details | Privacy policylaunch
ConsentLegitimate interesthelp_outline


LUMEN RESEARCH LIMITED

Doesn't use cookies.

Data collected and processed: Device characteristics, Browsing and interaction
data, IP addresses, Non-precise location data

more




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Legitimate interesthelp_outline


AMAZON AD SERVER

Cookie duration: 396 (days).

Data collected and processed: Device characteristics, Users’ profiles,
Authentication-derived identifiers, Browsing and interaction data, IP addresses,
Privacy choices, Device identifiers, Non-precise location data

more

Cookie duration resets each session. Uses other forms of storage.


View details | Storage details | Privacy policylaunch
ConsentLegitimate interesthelp_outline


OPENX

Cookie duration: 365 (days).

Data collected and processed: Device characteristics, Browsing and interaction
data, IP addresses, Privacy choices, Device identifiers, Non-precise location
data

more

Cookie duration resets each session.


View details | Storage details | Privacy policylaunch
Consent


YIELDLAB (VIRTUAL MINDS GMBH)

Cookie duration: 365 (days).

Data collected and processed: Device characteristics, Users’ profiles, Browsing
and interaction data, IP addresses, Privacy choices, Device identifiers,
Non-precise location data, Precise location data, User-provided data

more

Cookie duration resets each session.


View details | Storage details | Privacy policylaunch
Consent


ROKU ADVERTISING SERVICES

Cookie duration: 396 (days).

Data collected and processed: Device characteristics, Probabilistic identifiers,
Users’ profiles, Authentication-derived identifiers, Browsing and interaction
data, IP addresses, Privacy choices, Device identifiers, Non-precise location
data, Precise location data, User-provided data

more

Cookie duration resets each session. Uses other forms of storage.


View details | Storage details | Privacy policylaunch
ConsentLegitimate interesthelp_outline


SIMPLIFI HOLDINGS LLC

Cookie duration: 366 (days).

Data collected and processed: IP addresses, Device identifiers, Precise location
data

more

Uses other forms of storage.


View details | Privacy policylaunch
Consent


PUBMATIC, INC

Cookie duration: 90 (days).

Data collected and processed: Device characteristics, Probabilistic identifiers,
Users’ profiles, Authentication-derived identifiers, Browsing and interaction
data, IP addresses, Privacy choices, Device identifiers, Non-precise location
data, Precise location data, User-provided data

more

Uses other forms of storage.


View details | Storage details | Privacy policylaunch
ConsentLegitimate interesthelp_outline


COMSCORE B.V.

Cookie duration: 720 (days).

Data collected and processed: Device characteristics, Probabilistic identifiers,
Authentication-derived identifiers, Browsing and interaction data, IP addresses,
Privacy choices, Device identifiers, User-provided data

more

Cookie duration resets each session. Uses other forms of storage.


View details | Privacy policylaunch
Consent


FLASHTALKING

Cookie duration: 730 (days).

Data collected and processed: Device characteristics, Probabilistic identifiers,
Users’ profiles, Authentication-derived identifiers, Browsing and interaction
data, IP addresses, Privacy choices, Device identifiers, Non-precise location
data

more




View details | Privacy policylaunch
Consent


PULSEPOINT, INC.

Cookie duration: 365 (days).

Data collected and processed: Device characteristics, IP addresses, Device
identifiers

more

Cookie duration resets each session. Uses other forms of storage.


View details | Privacy policylaunch
Consent


SMAATO, INC.

Cookie duration: 21 (days).

Data collected and processed: Device characteristics, Users’ profiles,
Authentication-derived identifiers, Browsing and interaction data, IP addresses,
Privacy choices, Device identifiers, Non-precise location data, Precise location
data, User-provided data

more

Cookie duration resets each session. Uses other forms of storage.


View details | Storage details | Privacy policylaunch
ConsentLegitimate interesthelp_outline


SEMASIO GMBH

Cookie duration: 366 (days).

Data collected and processed: Browsing and interaction data, IP addresses,
Privacy choices, Device identifiers

more

Cookie duration resets each session.


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Consent


CRIMTAN HOLDINGS LIMITED

Cookie duration: 365 (days).

Data collected and processed: Device characteristics, Probabilistic identifiers,
Users’ profiles, Authentication-derived identifiers, Browsing and interaction
data, IP addresses, Privacy choices, Device identifiers, Non-precise location
data, Precise location data, User-provided data

more

Cookie duration resets each session.


View details | Privacy policylaunch
ConsentLegitimate interesthelp_outline


GENIUS SPORTS UK LIMITED

Cookie duration: 365 (days).

Data collected and processed: Device characteristics, Probabilistic identifiers,
Users’ profiles, Authentication-derived identifiers, Browsing and interaction
data, IP addresses, Privacy choices, Device identifiers, Non-precise location
data

more

Cookie duration resets each session.


View details | Storage details | Privacy policylaunch
Consent


CRITEO SA

Cookie duration: 390 (days).

Data collected and processed: Device characteristics, Probabilistic identifiers,
Users’ profiles, Authentication-derived identifiers, Browsing and interaction
data, IP addresses, Privacy choices, Device identifiers, Non-precise location
data

more

Uses other forms of storage.


View details | Storage details | Privacy policylaunch
ConsentLegitimate interesthelp_outline


ADLOOX SA

Doesn't use cookies.

Data collected and processed: Device characteristics, Probabilistic identifiers,
Browsing and interaction data, IP addresses, Device identifiers, Non-precise
location data

more

Uses other forms of storage.


View details | Privacy policylaunch
ConsentLegitimate interesthelp_outline


BLIS GLOBAL LIMITED

Cookie duration: 400 (days).

Data collected and processed: Device characteristics, Probabilistic identifiers,
Users’ profiles, Authentication-derived identifiers, Browsing and interaction
data, IP addresses, Privacy choices, Device identifiers, Non-precise location
data, Precise location data, User-provided data

more

Cookie duration resets each session. Uses other forms of storage.


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Consent


LOTAME SOLUTIONS, INC

Cookie duration: 274 (days).

Data collected and processed: Device characteristics, Probabilistic identifiers,
Users’ profiles, Authentication-derived identifiers, Browsing and interaction
data, IP addresses, Privacy choices, Device identifiers, User-provided data

more

Cookie duration resets each session. Uses other forms of storage.


View details | Privacy policylaunch
Consent


LIVERAMP

Cookie duration: 365 (days).

Data collected and processed: Device characteristics, Authentication-derived
identifiers, Browsing and interaction data, IP addresses, Privacy choices,
Device identifiers, Non-precise location data

more

Cookie duration resets each session. Uses other forms of storage.


View details | Storage details | Privacy policylaunch
Consent


GROUPM UK LIMITED

Cookie duration: 395 (days).

Data collected and processed: Device characteristics, Probabilistic identifiers,
Authentication-derived identifiers, Browsing and interaction data, IP addresses,
Privacy choices, Device identifiers, Non-precise location data, Precise location
data

more

Cookie duration resets each session.


View details | Storage details | Privacy policylaunch
ConsentLegitimate interesthelp_outline


LOOPME LIMITED

Cookie duration: 90 (days).

Data collected and processed: Device characteristics, Probabilistic identifiers,
Users’ profiles, Browsing and interaction data, IP addresses, Privacy choices,
Device identifiers, Non-precise location data, Precise location data,
User-provided data

more

Cookie duration resets each session. Uses other forms of storage.


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Consent


DYNATA LLC

Cookie duration: 365 (days).

Data collected and processed: Device characteristics, Users’ profiles,
Authentication-derived identifiers, Browsing and interaction data, IP addresses,
Privacy choices, Device identifiers, Non-precise location data, User-provided
data

more

Cookie duration resets each session.


View details | Storage details | Privacy policylaunch
Consent


ASK LOCALA

Doesn't use cookies.

Data collected and processed: Device characteristics, IP addresses, Privacy
choices, Device identifiers, Non-precise location data, Precise location data

more

Uses other forms of storage.


View details | Privacy policylaunch
Consent


NEAR INTELLIGENCE

Doesn't use cookies.

Data collected and processed: Device characteristics, Users’ profiles, Browsing
and interaction data, IP addresses, Privacy choices, Device identifiers,
Non-precise location data, Precise location data

more

Uses other forms of storage.


View details | Privacy policylaunch
ConsentLegitimate interesthelp_outline


DOUBLEVERIFY INC.

Doesn't use cookies.

Data collected and processed: Device characteristics, Probabilistic identifiers,
Browsing and interaction data, IP addresses, Privacy choices, Non-precise
location data

more




View details | Privacy policylaunch
Legitimate interesthelp_outline


BIDSWITCH GMBH

Cookie duration: 365 (days).

Data collected and processed: Device characteristics, Probabilistic identifiers,
Authentication-derived identifiers, Browsing and interaction data, IP addresses,
Privacy choices, Device identifiers, Non-precise location data, Precise location
data

more

Cookie duration resets each session. Uses other forms of storage.


View details | Storage details | Privacy policylaunch
Consent


IPONWEB GMBH

Cookie duration: 365 (days).

Data collected and processed: Device characteristics, Authentication-derived
identifiers, Browsing and interaction data, IP addresses, Privacy choices,
Device identifiers, Non-precise location data, User-provided data

more

Cookie duration resets each session. Uses other forms of storage.


View details | Storage details | Privacy policylaunch
Consent


NEXTROLL, INC.

Cookie duration: 183 (days).

Data collected and processed: Device characteristics, Users’ profiles, Browsing
and interaction data, IP addresses, Privacy choices, Device identifiers,
Non-precise location data, User-provided data

more

Cookie duration resets each session.


View details | Privacy policylaunch
Consent


TEADS FRANCE SAS

Cookie duration: 365 (days).

Data collected and processed: Device characteristics, Probabilistic identifiers,
Users’ profiles, Browsing and interaction data, IP addresses, Privacy choices,
Device identifiers, Non-precise location data

more

Uses other forms of storage.


View details | Storage details | Privacy policylaunch
ConsentLegitimate interesthelp_outline


STRÖER SSP GMBH (SSP)

Cookie duration: 365 (days).

Data collected and processed: Device characteristics, Probabilistic identifiers,
Users’ profiles, Browsing and interaction data, IP addresses, Privacy choices,
Device identifiers, Non-precise location data

more

Uses other forms of storage.


View details | Storage details | Privacy policylaunch
ConsentLegitimate interesthelp_outline


OS DATA SOLUTIONS GMBH & CO. KG

Cookie duration: 90 (days).

Data collected and processed: Device characteristics, Probabilistic identifiers,
Users’ profiles, Browsing and interaction data, IP addresses, Privacy choices,
Device identifiers, Non-precise location data, User-provided data

more

Uses other forms of storage.


View details | Storage details | Privacy policylaunch
ConsentLegitimate interesthelp_outline


PERMODO GMBH

Doesn't use cookies.

Data collected and processed: Device characteristics, Users’ profiles, Browsing
and interaction data, IP addresses, Privacy choices, Device identifiers,
Non-precise location data

more

Uses other forms of storage.


View details | Privacy policylaunch
Consent


PLATFORM161 B.V.

Cookie duration: 396 (days).

Data collected and processed: Device characteristics, Probabilistic identifiers,
Users’ profiles, Browsing and interaction data, IP addresses, Privacy choices,
Device identifiers, Non-precise location data, Precise location data

more

Cookie duration resets each session. Uses other forms of storage.


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Consent


ADACADO TECHNOLOGIES INC. (DBA ADACADO)

Cookie duration: 365 (days).

Data collected and processed: Browsing and interaction data, IP addresses,
Privacy choices, Non-precise location data

more

Cookie duration resets each session.


View details | Storage details | Privacy policylaunch
Consent


BASIS GLOBAL TECHNOLOGIES, INC.

Cookie duration: 365 (days).

Data collected and processed: Device characteristics, Users’ profiles,
Authentication-derived identifiers, Browsing and interaction data, IP addresses,
Privacy choices, Device identifiers, Non-precise location data, Precise location
data

more

Cookie duration resets each session.


View details | Privacy policylaunch
ConsentLegitimate interesthelp_outline


SMADEX, S.L.U.

Cookie duration: 365 (days).

Data collected and processed: Device characteristics, Probabilistic identifiers,
Users’ profiles, IP addresses, Privacy choices, Device identifiers, Non-precise
location data, User-provided data

more

Cookie duration resets each session.


View details | Storage details | Privacy policylaunch
Consent


BOMBORA INC.

Cookie duration: 365 (days).

Data collected and processed: Device characteristics, Users’ profiles,
Authentication-derived identifiers, Browsing and interaction data, IP addresses,
Device identifiers, Non-precise location data

more

Cookie duration resets each session. Uses other forms of storage.


View details | Storage details | Privacy policylaunch
ConsentLegitimate interesthelp_outline


EASYMEDIA GMBH

Cookie duration: 365 (days).

Data collected and processed: Device characteristics, Probabilistic identifiers,
Users’ profiles, Browsing and interaction data, IP addresses, Privacy choices,
Device identifiers, Non-precise location data, Precise location data

more

Cookie duration resets each session.


View details | Storage details | Privacy policylaunch
Consent


REMERGE GMBH

Doesn't use cookies.

Data collected and processed: Device characteristics, Browsing and interaction
data, IP addresses, Device identifiers, Non-precise location data

more

Uses other forms of storage.


View details | Privacy policylaunch
ConsentLegitimate interesthelp_outline


ADVANCED STORE GMBH

Cookie duration: 365 (days).

Data collected and processed: Device identifiers

more

Cookie duration resets each session. Uses other forms of storage.


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ConsentLegitimate interesthelp_outline


MAGNITE CTV, INC.

Cookie duration: 366 (days).

Data collected and processed: Device characteristics, Probabilistic identifiers,
Browsing and interaction data, IP addresses, Privacy choices, Device
identifiers, Non-precise location data, Precise location data

more




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ConsentLegitimate interesthelp_outline


DELTA PROJECTS AB

Cookie duration: 365 (days).

Data collected and processed: Device characteristics, Probabilistic identifiers,
Users’ profiles, Authentication-derived identifiers, Browsing and interaction
data, IP addresses, Privacy choices, Device identifiers, Non-precise location
data, Precise location data, User-provided data

more




View details | Storage details | Privacy policylaunch
ConsentLegitimate interesthelp_outline


USEMAX ADVERTISEMENT (EMEGO GMBH)

Cookie duration: 365 (days).

Data collected and processed: Users’ profiles

more

Cookie duration resets each session.


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Consent


EMETRIQ GMBH

Cookie duration: 365 (days).

Data collected and processed: Device characteristics, Probabilistic identifiers,
Users’ profiles, Authentication-derived identifiers, Browsing and interaction
data, IP addresses, Privacy choices, Device identifiers, Non-precise location
data, User-provided data

more

Cookie duration resets each session. Uses other forms of storage.


View details | Storage details | Privacy policylaunch
Consent


PUBLICIS MEDIA GMBH

Cookie duration: 1825 (days).

Data collected and processed: Device characteristics, Probabilistic identifiers,
Users’ profiles, Authentication-derived identifiers, Browsing and interaction
data, IP addresses, Privacy choices, Device identifiers, Non-precise location
data, User-provided data

more

Cookie duration resets each session. Uses other forms of storage.


View details | Privacy policylaunch
Consent


M.D. PRIMIS TECHNOLOGIES LTD.

Cookie duration: 25 (days).

Data collected and processed: Device characteristics, Probabilistic identifiers,
Browsing and interaction data, IP addresses, Privacy choices, Device
identifiers, Non-precise location data, User-provided data

more




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ConsentLegitimate interesthelp_outline


ONETAG LIMITED

Cookie duration: 396 (days).

Data collected and processed: Device characteristics, Browsing and interaction
data, IP addresses, Privacy choices, Device identifiers, Non-precise location
data

more

Cookie duration resets each session. Uses other forms of storage.


View details | Storage details | Privacy policylaunch
Consent


CLOUD TECHNOLOGIES S.A.

Cookie duration: 365 (days).

Data collected and processed: Device characteristics, Users’ profiles,
Authentication-derived identifiers, Browsing and interaction data, IP addresses,
Privacy choices, Device identifiers, Non-precise location data

more

Cookie duration resets each session.


View details | Privacy policylaunch
Consent


SMARTOLOGY LIMITED

Doesn't use cookies.

Data collected and processed: IP addresses

more

Uses other forms of storage.


View details | Privacy policylaunch
ConsentLegitimate interesthelp_outline


IMPROVE DIGITAL

Cookie duration: 90 (days).

Data collected and processed: Device characteristics, Probabilistic identifiers,
Users’ profiles, Authentication-derived identifiers, Browsing and interaction
data, IP addresses, Privacy choices, Device identifiers, Non-precise location
data, Precise location data, User-provided data

more

Cookie duration resets each session.


View details | Storage details | Privacy policylaunch
ConsentLegitimate interesthelp_outline


ADOBE ADVERTISING CLOUD

Cookie duration: 365 (days).

Data collected and processed: Authentication-derived identifiers, IP addresses,
Privacy choices, Device identifiers

more




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ConsentLegitimate interesthelp_outline


BANNERFLOW AB

Cookie duration: 366 (days).

Data collected and processed: Device characteristics, IP addresses, Privacy
choices, Non-precise location data

more




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ConsentLegitimate interesthelp_outline


TABMO SAS

Doesn't use cookies.

Data collected and processed: Device characteristics, Probabilistic identifiers,
Users’ profiles, Browsing and interaction data, IP addresses, Privacy choices,
Device identifiers, Non-precise location data, Precise location data,
User-provided data

more

Uses other forms of storage.


View details | Privacy policylaunch
Consent


INTEGRAL AD SCIENCE (INCORPORATING ADMANTX)

Doesn't use cookies.

Data collected and processed: Device characteristics, Browsing and interaction
data, IP addresses, Privacy choices, Non-precise location data

more




View details | Privacy policylaunch
Legitimate interesthelp_outline


WIZALY

Cookie duration: 365 (days).

Data collected and processed: Device characteristics, Authentication-derived
identifiers, Browsing and interaction data, IP addresses, Privacy choices,
Non-precise location data

more

Cookie duration resets each session. Uses other forms of storage.


View details | Storage details | Privacy policylaunch
Consent


WEBORAMA

Cookie duration: 393 (days).

Data collected and processed: Device characteristics, Probabilistic identifiers,
Users’ profiles, Authentication-derived identifiers, Browsing and interaction
data, IP addresses, Privacy choices, Device identifiers, Non-precise location
data, User-provided data

more

Uses other forms of storage.


View details | Storage details | Privacy policylaunch
ConsentLegitimate interesthelp_outline


JIVOX CORPORATION

Cookie duration: 30 (days).

Data collected and processed: Users’ profiles, Browsing and interaction data, IP
addresses, Privacy choices, Device identifiers, Non-precise location data,
Precise location data

more

Cookie duration resets each session.


View details | Storage details | Privacy policylaunch
Consent


SAGE+ARCHER BV

Doesn't use cookies.

Data collected and processed: Non-precise location data

more




View details | Privacy policylaunch
Consent


ON DEVICE RESEARCH LIMITED

Cookie duration: 30 (days).

Data collected and processed: Device characteristics, Browsing and interaction
data, IP addresses, Device identifiers, Non-precise location data, Precise
location data, User-provided data

more




View details | Storage details | Privacy policylaunch
Consent


ROCKABOX MEDIA LTD

Doesn't use cookies.

Data collected and processed: Device characteristics, Browsing and interaction
data, IP addresses, Non-precise location data

more




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Legitimate interesthelp_outline


EXACTAG GMBH

Cookie duration: 180 (days).

Data collected and processed: Device characteristics, Authentication-derived
identifiers, Browsing and interaction data, IP addresses, Privacy choices,
Device identifiers

more

Cookie duration resets each session.


View details | Storage details | Privacy policylaunch
Consent


CELTRA INC.

Doesn't use cookies.

Data collected and processed: Device characteristics, IP addresses, Device
identifiers, Precise location data

more

Uses other forms of storage.


View details | Storage details | Privacy policylaunch
Consent


MAINADV SRL

Cookie duration: 30 (days).

Data collected and processed: Device characteristics, Browsing and interaction
data, IP addresses, Privacy choices, Device identifiers, Non-precise location
data, User-provided data

more

Uses other forms of storage.


View details | Privacy policylaunch
Consent


GEMIUS SA

Cookie duration: 1825 (days).

Data collected and processed: Device characteristics, Users’ profiles, Browsing
and interaction data, Privacy choices, Device identifiers

more

Cookie duration resets each session. Uses other forms of storage.


View details | Storage details | Privacy policylaunch
Consent


THE KANTAR GROUP LIMITED

Cookie duration: 914 (days).

Data collected and processed: Device characteristics, Browsing and interaction
data, IP addresses, Privacy choices, Device identifiers, Non-precise location
data

more

Cookie duration resets each session. Uses other forms of storage.


View details | Privacy policylaunch
Consent


NIELSEN MEDIA RESEARCH LTD.

Cookie duration: 120 (days).

Data collected and processed: Device characteristics, Browsing and interaction
data, IP addresses, Privacy choices, Device identifiers

more

Cookie duration resets each session. Uses other forms of storage.


View details | Storage details | Privacy policylaunch
ConsentLegitimate interesthelp_outline


SOLOCAL SA

Cookie duration: 396 (days).

Data collected and processed: Device characteristics, Users’ profiles, Browsing
and interaction data, IP addresses, Privacy choices, Device identifiers,
Non-precise location data, Precise location data, User-provided data

more

Cookie duration resets each session. Uses other forms of storage.


View details | Storage details | Privacy policylaunch
ConsentLegitimate interesthelp_outline


PIXALATE, INC.

Doesn't use cookies.

Data collected and processed: Device characteristics, Browsing and interaction
data, IP addresses, Device identifiers, Non-precise location data

more




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Consent


ORACLE ADVERTISING

Cookie duration: 180 (days).

Data collected and processed: Device characteristics, Users’ profiles,
Authentication-derived identifiers, Browsing and interaction data, IP addresses,
Privacy choices, Device identifiers, Non-precise location data, User-provided
data

more

Uses other forms of storage.


View details | Storage details | Privacy policylaunch
Consent


NUMBERLY

Cookie duration: 180 (days).

Data collected and processed: Device characteristics, Users’ profiles,
Authentication-derived identifiers, Browsing and interaction data, IP addresses,
Privacy choices, Device identifiers, Non-precise location data, User-provided
data

more

Cookie duration resets each session.


View details | Storage details | Privacy policylaunch
Consent


AUDIENCEPROJECT APS

Cookie duration: 365 (days).

Data collected and processed: Device characteristics, Probabilistic identifiers,
Users’ profiles, Authentication-derived identifiers, Browsing and interaction
data, IP addresses, Privacy choices, Device identifiers, Non-precise location
data, User-provided data

more

Cookie duration resets each session. Uses other forms of storage.


View details | Storage details | Privacy policylaunch
ConsentLegitimate interesthelp_outline


DEMANDBASE, INC.

Cookie duration: 730 (days).

Data collected and processed: Device characteristics, Probabilistic identifiers,
Users’ profiles, Browsing and interaction data, IP addresses, Privacy choices,
Device identifiers, Non-precise location data, Precise location data,
User-provided data

more

Cookie duration resets each session. Uses other forms of storage.


View details | Storage details | Privacy policylaunch
Consent


EFFILIATION / EFFINITY

Cookie duration: 2 (days).

Data collected and processed: Device characteristics

more

Cookie duration resets each session. Uses other forms of storage.


View details | Privacy policylaunch
Consent


SEENTHIS AB

Doesn't use cookies.

Data collected and processed: Device characteristics, IP addresses

more




View details | Privacy policylaunch


COMMANDERS ACT

Cookie duration: 365 (days).

Data collected and processed: IP addresses, Device identifiers

more




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Consent


TRAVEL AUDIENCE GMBH

Cookie duration: 397 (days).

Data collected and processed: Device characteristics, Probabilistic identifiers,
Users’ profiles, Authentication-derived identifiers, Browsing and interaction
data, IP addresses, Device identifiers, Non-precise location data, Precise
location data

more

Cookie duration resets each session. Uses other forms of storage.


View details | Privacy policylaunch
Consent


HUMAN

Doesn't use cookies.

Data collected and processed: Device characteristics, Probabilistic identifiers,
IP addresses, Device identifiers, Non-precise location data

more




View details | Privacy policylaunch
Legitimate interesthelp_outline


ADLUDIO LTD.

Doesn't use cookies.

Data collected and processed: Device characteristics

more




View details | Privacy policylaunch
Consent


BLENDEE SRL

Cookie duration: 366 (days).

Data collected and processed: Device characteristics, Users’ profiles,
Authentication-derived identifiers, Browsing and interaction data, IP addresses,
Privacy choices, Device identifiers, Non-precise location data, User-provided
data

more

Cookie duration resets each session. Uses other forms of storage.


View details | Storage details | Privacy policylaunch
Consent


INNOVID LLC

Cookie duration: 90 (days).

Data collected and processed: Device characteristics, Browsing and interaction
data, IP addresses, Privacy choices, Device identifiers, Non-precise location
data

more

Cookie duration resets each session.


View details | Storage details | Privacy policylaunch
ConsentLegitimate interesthelp_outline


PAPIRFLY AS

Doesn't use cookies.

Data collected and processed: Device characteristics

more




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Legitimate interesthelp_outline


NEUSTAR, INC., A TRANSUNION COMPANY

Cookie duration: 365 (days).

Data collected and processed: Device characteristics, Probabilistic identifiers,
Users’ profiles, Authentication-derived identifiers, Browsing and interaction
data, IP addresses, Privacy choices, Device identifiers, Non-precise location
data, User-provided data

more

Cookie duration resets each session. Uses other forms of storage.


View details | Privacy policylaunch
ConsentLegitimate interesthelp_outline


VERVE GROUP EUROPE GMBH

Doesn't use cookies.

Data collected and processed: Device characteristics, Users’ profiles,
Authentication-derived identifiers, Browsing and interaction data, IP addresses,
Privacy choices, Device identifiers, Non-precise location data, Precise location
data, User-provided data

more

Uses other forms of storage.


View details | Privacy policylaunch
Consent


OTTO (GMBH & CO KG)

Cookie duration: 365 (days).

Data collected and processed: Users’ profiles, Browsing and interaction data, IP
addresses, Privacy choices, Device identifiers, User-provided data

more

Cookie duration resets each session. Uses other forms of storage.


View details | Storage details | Privacy policylaunch
ConsentLegitimate interesthelp_outline


ADOBE AUDIENCE MANAGER, ADOBE EXPERIENCE PLATFORM

Cookie duration: 180 (days).

Data collected and processed: Device characteristics, Probabilistic identifiers,
Users’ profiles, Authentication-derived identifiers, Browsing and interaction
data, IP addresses, Privacy choices, Device identifiers, Non-precise location
data, Precise location data, User-provided data

more

Cookie duration resets each session.


View details | Privacy policylaunch
Consent


LOCALSENSOR B.V.

Doesn't use cookies.

Data collected and processed: Device characteristics, IP addresses, Privacy
choices, Device identifiers, Non-precise location data, Precise location data

more

Uses other forms of storage.


View details | Privacy policylaunch
Consent


ONLINE SOLUTION

Cookie duration: 365 (days).

Data collected and processed: Device characteristics, Probabilistic identifiers,
Users’ profiles, Browsing and interaction data, IP addresses, Privacy choices,
Device identifiers, Non-precise location data, Precise location data,
User-provided data

more

Cookie duration resets each session. Uses other forms of storage.


View details | Privacy policylaunch
Consent


RELAY42 NETHERLANDS B.V.

Cookie duration: 730 (days).

Data collected and processed: Device characteristics, Probabilistic identifiers,
Users’ profiles, Browsing and interaction data, IP addresses, Privacy choices,
Device identifiers, User-provided data

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GP ONE GMBH

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THE MEDIAGRID INC.

Cookie duration: 365 (days).

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MINDTAKE RESEARCH GMBH

Cookie duration: 180 (days).

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CINT AB

Cookie duration: 730 (days).

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GOOGLE ADVERTISING PRODUCTS

Cookie duration: 396 (days).

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GFK GMBH

Cookie duration: 730 (days).

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REVJET

Cookie duration: 730 (days).

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PROTECTED MEDIA LTD

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CLINCH LABS LTD

Cookie duration: 730 (days).

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ORACLE DATA CLOUD - MOAT

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HEARTS AND SCIENCE MÜNCHEN GMBH

Cookie duration: 60 (days).

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AMAZON ADVERTISING

Cookie duration: 396 (days).

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MOLOCO, INC.

Cookie duration: 730 (days).

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ADTRIBA GMBH

Cookie duration: 730 (days).

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OBJECTIVE PARTNERS BV

Cookie duration: 90 (days).

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ENSIGHTEN

Cookie duration: 1825 (days).

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EBAY INC

Cookie duration: 90 (days).

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HURRA COMMUNICATIONS GMBH

Cookie duration: 366 (days).

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