September 14, 2023
Effective January 1, 2024, the total joint replacement (TJR) bundle with Providence St. Joseph Health through the Premera Designated Centers of Excellence benefit will be discontinued.
Impact to group size, plan years, and funding type
2024 plan years
- Fully insured small and large groups
- OptiFlex large groups
TJR services will remain covered by a member’s health plan benefits and standard cost shares will apply. Small group members won’t be restricted to Providence St. Joseph facilities for their TJR surgery.
2023 plan years
- Fully insured small and large groups
- OptiFlex large groups
Until the group renews in 2024, they’ll have the Premera Designated Centers of Excellence benefit.
Self-funded groups
- Effective January 1, 2024, the TJR Premera Designated Centers of Excellence benefit will no longer include Providence St. Joseph Health.
- Self-funded groups on the Heritage Prime network are not impacted because Providence St. Joseph Health isn’t included in the network.
Why we made the change
Our focus on ensuring members receive high quality, affordable care hasn’t wavered. Since implementing this benefit in 2019, TJR surgeries began migrating to the outpatient ambulatory surgical center setting. The shift to these outpatient centers was escalated by COVID-19, CMS payment updates, and rapid medical advances in regional pain control, surgical technique, and patient selection. National studies are beginning to demonstrate that TJR in outpatient settings not only offers better outcomes for patients, but also reduces costs and improves member satisfaction.
These medical and industry changes make it easier for members to self-navigate to facilities that provide a high-value experience. As a result, the TJR bundle with Providence St. Joseph was no longer providing the benefits to our members, Premera, or Providence St. Josephs as expected.