Defining Centers of Excellence - WCRI · 2020-04-27 · Are and How to Assemble Them." BMC Health...

© WCRI 2019

Defining Centers Of Excellence

Randall D. Lea MD, MPH

October 10, 2019

© WCRI 2019

About WCRI

• Independent, not-for-profit research organization providing high-quality, objective information about public policy issues involving workers' compensation systems

• Serve as a resource for public officials and stakeholders, but we do not make recommendations or take positions

• Studies are peer-reviewed with a focus on benefit delivery

• Diverse membership support, including gov’t agencies, employers, insurers, labor unions, service providers, etc.

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© WCRI 2019

About The Webinar

• The presentation is 60 minutes long: 45 minutes of slides and 15 minutes for your questions

• To submit a question, use the “Questions” box located on the right-hand side of your screen

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About The Webinar (Cont.)

• A copy of the slides can be downloaded under “Handouts” on the right-hand side of your screen

• Today’s presentation is being recorded and will be provided within 48 hours

• At the end of the webinar we ask that you take a short online survey. For every completed survey, WCRI will donate $2.00 to Kids’ Chance

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Your Presenter - Randall D. Lea MD, MPH

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• Currently serves as a Senior Research Fellow at Workers Compensation Research Institute

• Interim Chief Medical Officer for a health system in the Midwest.

• Past president of the American Academy of Disability Evaluating Physicians (IAIME) and was their alternate delegate to the AMA through May 2018.

• Served as a member of the American Academy of Orthopedic Surgeons’ Occupational Health Committee.

• Obtained his medical degree from LSU School of Medicine in New Orleans and completed all of his orthopedic training at the Tulane University School of Medicine

• In 2011, Dr. Lea took a one-year sabbatical and completed his MPH at The Dartmouth Institute for Health Policy and Clinical Practice in New Hampshire.

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Background: Why This Topic?

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• WCRI already studies a multitude of variables and factors

• Health Services Researchers and Health System Scientists highlight the importance of care delivery & design and how they influence clinical outcomes

• This is becoming more important given the different care models that are emerging; some of which may have policy relevance in workers compensation

• WCRI need to understand the different designs and consider how they might impact our study results

© WCRI 2019

Today’s Objectives

• Provide a definition for a center of excellence; identify the parts that combine together to make up a center

• Describe how they compare with other care delivery models

• Offer some explanation(s) for why centers of excellence may still be relevant in our current environment and what role they might play

• Do they really improve care or decrease costs?

• Potential opportunities??

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Centers Of Excellence: Definition

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• No universally agreed upon definition; term used for different reasons and different contexts

????

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Source: Elrod, James K., and John L. Fortenberry. "Centers of Excellence in Healthcare Institutions: What They Are and How to Assemble Them." BMC Health Services Research 17.1 (2017): 425.

“A program within a healthcare institution which is assembled to supply an exceptionally high concentration of expertise and related resources centered on a particular area of medicine, delivering associated care in a comprehensive, interdisciplinary fashion to afford the best patient outcomes”

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PROVIDER CREDENTIALING

• Board Certification

• Maintenance of Certification

• Fellowship Training

• Case Volumes

CENTER ACCREDITATION

• Governmental

• Payers/Insurance

• Specialty Societies

• Clinic or Physician Groups(s)

• Joint Commission

Centers Of Excellence: Expertise

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TEACHING

CULTURE OFLEARNING

RESEARCH

Centers Of Excellence: Expertise

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Centers Of Excellence: Resources

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FACILITIES & ANCILLARIES

TECHNOLOGY & DIAGNOSTICS

PERSONNEL

RESOURCES

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Centers Of Excellence: “Particular Area of Medicine”

“CUREABLE”• Most Pneumonias• Duodenal Ulcers• Uncomplicated wrist fractures

“MANAGEABLE”• Diabetes• Hypertension• Degenerative Spine

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TWO TYPES OF “CONDITIONS” IN HEALTHCARE

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Centers Of Excellence: “Particular Area of Medicine”

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Disease management is for those conditions that:- Complex and perhaps not curable- High/variable costs- Large variation in outcomes

Commonly the foundation for centers of excellence:- e.g. Spine, Pain, Infertility, Transplant

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Centers Of Excellence: Care That Is “Associated”, “Comprehensive”, And “Interdisciplinary”

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Optum: “…health care that is planned, coordinated and provided by a team of experts who specialize in your condition and regularly work together”

How is all of that achieved?

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“MULTI-””

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Physicians

Physical/OccupationalTherapist

Case Management

Nursing

Vocational Rehabilitation

INTERDISCIPLINARY ??

INTERPROFESSIONAL ??

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MEDICAL TREATMENT GUIDELINES

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CARE COORDINATION/ COMMUNICATION:

• What? Timely, frequent, and accurate; transitions and barriers to care, referrals, etc.

• By Whom? In-house…. new trend?

• To Whom? Patient and Payer

• Physician Role: Robust communication between providers

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Centers Of Excellence: Outcomes

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Source: Elrod, James K., and John L. Fortenberry. "Centers of Excellence in Healthcare Institutions: What They Are and How to Assemble Them." BMC Health Services Research 17.1 (2017): : 425.


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QUALITY

OUTCOMES

More Accurate Diagnoses

Shorter LengthOf Stays

Return ToWork ??

Fewer ComplicationsHigher Survival Rates

Fewer Repeat

Surgeries

Fewer Readmissions

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Centers Of Excellence: Two More Attributes

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COST

Joe Patient

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Centers Of Excellence: Two More Attributes

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PatientCentered ??

Joe Patient

SharedDecision Making

ValidPatient

Satisfaction

AccessTo Services

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Centers Of Excellence: Terms

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Joe Patient

Institute Service Line

Accountable Care Organization

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Accountable Care Organizations : Review

• Provider responsibility for more than just quality or clinical outcome …….Cost of care

• Payment linked to outcome

• Includes most, if not all , services for all conditions and procedures for an entire population, over a set time frame.

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Centers Of Excellence: Are They Still Relevant ?

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PAYERS HEALTH SYTEMS PROVIDERS

- Marketing- Recruitment- Provider Alignment

- Quality- Cost

- Negotiate/Compete With Hospital; Other Providers

- Ancillaries

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Centers Of Excellence: Service Gaps

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VendorOpportunities

Personnel

Protocols

Training

Telemedicine

Modular Based Full Service :“Carve-Out”

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Centers of Excellence: Do they improve outcomes?

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ARTICLE RESULTMehrotra, Ateev, et al. "Evaluation of a centers of excellence program for knee and hip replacement." Medical care 51.1 (2013): 28.

‐ Lower complication rate for Hip surgery in Center of Excellence but no difference for Knee surgeries

‐ No difference in costs for hip surgeriesMehrotra, Ateev, et al. "Evaluation of a center of excellence program for spine surgery." Medical care 51.8 (2013): 748.

‐ Spine center of excellence had similar complication and rates than non‐center of excellence facilities

Zhang, Hui, David W. Cowling, and Matthew Facer. "Comparing the effects of reference pricing and centers‐of‐excellence approaches to value‐based benefit design." Health Affairs 36.12 (2017): 2094‐2101.

‐ Center of excellence will impact use and utilization but not cost (ref based pricing had a larger impact)

Ibrahim, Andrew M., et al. "Variation in outcomes at bariatric surgery centers of excellence." JAMA surgery 152.7 (2017): 629‐636.

‐ Even in high performing centers that are accredited, there is wide variation in complication rates

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“CUREABLE”Most PneumoniasDuodenal Ulcers

Uncomplicated wrist fractures

“MANAGEABLE”Diabetes

HypertensionDegenerative Spine

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TWO TYPES OF “CONDITIONS” IN HEALTHCARE

- Some, but incomplete evidence based guides- Still associated with high cost and variability

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PATIENT -CENTERED

CLINICAL CONDITION OF

INTEREST

EXPERTISE

COMPRHENSIVE/MULTIDISCIPLINARY

COSTS/FINANCIAL

QUALITY/OUTCOMES

RESOURCES

CENTERS OF EXCELLENCE

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Example: Pain And Function

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• What is likelihood of complete pain relief?

• What is expected degree of pain relief?

• What is likelihood of return to work?

• What is the likelihood of chronic opioids?

• How do center’s outcomes compare with regional and national benchmarks ?

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Example: Utilization Of Services

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• What are your MRI rates; Rehab?; Meds?; Surgery?; Injections?

• How do they compare with regional and national benchmarks?

• Help define right service combinations and utilization rates

• If multidisciplinary, and not on a risk based contract, what are you cross-referral rates and costs?

• What is your policy on new technology?

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Example: Compliance With Standards

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• What is the provider compliance rate with clinic’s established guidelines?

• How do you address deviations from those guidelines?

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Example: Patient Centeredness

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• How is patient satisfaction measured?

• How are patient concerns or disputes about care addressed?(especially if captive group)?

• How do you identify and address the non-medical barriers to recovery, the social determinants of health, and the patient at-risk for chronic disease and disability?

• How do you measure and ensure equity of care among patients? Too much vs not enough care? Access?

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• Not just centers of excellence, but centers of…..- transparency - true accountability- measurable improvement

• Distinguish marketing from true excellence

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Centers Of Excellence: Conclusion

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Case Volume References:

• de Steiger, R.N., Lorimer, M. and Solomon, M., 2015. What is the learning curve for the anterior approach for total hip arthroplasty?. Clinical Orthopaedics and Related Research®, 473(12), pp.3860-3866.

• Torres, A., Goldberg, T., Bush, J.W. and Mahometa, M.J., 2019, April. LEARNING CURVE FOR DIRECT ANTERIOR APPROACH FOR TOTAL HIP ARTHROPLASTY. In Orthopaedic Proceedings (Vol. 101, No. SUPP_4, pp. 66-66). The British Editorial Society of Bone & Joint Surgery.

• Low, J.B., Du, J., Zhang, K. and Yue, J.J., 2012. ProDisc-L learning curve: 24-Month clinical and radiographic outcomes in 44 consecutive cases. International journal of spine surgery, 6, pp.184-189.

• Moga, I., Konstantinidis, G., Coady, C., Ghosh, S. and Wong, I.H.B., 2018. Arthroscopic Anatomic Glenoid Reconstruction: Analysis of the Learning Curve. Orthopaedic journal of sports medicine, 6(11), 2325967118807906.

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CENTERS OF EXCELLENCE

PATIENT -CENTERED

CLINICAL CONDITION OF INTEREST

EXPERTISE

COMPRHENSIVE/MULTIDISCIPLINARY

COSTS/FINANCIAL

QUALITY/OUTCOMES

RESOURCES

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Thank You!

• As mentioned earlier, you will be asked to take a quick survey when you exit out of this webinar

• Registration is open for WCRI’s 2020 Conference, March 5 and 6 in Boston, MA. Learn more at https://conference.wcrinet.org/

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Defining Centers of Excellence - WCRI · 2020-04-27 · Are and How to Assemble Them." BMC Health...

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