The Workers’ Compensation Research Institute (WCRI) hosted a webinar Thursday addressing “centers of excellence” (CsOE). The CsOE system is a delivery of care model that is emerging in workers’ comp to improve outcomes and decrease costs.
What are centers of excellence?
Orthopedic surgeon and WCRI senior research fellow Dr. Randall Lea led the webinar by defining CsOE and comparing them to other delivery care models like accountable care organizations (ACOs) and pay for performance.
“The term center of excellence is a descriptor, but there is no one accepted definition,” Lea said. However, Lea favors a definition from Dr. James K. Elrod, as follows:
“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.”
From this definition, there are several characteristics that in combination indicate a center of excellence:
- Expertise and related resources
- Board-certification and other types of provider credentials, fellowship training, and case volumes
- Center accreditation from government, payers/insurance, specialty societies, clinic or physician groups, and/or joint commissions
- Teaching, research, and culture of learning
- Resources: personnel, technology and diagnostics, and facilities and ancillaries
- “Particular area of medicine”
- Both curable and manageable conditions play into this
- Centers of excellence emerge in areas of manageable conditions like spine centers and infertility clinics
- Care that is “associated, comprehensive, and interdisciplinary”
- Many care providers work together with a team spirit and focus less on power differentials
- In workers’ comp, treatment guidelines offer standardization, but care coordination particularly matters
In sum, Dr. Lea explained, the idea of CsOE is to use these interdisciplinary assets to improve measurable outcomes: fewer complications, more accurate diagnoses, shorter length of stays, fewer repeat surgeries, and return to work. “Every part of the definition is done to create quality care, and so excellence and the measurement and management of outcomes is the cornerstone of a center of excellence,” Dr. Lea explained. “It’s not just token measures to meet a target to receive a financial reward, but those that are meaningful.”
What does the literature say?
Dr. Lea then asked attendees if they thought the definition was missing anything, after which he added two additional elements to the original definition. First, he noted that health care reform under the Affordable Care Act has garnered the emergence of new payment models, so cost is a significant factor. Secondly, patient-centeredness must reign supreme.
“We have the pay-for-performance, the risk-based models, all of those are very important so you can’t forget about them in the new era of health care,” Dr. Lea said, referring to such regulations like Obama-era reforms like penalties for hospital readmissions. “But more importantly, virtually everything should have a patient-centered focus.”
In the realm of patient-centered focus, Dr. Lea especially emphasized the patient’s role in care. “Patient-centered focus should have evidence of two things – patient engagement based on detailed and meaningful shared decision-making,” he said. “And then secondly, patient satisfaction marked by valid patient satisfaction metrics and tools and superior access to services.”
As far as research into centers of excellence, the demonstrable results vary depending on the study. Dr. Lea highlighted three studies. One study out of Harvard compared costs and complication rates for hip and knee replacements and found a lower complication rate for hip surgery but no difference in cost. Another study looked at utilization and cost and compared centers of excellence and facilities that used reference-based pricing. That author found lower utilization as CsOE but not lower costs. A third study assessed complication rates in bariatric surgeries at CsOE, and found a wide variation even among the high-performing centers.
Despite these gaps in the literature, Dr. Lea still believes that there are opportunities for care improvement and thought leadership in centers of excellence, especially for incurable, chronic conditions. “My proposition is this,” he said. “Perhaps a center of excellence can start to answer some of those unanswerable questions we have about clinical conditions, especially those we might be able to manage but not cure.”
WCRI regularly hosts free webinars about their research endeavors. Learn more about WCRI here.