If the best practices produce higher quality at lower cost, then where do you go to get the best?
An increasing body of evidence shows that best practices produce higher quality at lower cost. But how and where do you get the best?
"Centers of excellence." The lofty term once figured prominently in health care reform debates. They "popped up like mushrooms," recalls R. William Whitmer, president of the Health Enhancement Research Organization. But with so many facilities claiming that designation and no clear criteria to validate a center's level of excellence in a particular specialty, "they pretty much faded away."
Like old soldiers, however, they didn't die. The designation is still used for facilities that specialize in organ and bone marrow transplants, as well as treatment of severe burns. In other cases, it's sometimes a matter of semantics. That presents an ongoing problem for employers who are more determined than ever to spend every health care dollar wisely.
David Kasiarz, VP, compensation, benefits and risk management for The Pepsi Bottling Group in Somers, N.Y., for instance, stresses the importance of giving employees facing severe or life-threatening illnesses the opportunity to receive care at institutions that are "the best of the best." He's referring to facilities like New York's Memorial Sloan-Kettering Cancer Center. It's a policy he's trying to expand, although health plan provisions and providers themselves can make it difficult to implement, Kasiarz says.
More often, though, the focus among purchasers and health plans has shifted to finding and contracting with or encouraging enrollees to use the best hospitals within their area. How exactly are they chosen? Well, often on the basis of overall performance Among the criteria being used to identify them: morbidity and mortality rates, if they're available; report cards or rankings, such as Solucient's annual list of 100 Top Hospitals; safety measures, such as the use of a computerized physician order entry (CPOE) system to avoid medication errors; and volume.
Jean Chenoweth, executive director of the Solucient Institute, reports increasing interest in the hospitals that make its Top 100 list chosen on the basis of clinical outcomes and cost efficiency on the part of insurers, managed care organizations and employers. Some hospitals report that health plans are more interested in contracting with them if they make the list, Chenoweth reports. "And some employers send lists of the winners to their managed care organizations or third party administrations and ask, Are these in our network?'"
The 100 or so leading corporations that are members of the Leapfrog Group have zeroed in on three very specific measures of hospital safety and quality. A preferred facility must have a computerized prescribing system to detect and flag potential errors, staff its intensive care units with specialists in critical care and meet criteria for evidence-based hospital referral. To fulfill this last standard, a hospital must perform at least 500 heart bypass surgeries and 400 angioplasties each year, plus satisfy the group's specific volume requirements for five other high-risk conditions or procedures. "It also includes publicly reported risk-adjusted outcomes," says Suzanne Delbanco, executive director of the Leapfrog Group, "but this data is very rarely available; so you can use volume as a proxy."
Members have pledged to recognize and reward hospitals that meet these standards, Delbanco adds. But whether that will mean simply making the findings available to enrollees and letting them make the choice, using financial incentives to steer them to the facilities that measure up, or contracting only with those that make the grade is not clear. "We're not prescriptive about how they implement it," she says, and it's likely that strategies will vary.
What is clear is that all employees will receive the information. "We're all trying to get to a point where people understand that it matters where they go," Delbanco concludes.
Determining where enrollees will get the best and most cost-effective care remains far from clear-cut. A University of Michigan Health System study released last year questioned the prevailing notion that every candidate for coronary artery bypass should be directed to a high-volume facility or what the researchers call the "practice makes perfect effect." Their conclusion, reported in the December 2001 issue of The Journal of the American College of Cardiology, is that the majority of patients can safely be operated on at hospitals that perform less than 200 bypasses each year. For patients with additional risk factors, such as diabetes, high blood pressure or other complicating health problems, however, experience (read: high volume) remains important, they say.
HealthGrades, a Lakewood, CO, quality purveyor, rates hospitals nationwide strictly on the basis of clinical outcomes. Evaluations are based on mortality rates, which are measured for inpatients and patients at one month and six months after discharge, and on complication rates for areas like obstetrical care.
While HealthGrades makes some of its data available to consumers on its web site, more detailed information is available by subscription. The organization works closely with hospitals, helping those with high marks publicize the findings and those with poorer scores improve their performance. But insurers and employers, in particular, have not shown any great interest in its findings thus far. That surprises CEO Kevin Hicks and his colleague, Sarah Loughran, who are firm believers in the best practice: lower cost link. "If you're the CFO and you only care about cost, you would want every one of your employees to go to a high-quality center because results are much better and more predictable," Loughran asserts.
HealthGrades looks at specific diagnoses and procedures in evaluating outcomes, but its rankings are done by specialty, such as cancer, orthopedics or neurology. That harkens back to the centers of excellence approach, with a difference: "You don't have to travel that far to find a high-quality center," says Hicks. "The notion that there are only 10, 20 or 30 places where you can get excellent cancer care or cardiac care is just wrong." It's not like getting a transplant, where you have to go or should go to a designated center of excellence, he adds.
Employers concerned about the quality and cost of organ transplants, should the need ever arise, can get coverage that addresses both. Celtic Insurance Co.'s Transplant Program, for example, is "a full carveout," available at a per member per month cost that ranges from about $3 to $14, depending on a variety of factors, says Matt Hughes, communications coordinator. In addition to covering the costs of transplants performed at one of its designated centers of excellence or reduced benefits for those who go out of network it covers travel costs for a patient and companion. Case management is also available. While they may never use it, "all firms that purchase transplant insurance should see their stop-loss premiums go down," Hughes says.
Another option is to go directly to United Resource Networks. That's the same network Celtic provides access to, but URN takes an entirely different approach. Employers sign on but only use the service on a pay-as-you-go basis, says Heidi Svendsen, director of marketing. If you never have an employee or dependent who needs a transplant, it costs you nothing. If you do, you'll pay a fee that ranges from about $5,000 to $20,000 depending on the complexity of the case and the type of organ and get an average of 35 to 40 percent off billable charges, she asserts.
While URN doesn't actually provide the benefit, "We credential programs across the country; then we contract for global rates." The network has about 3,000 clients including some corporate giants such as Target about a third of the nation's HMOs and some 43 million people with access, reveals Svendsen. So it certainly has the bargaining power to get the best deals with the best facilities.
URN continually evaluates the designated centers based on criteria set by the United Network for Organ Sharing and reviews cases of patients recommended for transplants according to UNOS criteria. It's not unusual for a gastroenterologist to recommend a patient for a liver transplant, for instance, "but he may be too sick or too well," Svendsen says.
These days, more and more employers are purchasing transplant insurance or signing on with transplant services, those in the industry say. But is it worth it? That all depends.
"It is if you use it," Celtic's Hughes observes. Mitch Bramstaedt, a Segal Co. consultant, is more circumspect: It depends on the needs of the company and its health plan, and on factors like risk tolerance, ability to pay and willingness to negotiate, he points out.
While employers generally should have a plan in place to cover catastrophic illnesses, "transplant coverage is not for every company," Bramstaedt asserts. "If you're based in Chicago and your employees are in the area, and covered by the Blue Cross-Blue Shield PPO, for instance, it may not make sense because the major tertiary facilities may already be in your network," he says.
For a look at questions employers should be asking before signing on with a specialized network, please read this issue's Special questions to ask about specialized care networks article.
More Business & Health Articles on Centers of Excellence:
Do American hospitals get away with murder? (Apr. 1, 2000)
Health Enhancement Research Organization (HERO)http://www.the-hero.org/
A national coalition of employers united to facilitate quality employee health enhancement and disease management research.
The Solucient Institute's Top 100 Listhttp://www.100tophospitals.com/
Past winners of the Top 100 hospitals list, studies, free downloads and hospital profiles.
The Leapfrog Grouphttp://www.leapfroggroup.org/
Hospital survey results, patient safety standards, news, fact sheets, reports and more.
Hospital ratings based on clinical outcomes, as well as quality reports for professionals and consumers.
United Resource Networks (URN)http://www.urnweb.com/
A single source for transplant benefit management, the URN provides clients with a leading transplant network, transplant access program and extra contractual services.
Celtic Insurance Co. Transplant Programhttp://www.celtic-net.com/special/transplant.htm
Designed to eliminate a self-funded group's financial risks associated with transplant expenses, Celtic's Transplant Program ensures plan participants gain access to some of the premier transplant research institutions in the world.
Helen Lippman. Front and Center: Defining Excellence in Specialized Care.
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