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Your top questions on COEs and institutes, answered

By Deirdre SauletMegan Director

April 20, 2021

    Service line development is top-of-mind for many of the health systems we work with today. As leaders evaluate the multiple paths they can take, they're often faced with deciding what level of investment or infrastructure to put into place.

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    We recently published a cheat sheet exploring what it means to be a service line, and explaining how institutes and centers of excellence (COEs) fit into the equation. In response to that resource, strategy leaders have asked us for more details on institute and COE models. Below are the top three questions we've heard and our responses to each.

    Q: Have you seen organizations use institute models to better align across physician groups and specialties in a specific service line?

    We haven't seen this frequently, but there are a few examples where this has worked.

    For example, in the oncology space, we've come across both tumor site-specific (e.g., breast) institutes and ones that encompass the entire oncology service line. Often, at least from the cancer program administrator's viewpoint, the primary motivator for an institute model is to improve alignment with physicians, especially private practice physicians.

    Similarly, in the cardiovascular service line, we've seen heart and vascular institute models that aim to engage the variety of specialties that treat cardiovascular patients, as well as multiple sites and physician groups across a system. In one model we found in the research a few years back, the health system created a comprehensive heart and vascular institute charter to codify decision-making rights between the system and sites, and the role physicians and medical directors played in making these decisions. The governing leadership council balanced physician to administrator voting roles in a 2:1 ratio, and represented employed, co-managed, and independent physicians. Interestingly, the model also allowed for non-CV specialists to participate on committees to help design and execute service line strategy. This feature was intentional to help advance the service line's goal of designing care around the patient and their multidisciplinary, cross-continuum care needs.

    When these succeed, they can be immensely effective. For instance, one breast cancer institute we've profiled in our research saw more than a 50% increase in market share and new breast cancer patient volumes, along with improved turnaround times to diagnosis and treatment start. In the above heart and vascular institute example, the system was able to get cross-specialty engagement in readmissions reduction efforts that required multidisciplinary involvement and helped reduce turf battles between the independent and employed groups.

    But achieving those types of results isn't easy—nor are they guaranteed. To be successful, there are several key elements you can't overlook:

    • Account for the entire care continuum—from the patient's perspective: As with the above heart and vascular institute example, it's critical that institutes include the full range of specialties involved in caring for this patient population. They may not have the same level of responsibility or leadership within the institute, but they need to be engaged and bought in. In oncology, this means not just surgeons, radiation oncologists, and medical oncologists, but all the other providers who are integral to diagnosis, treatment, supportive care, and survivorship. Make sure to include representatives from primary care, OB/GYN, plastic and reconstructive surgery, radiology, pathology, and palliative care—just to name a few.


    • Construct the right infrastructure and accountability: You need a foundation that will set you up for success. Importantly, establish a governance structure with clear delineation of responsibilities. We often see a board of directors or council with several committees reporting up to them. You also need membership terms and eligibility criteria, which are revisited and updated as needed; goals for the institute; clinical standards; and frequent performance monitoring.


    • Ensure a compelling ROI for participating physicians: You'll need to be clear about what's required for physician participation, such as involvement in multidisciplinary committees, community outreach, or adherence to evidence-based care, and physicians will need to know what they're getting in return. That could include access to hospital-provided services, such as social workers and research staff, support for quality reporting, and/or promotion in marketing materials (pending your legal team's sign-off). Interestingly, one institute stipulated that physicians would pay membership fees, which got them financially invested in the success of the institute and created funding to distribute across community outreach, the medical director's stipend, and other infrastructure costs. On the other hand, other organizations might find it necessary to compensate participating physicians for their time.

    Q: Do "Centers of Excellence" and other service line accreditations actually drive referrals?

    Long story short: No. That might sound harsh, and of course, there are some exceptions, but for the vast majority of organizations and markets, accreditation is not going to differentiate your service line in the eyes of consumers, referring physicians, or payers.

    However, this hasn't necessarily tampered adoption. For example, when we surveyed our cancer programs in 2018, 93% of respondents held at least one accreditation—and the vast majority held more than one.

    Accrediting bodies and societies have also launched new COE style designations for entire service lines, like the Joint Commission's Comprehensive Cardiac Center Certification, and the ACC's HeartCARE Center National Distinction of Excellence.

    And we have heard that there is some value to be found in accreditations when leveraged correctly. Primarily, they can be helpful to secure physician buy-in for specific programmatic or quality improvement projects, make the case to executives for resources, and ensure some level of consistency across a system service line.

    Still, in the same survey mentioned above, 8% of cancer programs reported that their organization has not gained any value from participating in an accreditation program. And a recent Advisory Board analysis of advanced stroke accreditation found that, while programs saw an increase in volumes the year prior to advanced accreditation, the growth rate fell back to national average the year after accreditation. This underscores how important it is to be crystal clear about why your organization is pursuing accreditation and make sure it's delivering ROI. And understand that this ROI isn't likely to be a volume play as much as a performance improvement mechanism. 

    Q: How are purchasers—both employers and payers—thinking about and using COEs today?

    Health plans have been defining their own criteria for centers of excellence for years and these are the ones we have been watching most closely as they could actually lead to steerage from these payers. Yet while they do have the potential to be a growth avenue for service lines, these centers of excellence designations may actually not mean differentiated care in themselves. For example, a 2019 analysis in JAMA Internal Medicine evaluated clinical outcomes of percutaneous coronary interventions (PCI) performed at hospitals with and without a COE designation from three payers. The results were surprising: investigators found no correlation between COE designation and quality outcomes. Of course, we could argue both sides of the data and study design, but what this signals to us is that payers and service line leaders have an opportunity to better partner in designing COE models and selecting metrics that will actually drive higher-value care.

    Interesting things are also happening in the employer space through the evolution of direct-to-employer contracting arrangements and COE networks. Employers are increasingly looking to these approaches to reduce unsustainable cost growth while avoiding pushing more costs onto employees. But while past models focused on just bundling for the acute procedure (e.g., joint replacement, CABG), more progressive models look to encompass the full patient pathway and more complex, chronic condition management (e.g., spine, cancer). In these models, the value to the employer is not in negotiating a better price for the procedure itself, but assurance from the COE of the most appropriate, multidisciplinary care pathway.

    Let's take oncology as an example. Traditionally, employer partnerships have centered around screening and preventive care, such as smoking cessation or mammography. More and more, employers are realizing they need to do more to both support their employees who receive a cancer diagnosis as well as control their oncology spend. Although cancer-related claims make up less than 1% of employers' total medical claims, they account for over 12% of total costs. There are multiple flavors of cancer program-employer partnerships—ranging from the more traditional screening and educational partner to becoming a COE. In oncology, COE doesn't necessarily mean direct-to-employer contracting because of the complexity, longevity, and often unpredictability of cancer treatment. Instead, the value to employers is on-demand access to subspecialist expertise to ensure the proper diagnosis and highest-value treatment plan for their employees. Over the past few years, we've seen some of the biggest names in cancer care, such as City of Hope, Mayo Clinic, and Memorial Sloan Kettering, explore these types of partnerships with employers.

    Direct-to-employer steerage partnerships for spine care are also growing rapidly. Given the range of non-surgical options, these arrangements hinge on spine COEs avoiding unnecessary procedures and instead looking to multidisciplinary management options. As an oft-cited example, Walmart found 54% of employees were in fact able to avoid spine surgery when referred to one of their spine COEs.

    While we hear of large, national examples in the press like Lowe's and Walmart, there is likely untapped opportunity for more local employer relationships. High-performing providers can learn more about the health care needs of large local employers to identify opportunities to better manage their employees. By partnering with local employers, organizations can also lessen the infrastructure needed to coordinate travel accommodations and heighten their ability to capture the full continuum of upstream and downstream care for local patients.

    Are you in a Center of Excellence or institute model? Share your story!

    We are continuing to research what it takes for service lines to be the specialty provider of choice—from private plan COEs, to direct-to-employer contracts, to primary care innovators. We'd love to hear what you're doing in this space. Email directorm@advisory.com to share your experiences or questions.

    May 20: Register for Advisory Board's upcoming 2021 Provider of Choice Summit

    As vaccine administration continues to ramp up, the "next normal" is in sight—and for provider organizations, that means it's time to refocus on growth. But what does strategic growth look like in a peri-Covid-19 world? Join the Advisory Board Provider of Choice 2021 Summit on May 20th to discover how Covid-19 and other industry disruptors have affected referral pathways, discuss what key stakeholders are looking for today, and learn how to prioritize your efforts to become the provider of choice for new and newly important stakeholders.

    Register now

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