One question workers’ compensation payers must ask before they invest in a center of excellence for injured worker care: Is it worth the cost?

That question may hark back to a time before injured worker advocacy became a buzz phrase in workers’ comp. But looking at issues of cost when evaluating the quality of care may not be antithetical, especially since a JAMA study found that even accredited, high performing centers of excellence have a wide variation in patient outcomes. 

“It’s not clear,” said Dr. Randall Lea, senior research fellow at the Workers Compensation Research Institute (WCRI).

“The term ‘center of excellence’ is a descriptor that providers, payers and regulators have heard used in a variety of contexts. But in my work I haven’t found a universally agreed upon definition, other than an implied one that a center of excellence is ostensibly something better than anything else being offered.” 

In a recent WCRI webinar, “Defining Centers of Excellence,” Lea dove into whether centers of excellence are worth the cost and how payers, providers and injured workers can evaluate the care provided at these institutions. 

“I’m hoping this material today will help you identify not only centers of excellence, but those centers of transparency, true accountability and those with a commitment to measurable improvements over time,” Lea said. 

“That is, true centers of excellence whose primary aim is to provide the best and most comprehensive care possible.”

Are Centers of Excellence Worth the Money?

Centers of excellence are often touted as having better treatments and recovery outcomes for patients because of their emphasis on research and multidisciplinary care practices. 

During the webinar, Lea tested these claims by diving into the available research on centers of excellence and their patient outcomes. 

What he found was that the research on the efficacy of centers of excellence was rather mixed. 

A study from the Medical Care journal found that centers of excellence had a lower rate of complications for hip surgery, but there was no difference between the complication rates for knee surgery when centers of excellence were compared to other medical institutions. 

Another study that compared the rates of complication for spine surgery at centers of excellence to non-centers, found that centers of excellence had similar rates of complications and types of complications to non-centers. 

Lea noted that some of these mixed results are due to the gaps in defining and evaluating centers of excellence.  

“There are gaps in the literature in regards to defining, standardizing and comparing different centers of excellence to the extent that I asked myself a question while researching this topic: are there any opportunities for care improvement and thought innovation that can occur in centers of excellence? And my answer today, at least, is maybe they can,” he said.     

Defining and Evaluating Centers of Excellence

Because there is no standardized definition of what a center of excellence is, some critics say the term is used more for marketing purposes than for measuring the quality of care the institution provides. 

“The payers and the insurance carriers, the Anthems, the Blue Crosses, the Etna’s, the Cignas, the Optums for United — they all have their own definitions of a center of excellence,” Lea said. 

“I think it’s likely that more and different types of centers of excellence are going to emerge in workers’ comp.”

During the webinar, Lea offered a definition from the article “Centers of Excellence in Healthcare Institutions: What They Are and How to Assemble Them” as a means for both identifying what a center of excellence is and evaluating the care patients receive. 

According to the article, a center of excellence is: “A program within a health care 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.”

Using this definition as a guide, Lea identified six different characteristics that can be used to define and evaluate centers of excellence.

6 Key Characteristics of Centers of Excellence   

1) Expertise and Accreditation: This criteria seems like the most obvious one of the six. The expertise of a center’s physicians and its accreditation status are obviously key to determining whether a center of excellence can provide the highest value for the cost.

To evaluate expertise, Lea recommended checking out a center’s physicians and making sure they have board certification in their specialty and have received fellowship training from a renowned facility or experts. 

He also noted that the volume of cases a physician has seen can be used to evaluate their expertise.   

In terms of center accreditation, he said governmental accreditation, accreditation by payers and insurance providers, specialty society accreditation, joint commission accreditation and being a part of clinic or physician groups were all ways employers could evaluate centers of excellence. 

2) Research and a Culture of Learning: Payers should be aware when choosing a center of excellence whether or not the center is involved in research and if they’re using that research to improve care.

“Do they have something that’s worth sharing with others? And if they have something worth studying, are they willing to share it with others?” Lea said.

Looking for publications from the center and its physicians, seeing if the center takes on fellows, and academic affiliations can be used by workers’ compensation payers to determine whether a center’s practices are based on research and a culture of learning. 

3) Resources: A center’s resources should also be considered when determining whether or not to send an injured worker to a center of excellence. 

“Not only do you need expertise, but you’re going to need a variety of resources to birth a center of excellence,” Lea said.

Electronic health records, sophisticated diagnostic services and nurse to patient ratio are all factors that contribute to an institutions ability to care for patients and they can make or break a center of excellence. 

One other resource that Lea said was often overlooked is the overall facility a center is housed within. And its openness to new technologies.

“Facilities and ancillaries are starting to play a bigger role, or a bigger part in the health care delivery discussions with the buzzword being ‘servicescape,’ that is the importance of the physical plant and facilities,” Lea said. 

“What impact do the physical plant and facilities have on the outcome? Because there’s some data to suggest that’s the case.”

4) Outcomes: Given that centers of excellence focus on specific medical conditions, their expertise on those injuries or illnesses should allow them to produce better outcomes. 

Additionally, a center of excellence should employ a range of physicians with different specialties in order to provide the best care possible for a patient. 

In the case of, for example, knee replacements, this means employing the doctor and all the personnel who will complete the surgery and the physical therapist who will help the patient get back to their full functionality.   

“It’s not only interdisciplinary, but inter-professional,” Lea said. “You have to have a group of providers that can meet virtually all the needs for the condition being treated.”

Patient outcomes aren’t just about having an interdisciplinary team that executes a long-term care plan for patients, however. They also depend on physicians prioritizing patient well being during the healing process over other measures of success.  

“Excellence in the collection and measurement of outcomes is the cornerstone of a center of excellence. It’s not just token measures for the sake of meeting a target to receive a financial reward, but those that are meaningful and that make a true difference,” Lea said. 

5) Cost and Financials: Lea said it best during the webinar: “Cost cannot be forgotten.”

“We have … the pay for performance programs, the risk-based models, all of those are important. So you can’t forget about them in the new era of health care,” he continued.

When it comes to centers of excellence, the costs aren’t cheap and many workers’ compensation fee schedules may not accommodate the higher fees. 

Considering a center of excellence for an injured worker’s treatment should focus on making sure they receive the best care possible. If the center’s outcomes don’t live up to the extra cost, it may be worth finding a different type of treatment that has better outcomes.   

6) Patient Centered: While not a part of the original definition Lea used to derive his criteria, patient-centered facilities are necessary for true worker advocacy — an issue that has become increasingly important in workers’ comp. 

“Virtually everything should have a patient-centered focus,” Lea said.

Lea said that workers’ compensation payers should look into a center to see if the patient is a part of the decision-making process for their care and that they should look into patient satisfaction when evaluating centers.   

Curable vs. Manageable Conditions

While evaluating centers of excellence is one way that workers’ compensation payers can ensure injured workers are receiving the highest quality care, knowing what kinds of conditions benefit from centers of excellence plays a major role in whether or not they will make a difference in patient outcomes.

Lea suggested that two broad categories, curable conditions and manageable conditions, should be used to determine whether a center of excellence should be used for a patient’s care. 

Curable conditions are ones that can be treated and cured. Lea gave the examples of stomach ulcers, most pneumonias and uncomplicated wrist fractures as conditions that are curable.

Manageable conditions, on the other hand, can be medically managed, but can never be cured. Lea listed diabetes, degenerative spine conditions and hypertension as illnesses that can be medically managed, but are not curable. 

According to Lea, manageable conditions are more likely to benefit from a center of excellence because of their emphasis on research and interdisciplinary care. 

Manageable conditions have high variability in treatment and outcomes and often there is still a lot of research to be done on the best ways to treat these conditions. Centers focused on research that utilize an interdisciplinary approach to treatments, therefore, may be the best fit to work with these conditions. 

“Perhaps a center of excellence can be an entity that starts to answer some of the unanswerable questions we have about clinical conditions, especially those we may be able to manage, but not cure,” Lea said. &