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Clinical Pathways GPS

Centers of Excellence: Criteria and Comprehensive Clinical Pathways

Authored by

Matthew Pakizegee, PharmD, MS; Richard G Stefanacci, DO, MGH, MBA, AGSF, CMD—Column Editor

Affiliation

EVERSANA™, Berkeley Heights, NJ

Disclosures

Dr Stefanacci is the chief medical director for the managed markets agency of EVERSANA™. Dr Pakizegee is the clinical content lead for Government Policy Systems at the managed markets agency of EVERSANA™.

Citation

J Clin Pathways. 2019;5(2):28-30. doi:10.25270/jcp.2019.03.00063

The Center of Excellence (CoE) model of care is an excellent approach to the growing need for disease-based medical management of chronic-type conditions with its multidisciplinary team approach and dedication to demonstrated efficacy and better outcomes. Criteria defining CoEs is needed as well as clinical pathways to guide providers in referral, management, and coordination of care. These considerations are especially critical as the number of institutions functioning as CoE is likely to grow with health systems looking to cement their position and secure a flow of patients.


The concepts of coordinating care, reducing inefficiencies, and improving the quality of care delivered have been core tenants of health care reform for decades. A key part of this effort has been the establishment of Centers of Excellence (CoE) across the country. While there is no single definition or approach for a CoE across the United States, there is one commonality; they are centers made up of highly skilled experts dedicated to specific therapeutic areas and who are often at the forefront of innovation in their field.1,2 

CoEs are health systems and hospitals that provide highly specialized treatment, procedures, and/or surgeries for complex conditions. For example, a CoE for transplants would perform hundreds of transplants per year, rather than a few dozen. CoEs are also involved in clinical trials and research that impact the disease state in which they are experts. Many CoEs are created by stakeholders without a mandate from an outside institution. CoEs may be established by a specialty professional society, government programs, or a consumer advocacy group to focus on improving health care within a specific disease state. These centers fill a gap in the community for highly skilled expertise in rare diseases and specialized procedures. The use of the term “center of excellence” by a health system does not refer to a universal certification or licensing process but established expertise in a specific disease or field in medicine. 

More definitive guidance is sorely needed regarding how such “established expertise” is accomplished. First, more structuring is needed related to the standardized care practices in CoEs. For example, treatment delivery for the rare and complex treatments provided in CoEs often becomes standardized, resulting in clinical care pathways and treatment standards specific to their endeavors; these pathways often become the foundation for standard of practice guidelines adopted by professional associations, integrated delivery systems, and providers throughout the country, yet no guidance exists for their creation or adoption. 1,2 Also, community providers need guidance in how to identify patients for referral to CoEs and best practices for how to continue and coordinate care for a patient after treatment at a CoE.

Evolving Use and Creation of Centers of Excellence

Payers, including employers and health insurers, are becoming more selective about the health care providers, sites of care (eg, hospitals, ambulatory care), and provider networks offered to members with the goal of boosting quality and reducing health care costs. Provider networks, including doctors, hospitals, and health systems are being selectively chosen to create more efficient and standardized pathways by tapping into the CoE model.3 This results in certain health systems being shut out in favor of others for high-cost procedures such as joint replacements, spine surgeries, organ transplants, and cancer treatments. By subsidizing the use of specific health systems, employers may reduce a worker’s ability to receive care at his or her desired hospital or health system; but these forces may lead to a market solution that reduces costs and improves the quality of care over time. In many cases, quality improvement is more complex than simply looking at the costs associated with a treatment or procedure, because the wrong choice by a specialist or provision of suboptimal care can mean additional direct and indirect costs over time. This is why some of the largest employers are sending their employees to CoEs for treatment, procedures, and surgeries.

Many large employers are self-insured, meaning they take on all financial risk related to their employees’ health. Most self-insured employers have developed an infrastructure for primary care services to manage basic care for common conditions. Care from specialists, on the other hand, can be costly and more difficult to manage. Partnerships with CoEs are a potential solution to this problem, allowing employees to be guided to specialists focused on the best outcomes for difficult-to-treat conditions. Many partnerships reimburse health systems a total rate for employee care, thus incentivizing these health systems to ensure patients see better outcomes.

Atypical health care stakeholders are now developing and seeking relationships with CoEs. Payers including full-risk employers seeking value are encouraged to join these partnerships with health systems to keep pace with the shift to value-based care delivery. Ignoring these partnerships may mean missing out on business from self-insured employers and result in failure to gain market share in this new, growing market. Many large employers, including Cisco, Intel, Boeing, Lowe’s, and General Electric are seeking to bypass insurers and contract directly with health systems.4,5  As the health systems and hospitals transition from a fee-for-service reimbursement system (ie, based on volume) to a system based on value, it makes sense for certain providers to specialize in treating specific conditions as a CoE. Walmart recently created its own CoE network, partnering with 6 nationally well-known health care organizations, including the Mayo Clinic and the Cleveland Clinic.6,7

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