The Clinton healthcare reform proposal is as concerned with quality as it is with cost and access. Even the federal government is beginning to see that all three of those concerns are interrelated.
But the implications of reform are raising questions for national centers of excellence. Among them are:
|Who or what agency is validating claims that a facility is truly a national center of excellence?
|What role will national centers of excellence have in the development of practice protocols?
|How are national centers of excellence preparing for reform?
|Will healthcare purchasing alliances restrict healthcare purchases to local markets?
A definition.Through research involving more than 100 nationally recognized centers of excellence, we've developed this definition of a clinical center of excellence-it's a medical entity that focuses on a specialty in medicine or surgery characterized by a national perception of high-quality care. The quality is measured by consistent, successful and predictable clinical outcomes, which are a result of appropriate diagnostic and medical-surgical procedures.
These medical entities are housed in hospitals, clinics or medical group practices, which are usually administered by physicians. Of the many characteristics shared by these centers, prominent among them are the commitment to education, research and publication.
In many major metropolitan areas, some tertiary-care facilities are making claims that they are a center of excellence for certain specialties. This is an attempt to market themselves to managed-care organizations, self-insured industries and referring primary-care providers.
Role in guidelines.Demands on bona fide centers of excellence are likely to grow if their expertise will be tapped-as it should-to aid the current movement to develop and implement practice protocols.
The Clinton reform proposal endorses the establishment of these protocols, and the Joint Commission on Accreditation of Healthcare Organizations will promote them by including them in its review process. The American Medical Association estimates there are 1,600 protocols in use today with 200 to 300 being added each year.
Strategies for competing.Reform can be frightening for national centers of excellence because of the expected emphasis on regional referrals. In response, centers of excellence are pursuing three strategies.
Many are attempting to magnify their presence in their home markets by establishing networks in surrounding areas. For example, in New England, Dana-Farber Cancer Institute in Boston is expanding its internationally recognized oncology care to its immediate area.
As a central member in the National Cancer and Leukemia Group B Network, Dana-Farber has formed clinical relations with four hospitals in Vermont, two hospitals in both Maine and Massachusetts, and a single hospital in New Hampshire. More affiliations are expected. In the year ending Aug. 31, 1993, about 255 patients were seen in this network, generating 308 patient accruals or diagnostic or treatment encounters. The community hospitals were able to enhance their care of oncology patients by using Dana-Farber's expertise.
Building on this success, other hospitals and HMOs, such as Harvard Community Health Plan, have established new clinical affiliations with Dana-Farber. In addition, Dana-Farber is providing clinical expertise to local tumor boards, clinical consultations to community hospitals and in-house education.
New niches, new locations.Centers of excellence also are seeking to enter new market niches. For example, the Cleveland Clinic recently opened an expansive emergency department and supporting facility, which it had never done previously.
Centers also are entering marketplaces in new geographic locations and, in doing so, competing with the established healthcare providers in the new markets. This has been demonstrated by the Mayo Clinic's expansion in Arizona and Florida.
Steps to take.What's the best route for centers of excellence? They should guard those characteristics and qualities that have made them great and not compete with community hospitals. Instead, they should seek to clinically affiliate with community providers. This will be the best way to serve patients while allowing their reputation and influence to grow. Our research indicates that one of every three centers of excellence are open to the idea of national clinical affiliations.
For their parts, local hospitals' boards of trustees, chief executives and physicians must unreservedly embrace the concept of clinical affiliations. At this level, physicians will be the real link to success because they must be willing to affiliate clinically with a center. Affiliations will require of them an openness to new ideas and a willingness to spend time to learn new practice protocols or procedures.
One example of a success story is St. Vincent Hospital and Medical Center, which has developed an excellent reputation in northwest Ohio for its open-heart surgery program, started through a clinical affiliation with the Cleveland Clinic. St. Vincent's trustees, administration and medical staff all joined to make the affiliation work.
The medical staff's efforts played a crucial role. Its members worked closely with physicians from the Cleveland Clinic to assemble and develop the best physician team. The Cleveland Clinic even recruited the chief surgeon for the program. After the first year, St. Vincent's mortality rate for its open-heart program was approximately the same as the Cleveland Clinic's and 90% better than competing hospitals.
It may be hard to believe an affiliation of this magnitude would work, but these are unusual times, and brave vision will form healthcare into new structures that, until now, have been only dreams.