Bob Reznik, President of Prizm Development, discusses the key elements of true spine centers of excellence.
1. Interconnect specialists for constant communication. Just developing a spine center that includes all types of specialists isn't enough; spine centers must promote constant collaboration between the specialists to ensure patients receive comprehensive care.
"One of the trap doors to failure of working in a spine center is that the all-inclusive approach brings in a variety of spine specialists — such as physical medicine MDs, spine therapists, orthopedic spine surgeons and neurospine surgeons — and puts them in the same place but they remain fragmented like single silo practices," says Mr. Reznik. "They haven't typically communicated with others in the spine realm and now they are part of the spine center, but their habits don't change. This fragmentation and lack of communication between the specialists really frustrates patients as well as payers."
2. Concentrate on core components for payers to take you seriously. Some spine centers bring in everyone from the surgeon to the yoga instructor and acupuncturist and then expect to have leverage with payers. However, most insurance companies want to see proof of the center's ability to provide high quality care at a low cost.
"We find that in a sense, less is more," says Mr. Reznik. "We find that payers view many spine centers out there as amusing when they say their center includes every service in the marketplace. Focus on the effort to create a true spine center of excellence by eliminating some of the side services and concentrating on core components."
For example, there are many services heart centers could offer to promote exercise, healthy eating and well-being, but the best focus on three core components: the cardiothoracic surgeons, cardiologists and cardio rehab.
3. Make the physical medicine and rehabilitation specialist the gatekeeper. The three core components of the spine program are spine surgeons (orthopedic and neuro), physical medicine physicians and spine therapists. The physical medicine physicians should include injectionists as well as non-injectionists and see patients through their treatment pathway.
"In spine, you still have a lot of ways people with an acute strain could be treated," says Mr. Reznik. "Spine surgeons don't usually have soft tissue injury expertise, like a fellowship-trained physical medicine physician does. The PMR specialist can connect patients with different treatment options to relieve their problems."
4. Construct an ambulatory surgery center. The foundation of spine centers of excellence in the future will be the ability to perform minimally invasive, outpatient spine surgery. Ambulatory surgery centers offer the ideal setting to perform these procedures so patients can recover safely and comfortably at home.
"The one thing that is evolving with a spine center of excellence over the next year is for surgeons to perform minimally invasive procedures and to get patients out of their facility as quickly as possible," says Mr. Reznik. "In many ways, that's where the ASC comes in. The ASC, or hospital for more complex procedures, must be linked to the physicians. Gain the necessary involvement of the ASC or hospital to provide the type of quality care patients expect."
Payers are especially interested in moving spine cases into outpatient ASCs as the procedures become safe and effective in that setting. For some patients, especially older patients, a step-down, skilled nursing facility may be necessary to help them transition into activity before returning home.
"Payers are going to start looking for bundled rates in spine care, and it's a matter of time before everyone has a menu of what the different common procedures are," says Mr. Reznik. "There will be people who don't fit into those packaged case rates, but for the most part the many spine surgeries and even non-surgical episodes of care will be provided under a predictable rate. All this helps with the transition into ASCs."
5. Develop a protocol for patients. All spine specialists in the center must participate in developing protocol for patients presenting with common conditions or injuries at the center. If the person presents with red flags, such as loss of bowel or bladder control, or neurological deficit, they are put on the express lane to the surgeon.
"It's crucial to triage patients at intake so acute problems go to the PMR specialist to exhaust nonsurgical treatment options, and the patients with red flags get to the surgeon without delay for assessment and appropriate treatment," says Mr. Reznik. "Some of these red flags could have serious complications if they aren't sent to the spine surgeons within a few days. The key is have written protocols so patients are matched with the right type of spine specialist."
6. Measure clinical outcomes. Spine centers of excellence should measure their outcomes and compare them among different specialists and other benchmark spine centers. Hospital-side outcomes include infection rates and length of inpatient stay. But there are a multitude of other outcome measures, such as: what percent of patients get therapy; what percent get spinal injections and then resolve; and what percent need surgery. In addition to surgery rate, a health insurance company wants to know what percent of patients are still taking pills for pain relief after treatment. The biggest costs for payers are surgery, hospitalization and ongoing pharmacy costs.
However, some payers consider that patients having spine surgery are failures, because many times there are ongoing symptoms related to failed back surgery syndrome. "When that person has surgery, the payer feels they have lost the patient," says Mr. Reznik. "Payers expect a true spine center of excellence to have capabilities related to nonsurgical treatment options. Despite what a hospital may want economically, a respected spine center is not a surgical mill."
If you can't show payers that most of your patients recover without surgery, they won't want you seeing their customers.
7. Emphasize exercise and movement with patients. Overwhelm patients with educational material on movement and exercise that can reduce pain and improve mobility. This is the key for many patients to recover from their conditions without depending on pain medication.
All centers credentialed by the Spine Center Network must distribute a "home remedy book" to patients detailing why movement is important and how certain stretches will help them prevent recurrence of back strain.
"Stretches play a key role in the patient's recovery, and the book helps people understand that relying on a needle, a surgery or pills to feel good won't change them in the long run," says Mr. Reznik. "The key is to make the back stronger, more flexible and more resistant to future injury."
8. Assign a clinical coordinator to follow up with patients. Even when spine specialists work collaboratively and centers have many treatment options available, it's not guaranteed the patient will move through treatment pathways quickly enough. A clinical coordinator, or "nurse navigator," can follow up on cases to make sure patients aren't stuck in a silo with too many visits to the injectionist. Just as you have to watch surgical rate, you also have to watch that patients don't get stuck in the PMR silo. Neither is appropriate.
"The most logical person to do that would be the registered nurse who has experience in spine and is familiar with emergent symptoms, and would look at the schedule to see how many visits the patient has with the PMR specialist over six months," says Mr. Reznik. "They would question why the patient is coming back so often when they haven't seen the surgeon for complementary expertise. You need a nurse navigator who looks at the silos to make sure they aren't getting into surgery too quickly or staying in PMR too long."
Empower the nurse to schedule patients with the appropriate specialist based on set protocol if necessary. "A true center of excellence combines the expertise of surgical and non-surgical specialists with clinical tracking and protocols, and has an emphasis on non-surgical treatment with movement and exercise," says Mr. Reznik.
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