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The Voice of Business,
Industry & the Professions Since 1942
North Carolina's largest
business group proudly serves as the state chamber of commerce
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January 2005
Healthcare
Healing
Themselves
Organizing providers into
multi-talented teams helps
hospitals deliver better care
and control costs
By Lawrence Bivins
It’s
mid-afternoon, and Dr. Edward Shaw has just conferred with colleagues on a
difficult case: a young girl with a brain tumor. A radiation oncologist,
he confers with neurosurgeons, chemotherapy specialists and other allied
health professionals skilled in cancer treatment before moving ahead with
the child’s care plan. Unlike years past when a poorly coordinated
patchwork of providers had no formal system of sharing information,
experiences and opinions, Shaw and his colleagues at Baptist Medical
Center’s Comprehensive Cancer Center enjoy close-knit collaboration based
on face-to-face interaction. |
East Carolina University's
Dr. Randolph Chitwood is a pioneer in robotic surgery. Photo by Cliff
Holliss
Learn more
List of
specialty healthcare centers
Teamwork improves bariatric
surgery
|
“It’s
a far more collegial setting than you’d find at most hospitals,” says
Shaw, who chairs the radiation oncology department at the Wake Forest
University-affiliated center. Prior to joining Baptist’s medical staff a
decade ago, Shaw trained at Minnesota’s renowned Mayo Clinic, which
pioneered the highly specialized team-oriented practice model that has
made Baptist one of the premiere institutions in the nation for cancer
treatment. “When you work together as a team, you’re there thinking with
your colleagues side by side,” Shaw says.
While it’s a far more appealing practice environment for specialists, the
model is even more beneficial to patients and their families, according to
Shaw. Instead of navigating a confederation of solo-minded providers,
often flung far across various buildings and locations, the patient can
access specialty and sub-specialty services under a single physical and
organizational roof. “It’s not only one-stop-shopping, it’s one-stop
boutique shopping,” Shaw explains.
In North Carolina, already envied for the excellent quality of its health
institutions, the movement toward tightly focused, highly collaborative
specialty care improves efficiency and user-friendliness across a range of
practice areas and in every corner of the state. Models such as that found
at Baptist’s cancer center also enhance data collection, a key to quality
improvement and cost containment. And the new structures are facilitating
groundbreaking research into new treatments — benefits that ultimately
spread well beyond the state’s borders.
Cancer, the nation’s second most deadly health condition, lends itself to
treatment under this type of model, according to Frank Torti, director of
Baptist’s Comprehensive Cancer Center. “Cancer is a very complex disease,
and the treatment requires the assembly in real time and space of a
variety of people in various specialties,” explains Torti.
It also exacts a mental and emotional toll on patients like few other
diseases, he adds. “A cancer diagnosis is a moment of great urgency, great
anxiety and great confusion for the patient,” says Torti, a specialist in
prostate and testicular cancers. Organizing services more effectively
enables the patient to get answers quickly and conveniently. “In the old
days, a woman would go to one place for a mammogram, another for a biopsy,
then make an appointment with a radiation oncologist,” Torti recalls. She
might have to visit yet another location to explore cosmetic options.
“Time would drag on and it would be a terrible time for the patient,” he
says. Torti’s center — which includes diagnostic and treatment facilities,
and even an “appearance boutique” to help patients preserve their
pre-treatment look – brings everything to the patient. “Now, we’ve got it
all wrapped up in one place,” Torti says.
Improving Care Controls Costs
Greater convenience for patients and providers translates to better care.
It can also save real money, Torti and others believe. “It certainly saves
the patient money not having to make numerous trips,” he says. Better
coordination of diagnostics also keeps a lid on unneeded costs. “Poorly
coordinated care is more expensive care,” Torti says. “We’re looking
closely at expense and feel this is an efficient way to organize.”
Jennifer Troyer, a health economist at UNC-Charlotte’s Belk College of
Business, says, “They are relatively new, and the jury is still out from
an economic perspective,” she says. But – in theory, at least — high
patient loads alone might be enough to spur greater efficiency. “If you
can get high enough volume for a specific service, that can bring down the
unit cost,” Troyer says. Space and staff are better utilized, and
specialized technologies and equipment aren’t sitting idle as often.
Troyer adds. “Saving lives also saves money.” The fact that most
specialized centers operate under the umbrella of a larger hospital system
means they can take advantage of a larger administrative infrastructure —
HR offices, accounting departments, and computer support, for example.
This may also provide savings. “Size is an important issue,” Troyer says.
Volume certainly counts at Presbyterian Orthopaedic Hospital in Charlotte,
which treats some 600 cases per month, on average. It’s more than enough
to enable the hospital to obtain the latest medical technologies and
employ the personnel trained to use it. Those resources help attract top
specialists, according to Tanya Blackmon, administrator of Presbyterian
Orthopaedic. “Physicians like having access to the best equipment and the
best support staff,” Blackmon says.
Just as Baptist Medical Center has gathered cancer specialists under a
single roof, Presbyterian Orthopaedic has assembled an array of bone and
joint experts: surgeons, physiatrists (rehabilitation specialists),
orthotists (individuals who work with artificial limbs), sports medicine
professionals and those trained in pain management. Social workers,
physical therapists and nurses with training and experience in
orthopaedics also comprise the hospital’s 334-person staff. “We even have
sub-specialists who focus on spines, joints and hands,” Blackmon adds.
HealthGrades, a Colorado-based firm that rates the nation’s hospitals,
ranks Presbyterian Orthopaedic the best orthopaedic care in North
Carolina. “The more you do of anything, the better you get at it,”
explains Blackmon. Earlier this year, Charlotte’s NBA expansion team, the
Bobcats, along with its WNBA counterpart, the Charlotte Sting, selected
Presbyterian as its official healthcare provider based on the teams’
confidence in its orthopaedic care. Not long thereafter, the Charlotte
Checkers, the city’s minor league hockey franchise, signed a similar
agreement with the institution, a unit of Winston-Salem-based Novant
Health. “As we sought a partner for medical services, Presbyterian was a
natural choice with its nationally-recognized orthopaedic hospital and
community-minded focus,” said Ed Tapscott, chief operating officer of the
Bobcats and Sting, last spring.
Focusing on Heart Disease
Across town, the Carolinas Heart Institute enjoys similar “go-to” status.
The institute performs more than a thousand open-heart surgeries each year
and sees thousands of patients from across the Carolinas needing other
types of cardiac treatment. Home to one of the largest heart transplant
programs in the Carolinas, the institute was the first site in the state
after organ surgery pioneer Duke Medical Center to successfully perform a
heart transplant.
Like cancer, heart disease is both deadly and complex, and its human toll
is formidable: about a million Americans die from cardiovascular illnesses
each year, more than any other disease. Nearly one in four men suffering
their first heart attack will be dead within 12 months; for women,
year-end mortality is almost twice as likely.
These were among the driving motivations that led the Carolinas Heart
Institute to introduce its innovative heart failure program in 1997. The
multi-disciplinary program unites home care and home infusion specialists,
dietitians and pharmacists together with cardiologists and transplant
experts. Focusing completely on end-stage heart disease patients, the
program has been a success on several fronts. Patients have shown sharply
lower hospital admission rates, shorter hospital stays among those
admitted, and healthier overall heart function.
Last month, Carolinas Heart Institute joined the small number of hospitals
able to perform minimally invasive surgery with robotics. A da Vinci robot
allows surgeons to repair faulty hearts by slipping tiny mechanical arms
through dime-sized incisions between the patient’s ribs. It gets patients
out of the hospital and on their feet in about half the time required
after a traditional procedure, where surgeons saw a gash through the
length of the breastbone.
With its $1 million price tag, the da Vinci device was approved two years
ago by the U.S. Food and Drug Administration (FDA) after clinical trials
were completed at ten medical centers. Heart surgeons at East Carolina
University’s Brody School of Medicine led the trials. Randolph Chitwood,
the ECU surgeon whose name is synonymous with robotic heart surgery, says
advances in surgical care are only part of the formula for addressing the
prevalence of heart disease in North Carolina, where it accounts for one
in every four deaths. Better diagnostics are also needed.
Partnering with Universities
All those needs will be addressed at ECU’s new cardiovascular institute
announced last August. “We plan to make it one of a kind,” says Chitwood.
“There’s no model like this anywhere,” says Chitwood, who is jointly
affiliated with the Brody School and Greenville-based University Health
Systems of Eastern North Carolina. Both institutions are partnering in the
creation and operation of the $60 million institute.
The new institute will include 180,000 square feet of new space for
cardiovascular clinical research, outpatient treatment and education
programs, as well as 40,000-square-foot expansion of the Warren Life
Sciences Building. That facility now houses Brody’s robotic research
training, which is visited by surgeons from around the world travel to
learn the da Vinci system.
Chitwood’s vision for the institute involves drawing private practice and
university-based cardiologists, cardiothoracic and vascular surgeons,
radiologists, pediatric heart specialists, nurses and therapists onto a
common platform that is focused exclusively on diseases of the heart and
blood vessels. Key to the successful treatment of those ailments is early
detection, when patients have better odds of survival, Chitwood explains.
And the institute’s collaborative model is designed to eliminate “delays,
disconnects and redundant testing that occur when providers work in
relative isolation from each other.”
Organizing cardiovascular expertise on a single platform facilitates
better research, Chitwood adds. “It will help us bring in NIH dollars,” he
says, referring to federal government grants. The same principles apply at
Baptist’s Comprehensive Cancer Center, which is funded in large part
through National Cancer Institute grants.
“This model enhances our ability to bring forward new protocols,” says
Bayard Powell, section head of hematology and oncology at Baptist. With
physicians and patients consolidated under a single roof, data collection
and analysis, as well as cross-specialty research, is facilitated more
effectively, Powell says.
Discovering Better Treatments
In settings such as Asheville’s Mission Hospitals, which is not associated
with an academic institution, data sharing is also an important element in
the organization of specialty services. In the end, that is key to
discovery of new, better and more cost-effective treatments. “We are able
to develop clinical paths and care algorithms based on evidence and
consensus,” explains William Brannan, medical director of Mission
Children’s Hospital and the Helen Powers Women’s Health Center. That means
shorter hospital stays for patients and a corresponding cost savings.
As part of its strategic plan, Mission is attempting to hold cost
increases for its overall services to 3 percent, an ambitious target since
medical inflation has hovered at more than twice that in recent years.
They won’t sacrifice patient interests in new specialty care models,
however. “We’re talking about a philosophy that is patient-centered,”
Brannan explains.
The Powers Center’s obstetrics program now delivers 3,700 babies a year.
The center assembles a full complement of related specialists:
obstetricians, certified nurse midwives, maternal fetal medicine
specialists, reproductive endocrinology and infertility specialists,
osteopaths and family physicians. But a patient-friendly physical
environment also distinguishes the center. The Powers Center keeps
expectant moms in a single, home-like suite through labor, birth and
recovery. When C-Sections are called for, as they are in nearly one-third
of all deliveries, the appropriate facilities are available several yards
away, not at the other end of the hospital complex as once they were.
Newborns and moms share residence in a family-compatible room until
discharge.
The Powers Center was established in 1993 with leadership from Helen
Powers, a fixture in Western North Carolina banking circles and former
N.C. Secretary of Revenue. While serving as a member of Mission’s board,
Powers realized that most of the hospital’s women’s services were oriented
toward the health of women during their child-bearing years. “Quality
healthcare for women should span the life course,” Powers says, “starting
in youth and extending throughout the post-menopausal years.”
So, Powers set out to secure the resources for building a new “tower” to
accommodate women and children’s services. With the help of many donors,
including a six-figure contribution from Bank of America, the new
structure opened in 1995. It currently covers seven floors. It acts as a
point of entry for women into Mission’s sprawling 90-acre campus, Powers
says.
Mission Children’s Hospital is organized along a similarly
patient-centered philosophy, according to William Brannan. “Because
children can’t communicate as well as adult patients, you need a highly
specialized staff trained on how to communicate with them,” he says.
Specialized equipment and instruments are also required, along with health
professionals well versed in child-related anesthesia, pharmacology and
patient monitoring, adds Brannan.
To better serve ill children and their parents, Mission is constructing a
70,000-square-foot pediatric outpatient building off I-40 to replace the
smaller, older facility in which those services are now offered. “We’re
raising over $10 million for the new outpatient facility,” says Stephen
Miller, Mission’s board chairman emeritus.
Miller, an executive at The Biltmore Company and first vice chair of
NCCBI, views facilities aimed at children’s health as a smart long-term
investment. “When we can take care of these health problems early, they
won’t develop into bigger problems later,” says Miller, who believes
business people should work with employees and providers to make
cost-effective health and wellness decisions.
Miller says. “What we as businesses have to do now is become part of the
solution.”
Specialty
Healthcare Centers -- a Partial List
Specialty medical centers offer patients many benefits and most large
regional medical centers now offer focused professional attention to a
wide range of diseases and physical problems.
Those covered in our feature article include: Carolinas Heathcare,
Charlotte, which has numerous other specialized centers in addition to its
Carolinas Heart Institute, Wake Forest Baptist Medical’s Comprehensive
Cancer Center, Charlotte Presbyterian Orthopaedic, and Ashville’s Mission
Hospitals.
Too many specialty medical facilities exist in North Carolina to list them
all—74 heart rehabilitation centers alone, for instance. But those among
the most prominent include:
Duke Comprehensive Cancer Center, Durham, treats 5,000 patients annually.
It was ranked seventh among the best U.S. cancer treatment hospitals in
2003 by U.S. News &World Report.
Duke Heart Center has more than 80 board-certified cardiologists, cardiac
surgeons and anesthesiologists.
Duke Children’s Hospital is a self-contained “hospital within a hospital”
on the fifth floor of Duke Hospital.
WakeMed Heart Center, Raleigh, is one of the state’s leading providers of
care for cardiac disease, ranking in volume and outcomes as one of the top
three North Carolina hospitals. The center is adding a $30 million-plus
expansion.
Other WakeMed specialty facilities include the Women’s Pavilion &
Birthplace.
UNC’s Healthcare System, based in Chapel Hill, includes special treatment
centers for alcohol and substance abuse, special surgery for children,
diabetes, and heartburn, in addition to the Lineberger Comprehensive
Cancer Center and the UNC Heart Center.
The UNC Heart Center at Meadowmont treats 8,000 to 10,000 patients
annually.
The UNC Lineberger Comprehensive Cancer Center, part of the University of
North Carolina School of Medicine, offers unique treatment innovations for
the toughest cases through clinical trials – from novel cancer vaccines
and drugs to new ways of enhancing current chemotherapy.
Southeastern Regional Medical Center (SRMC), Lumberton, serving the health
care needs of Robeson and surrounding counties has specialty treatment
centers that include a Heart Center, the Gibson Cancer Center, and the
Alzheimer’s Care Center.
The new SMRC Heart Center, an $11 million 29,000 square foot space on the
third floor of the hospital, is scheduled to open in 2006.
New Hanover Regional Medical Center, Wilmington, offers specialty medical
and surgical care and includes freestanding rehabilitation and psychiatric
hospitals. It has one of 10 trauma centers in the state certified at Level
II or above and one of 12 neonatal intensive care units.
Specialty facilities include the Coastal Heart Center, which has the only
open-heart surgery program in the area and the Zimmer Cancer Center.
Teamwork Improves Bariatric
Surgery
Like most Americans, you
may now be working to shed the few pounds you acquired over the holidays.
But for some, diet and exercise alone won’t conquer their weight problem.
An increasingly common procedure known as bariatric surgery may be the
only hope for the truly obese.
Given the many sides of obesity – there are nutritional, psychological,
social, as well as medical factors at work – bariatric treatment works
best in a cross-functional environment. The procedure is expensive – as
much as $30,000 in North Carolina, assuming there are no complications. It
is also risky, with a range of possible complications making follow-on
hospital stays possible.
The operation itself, which has been around since the 1970s, reduces the
size of the stomach. Today, the surgery can be performed laparoscopically
through an opening much smaller than before. Media attention around that
innovation reignited interest in the treatment. “But the procedure is only
about ten percent of the total process,” explains Kenneth Mitchell, a
surgeon who founded FirstHealth Moore Regional Hospital’s bariatric
program five years ago. “Unfortunately, it’s the ten percent that can kill
you,” says Mitchell, who has performed the procedure over 400 times.
Prior to undergoing bariatric surgery, FirstHealth patients must undergo a
psychological evaluation and screening for depression, a condition
frequently associated with obesity. Psychologists evaluate patients’
capacity to grasp the seriousness of what they are entering into, along
with their willingness to adhere to dietary and lifestyle changes that are
keys to the ultimate success of bariatric treatment. Cardiologists check
subjects for heart disease. Endocrinologists screen for diabetes. Finally,
bariatric patients will interact with nutritionists and exercise
physiologists, and specially trained nurses and anesthesiologists are also
involved.
Cost and quality considerations surrounding bariatric treatment led Blue
Cross and Blue of North Carolina (BCBSNC), the state’s largest health
insurer, to design and implement an innovative “Centers of Excellence”
program that gives patients and participants more information on where to
find better-qualified bariatrics specialists. Moore Regional is one of six
programs given that distinction, along with Pitt County Memorial in
Greenville, Durham Regional in Durham, Frye Regional Medical Center in
Hickory and Fayetteville’s Cape Fear Valley Hospital.
Before launching Centers of Excellence last September, BCBSNC spent 18
months designing the program, according to Don Bradley, the Chapel
Hill-based insurer’s senior medical director. Bradley and his colleagues
arrived at a list of criteria for the Centers of Excellence designation.
“It was a great discussion,” says Bradley.
BCBSNC’s saw a need for action as it watched the volume of bariatric
surgery claims spike dramatically in recent years. “In 2001, we paid for
75 bariatric procedures,” he says. “In 2004, we’ll cover 680.”
By naming Centers of Excellence, BCBSNC hopes to reduce instances of
complications, which for some surgeons were occurring in half of their
bariatric patients. The insurer, continues to reimburse claims for
treatment performed at facilities that aren’t Centers of Excellence. But
those with the designation don’t have to adhere to pre-approval
requirements. “That saves them and us administrative costs,” Bradley says.
The centers are reimbursed 30 to 50 percent more for the procedure, part
of which is designed to offset the expense of submitting outcome reports
BCBSNC requires. They also get a special listing in the insurer’s provider
directory. “Conceptually, it’s a win-win all around,” concludes Bradley. —
Lawrence Bivins
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