The CFA Perspective

Physician/Hospital Alignment and Bundled Payment – Part Two

Continuing the discussion from Part One of physician/hospital alignment and the reemergence of bundled payment initiatives, let’s discuss the impact of health care reform in the area of bundled payment for care.  A national pilot program on payment bundling is included in H.R. 3590, the Patient Protection & Affordable Care Act.  This pilot program is set to commence in 2012 (no later than January 1, 2013) and run for five years.

 

Although conceptually similar to previous efforts by HHS, this pilot is intended to bundle payment for an entire episode of care inclusive of up to 30 days post-hospital discharge (implying an unprecedented level of physician/hospital cooperation, coordination and collaboration!).  While no identification of covered procedures/conditions has yet been made, but it seems reasonable that major cardiovascular procedures, and possibly certain medical cardiology admissions such as heart failure, will be included as has been done in past pilot projects.  Some other details included in the legislation (and pending final detailed regulations), include the following:

 

• Inclusive of Medicare beneficiaries
• Up to eight medical conditions for an episode of care to be selected
• Conditions will be a mix of chronic and acute
• Bundled services to include acute inpatient, physician, outpatient hospital, post acute, and other appropriate services
• An episode of care is defined as three days prior to admission, inpatient hospital admission, and the 30 days following discharge from a hospital
• Program to be established no later than January 1, 2013
• Quality measures to be developed under contract for use in the program
• The pilot to be conducted for a period of five years
• Applications can be submitted by an “entity” consisting of a hospital, a physician group, an SNF, and a home health care agency
• The Secretary of HHS will make bundled payments (amounts to-be-determined) to the contracting entity
• Quality measure to be reported and to include:
  • Functional status improvement
  • Reducing rates of avoidable hospital readmission
  • Rates of admission to emergency room after hospitalization
  • Incidence of healthcare acquired infection
  • Efficiency measures
  • Measures of patient-centeredness of care
  • Measures of patient perception of care
  • Other appropriate measures of patient outcome
• An interim report on the demonstration not less than two years after implementation
• A final report no later than three years after implementation

 

Participation in such a pilot project is always challenging – it must make both strategic and operational sense to the participant(s).  Notice the high level of cooperation, coordination and information required of the participating “entities” especially among hospital and physicians inclusive of both pre-hospitalization, hospitalization and 30-days post-acute care phases!  The work that will need to go into the program design on the part of all of the participants, just to be able to file an application, let alone pull off designing and managing such a program at the local level will be extraordinary.

 

Will this pilot program “have legs?”  Only time will tell.  However, it is vital for hospitals and physicians to recognize that such efforts will only continue and place an increased burden on hospitals to solidify their alignment strategies with select physicians.  It is hard to image that success under the requirements of care coordination, bundled payment and pay-for-performance scenarios can be possible without the appropriate physician/hospital alignment strategies in place.

 

CFA will keep you informed on further developments on hospital/physician alignment and bundled pricing, and would welcome your thoughts and comments as we progress. For further information, CFA recommends you review H.R. 3590 and, in particular, the proposed bundled payment pilot program.

Physician/Hospital Alignment and Bundled Payment – Part One

Bundled or package payment across an episode of care such as a hospitalization, the subject of Medicare demonstration projects in the 1990’s, may be poised for a comeback.  Many will remember the Medicare CABG demonstration project of 1991-1996 – an early attempt to promote incentives through physician/hospital alignment.  Subsequently, there was an attempt to expand upon this demo with select cardiovascular and orthopedic procedures a few years later that never got off the ground.

 

The Medicare Payment Advisory Commission’s (MedPAC) June 2008 Report to Congress touted bundled payment as the best way to achieve the objectives of “financially motivating hospital/physician collaboration in identifying and implementing opportunities to limit the use of low-value services, coordinate beneficiaries’ care, and working together to improve efficiency…”  (http://www.medpac.gov/documents.cfm).  It is worth reviewing this document in its entirety as a background on MedPAC’s thinking.  Various bundled or global payment projects are ongoing regionally, including Medicare’s Acute Care Episode (ACE) Demonstration, Prometheus Payment, Geisinger Health System’s ProvenCare program in Pennsylvania, Integrated Healthcare Association in California, and various hospital and employer/business coalition-sponsored initiatives.  A national pilot program on payment bundling is included in H.R. 3590, the Patient Protection & Affordable Care Act (See Part Two of this topic for a more detailed discussion).

 

Previous demonstration projects, including the Medicare CABG demonstration, concluded that bundling payment successfully lowered costs, promoted collaborative medicine and produced acceptable levels of quality and customer satisfaction.  We all knew intuitively that it would (or should!)  Subsequent bundling projects by the Federal government were never implemented and widespread adoption of the methodology never took place.

 

Importantly for us all, very few hospitals and physicians have ever participated in bundled payment initiatives of any type.  We are not including capitation as a related, but very different animal.  Most of us that have participated in these efforts in the private payer arena remember how difficult it was to reach an accord between hospitals and physicians over participation in general and pricing in particular.  Beyond the legal issues of negotiating price between competing entities, non-aligned physicians had little real reason to participate.  Generally conservative and skeptical of government (and maybe consultants too), the private bundled price market was seen as just too small and risk-prone for them.  In reality, their intransigence proved prescient, and this market, where it existed at all, simply disappeared until recent events resurrected it.

 

It would seem that everything old is new again and bundled payments are back, although not in most markets and not at this time.  Will this trend be revitalized and become predominate in some markets?  Time will tell.  Certainly times and market conditions have changed for healthcare and physicians in particular.  Economic conditions, changing regulation and the shape of healthcare reform will dictate if this trend really gains traction. 

 

What lessons can be learned from the completed and currently ongoing bundled payment projects?  What benefits are derived by hospitals and their medical staffs to participate in such ventures?  Is participation more strategic or practical?  Is physician/hospital alignment mandatory for success in this market, and what model(s) are advantageous (if any)?  Can market share be moved?  How would a hospital prepare for such a radical change in reimbursement?  How viable a trend are bundled payments?  What role does each of the stakeholders play in the increasing adoption of bundled payments by government, businesses and managed care organizations? These and other questions are open and will need to be addressed by hospitals and physicians (aligned and non-aligned).

 

We believe that hospital preparation for bundled payments will be critical to success.  Those that have adopted aggressive hospital/physician alignment strategies have laid a positive foundation, but will also have to make significant operational, informational, clinical and financial preparations for the close working relationship necessary to be successful.

 

This blog is the tip of the iceberg on this subject.  In part two, we will review the H.R. 3950 bundled payment demonstration. CFA will continue to provide its insight on hospital/physician alignment and bundled pricing, and would welcome your thoughts and comments as we progress.

 

For further information, CFA recommends you visit http://www.prometheuspayment.org/, www.geisenger.org/provencare, www.iha.org, and/or http://www.medpac.gov/.

Is the Heart Hospital Dead? (Well…Maybe)

The future of physician-owned or joint-ventured heart hospitals would seem to be dead.  What officially killed it is H.R. 3950, the Patient Protection & Affordable Care Act, which declares that, unless they have a provider agreement in place prior to December 31, 2010, physician-owned hospitals (of any type) are excluded from Medicare participation.  These controversial entities have suffered as of late from a confluence of market forces that did not bode well for the long-term health of the heart hospital.  In particular, two major factors worked against them:

 

• the continuing trend towards physician/hospital alignment, particularly specialty physician employment by hospitals; and,
• the continuing trend towards the development of outpatient services at the expense of inpatient hospital services.

 

Thus, freestanding, for-profit heart hospitals began to lose their novelty and market luster.  Even MedCath, the proprietary developer of heart hospitals, is divesting some properties and looking to sell itself or more of its hospitals.  It recently sold its ownership stake in the Heart Hospital of Austin (Texas) to St. David's Medical Center of Austin.

 

On June 3, Physician Hospitals of America, representing 260 physician-owned hospitals, along with the Texas Spine & Joint Hospital filed suit in U.S. Federal Court challenging the constitutionality of Section 6001 of the new law.  They denounce the passage of healthcare reform, saying it will destroy the 60 hospitals currently under development, cost 25,000 jobs in 38 states, and cost billions of dollars in invested costs.   This time, politics, and of course, supporting market trends, seem to have won out over entrepreneurship and the free market.  Unless, that is, that section of the law is overturned in court!

 

The overall strategic, competitive and financial value of the freestanding heart hospital concept has been debated time and again over the past several years, with full-service hospitals out to kill it, and our purpose is not to rehash this debate here.  It would seem then, that the following conclusions can be drawn from a distillation of current trends and recent legislation:

 

• There will be no new physician-owned heart hospitals developed in the U.S. if H.R. 3950 stands and/or the specific prohibition on physician ownership is not repealed or overturned in court.
• Existing physician-owned or joint-ventured heart hospitals, while under increasing economic pressure, are still viable competitors to hospital cardiovascular programs in specific markets and under specific market circumstances.
• Physician/hospital alignment strategies up to and including employment models can be viewed as a successful alternative against physicians considering options such as heart hospital support, ownership or participation.
• Hospitals and health systems will continue to develop their cardiovascular programs by incorporating heart hospital concepts into their strategies, including developing new hospital-owned heart hospitals and/or purchasing existing/competing heart hospital ventures to expand their capabilities, market reach and market share.
• Physicians can no longer view freestanding heart hospitals as viable investment opportunities. Existing development will be halted and no new development will be allowed.

 

If there is a lesson here, it is that even in a market-driven economy such as healthcare, politics cannot be divorced from economics and market trends must be continuously and critically evaluated by all providers if they are to succeed and prosper.

 

What do you think?  As always, CFA values your thoughts and comments.

The Transradial Approach to PCI – A “Win-Win” for Everybody?

When was the last time you came across a simple and straightforward change in clinical technique that typically results in better clinical outcomes, fewer complications, higher patient satisfaction, and lower cost per procedure?  While that has occasionally happened in the cardiovascular field, the increasing trend for substitution of the transradial (through the wrist) for the transfemoral (through the groin) approach for PCI, seems to be a real "win-win" for everyone involved.

 Traditionally, guidewires and catheters for PCI are inserted through the femoral artery.  Bleeding or vascular complications occur about 2% of the time.  Patients are recovered lying flat and immobile for 4-6 hours to prevent bleeding, which has also been helped by the advent of vascular closure devices.  The patient is more comfortable, dangerous bleeds are reduced, but vascular complications still exist.  Enter the transradial approach in the late 1980's.  Outside of the U.S., about 40-50% of all PCI's are done transradially.  In the U.S., that number currently is in the low single digits and only a small percentage of U.S. interventional cardiologists have been trained to use this approach.

 The advantages of the transradial over transfemoral approach are significant and include:

• The initial needle puncture is simple and straightforward
• Not impacted by a patient with peripheral vascular disease, obesity or female gender
• No need to recover the patient lying flat and immobile; patients are recovered sitting up and can leave the cath lab almost immediately post-procedure; this allows (theoretically) the patient to forgo spending an overnight stay in the hospital
• Because no vascular closure device is required, a significant cost is eliminated
• Less bleeding and other complications, significantly decreasing the risk of mortality
• If present, bleeding or other complications are readily identified and easy to address
• Overall case cost is decreased by obviating the use of vascular closure devices
• It is safer, more convenient, and more comfortable for the patient

 There are several reasons the approach has not been used more frequently, including:

• Lack of trained cardiologists
• Lack of financial incentives due to the existing reimbursement structure
• Lack of a marketing campaign by device manufacturers (who have concentrated their efforts outside the U.S.)
• Lack of patient demand because the approach has not been widely publicized
• An impression that the learning curve is too steep and learning inertia on the part of busy interventional cardiologists
• Lack of recognition and inclusion in practice guidelines or recommended practices by professional societies

 As with any procedure, there are certain contraindications and potential complications.  Additionally, physicians need to be trained in the procedure by those with solid experience.  Like all new procedures, there is a learning curve.  Despite these factors, the transradial approach is gaining momentum, fostered by recent study results and an increasing recognition by influential physicians that this approach has real benefit.  CV services management staff should fully evaluate this approach, seek out physician champions and put together an implementation plan to successfully integrate this technology into their program.  This can be a perfect hospital and physician performance improvement project or targeted metric as part of a physician/hospital alignment effort.  It's not very often that a modest clinical change can simultaneously improve clinical outcomes, reduce complication rates, increase patient satisfaction, and lower procedure costs and be a "win-win" for all involved!

 For further information, CFA suggests you review the article, Trends in the Prevalence and Outcomes of Radial and Femoral Approaches to Percutaneous Coronary Intervention:  A Report from the National Cardiovascular Data Registry, published in the November 2009 Journal of the American College of Cardiology - Cardiac Interventions.

Clinical Performance Improvement: “The Best Measure of Outcome is Outcome”

Over the long consulting careers of CFA's Principals, the relationship between cardiovascular procedural volume and quality outcomes has continually merited examination.  Multiple studies have addressed the issue for a wide range of cardiovascular procedures.  It is intuitive-isn't it?-that higher volume cardiovascular programs produce better outcomes, and vice versa?

Researchers, professional societies (through evidence-based practices), payers and the media have all addressed the issue, in some cases setting guidelines and standards for minimum volumes at both the program and physician operator level.  In certain states, falling below a minimum volume standard can trigger a clinical audit and could result in program decertification.  Unfortunately, we all know that "volume equals quality" just isn't that simple-it is complex and heavily nuanced.

A recent example of research into this issue was published in the Journal of the American Medical Association in November 2009.  The article examined the association of hospital primary angioplasty volume with quality and outcome.  One of its authors, Dr. Deepak L. Bhatt of the Cleveland Clinic, concluded that the mortality from small, medium and large volume providers does not differ considerably. Other markers of quality were also studied, such as door-to-balloon times and length of stay.  He further concluded that,

"As common sense would suggest, certainly there is a level where volume does matter, but in the contemporary era, that threshold may vary.  The best measure of outcome is outcome."    

Dr. Bhatt's conclusion is surprising simple, yet profound:  the best measure of outcome is outcome.  In this era of pay for performance, bundling payments, rewarding specific levels of outcome metrics, demand for increasingly transparent results and heightened public expectations, hospitals need to pay strict attention to Dr. Bhatt's simple conclusion and make it work for their program.

CFA recommends that hospitals (and individual physician operators) whose CV service line volume of a key procedure falls below generally accepted minimum volume indicators take the following actions:

• Acknowledge that for some individuals and organizations, volumes and outcomes will always be linked.
• Establish specific and detailed outcome metrics for your program and insure that all applicable quality outcomes for the procedure meet or exceed generally accepted standards.
• If there are deficiencies, internally acknowledge them and work vigorously, in a coordinated manner, to address and improve performance to initially attain acceptable and then higher levels of performance.
• Enlist the aid of your physician staff in understanding the problem, setting acceptable levels of performance and addressing the underlying issues.
• Take the necessary strategic planning steps to understand the underlying reasons for volume changes and explore what must occur to raise volume above applicable standards. Has volume declined in the overall market? Is there a trend in just one clinical segment of the market? Has a competitor moved market share? Has a key technology changed? Is this a physician supply issue? Remember however, that successfully raising volume does not obviate the need to aggressively manage outcome metrics. Raising volume in the presence of a significant underlying issue could actually negatively impact a key outcome metric.
• Be prepared to defend your volume and related outcomes against any assault-from the media, your competitors, regulators or other interest groups. Have your data ready and your communication plan developed well in advance. In this case, the best offense is a good defense.
• If all else fails, carefully consider any programmatic consolidation opportunity that may arise within the service line. Obviously not for everyone, but for a select few, consolidation may be the optimal solution.

For further information, CFA refers you to Association of Hospital Primary Angioplasty Volume in ST-Segment Elevation Myocardial Infarction with Quality and Outcomes, published in JAMA, November 25, 2009; 302(20); 2207-2213. (http://jama.ama-assn.org/content/vol302/issue20/index.dtl)

Cardiovascular CT in the ED – The CT-STAT Trial

If a blog is an electronic soap box, then CFA can be accused of standing on one and shouting about the continuing positive evidence of the utility of cardiac CT angiography in cardiovascular diagnoses. The reported results of the CT-STAT (Coronary Computed Tomography for Systematic Triage of Acute Chest Pain Patients to Treatment) Trial presented at the AHA meeting in November, 2009, gives positive results for the use of coronary CT angiography on chest pain patients in hospital emergency departments. Previous studies have produced similar results, but they tended to be small and single facility-based trials.

We all realize what a challenge the ED has in the diagnosis of chest pain patients. Six million chest pain patients present to ED's in U.S. hospitals each year. Of these, 75% are found to have non-ischemic or non-cardiac etiologies for their chest pain. The diagnostic cost of diagnosing these patients is estimated at $12 to $14 billion a year. About 2% to 4% of acute coronary syndromes are missed and inappropriately discharged. This leads to an estimated 20% of malpractice costs being assigned to missed diagnosis of chest pain in the ED each year. The standard-of-care testing (rest and stress imaging after serial electrocardiograph and cardiac enzyme tests) for chest pain patients is time consuming and resource intensive, with results that are not always definitive.

In the study 750 low-risk chest pain patients were randomized in 16 hospital sites to receive either CT angiography or standard-of-care workups in an attempt to produce a diagnosis. The results of the trial were striking:

• The use of CT resulted in a mean diagnosis time of 2.9 hours, compared to 6.2 hours for the standard of care.
• Use of CT decreased the overall radiation exposure from about 15 mSv for the standard of care to 10.8 mSv for CT angiography.
• Use of CT decreased overall costs for patients from a mean of $3,458 for standard of care to $2,137 for CT angiography.

In summary, the trial concludes that the use of CT angiography was safe, faster, and cheaper than the standard of care. CFA encourages all hospitals with emergency departments and cardiac CT technology to evaluate chest pain strategies based on cardiac CT angiography, but cautions that there are many factors that must be considered with implementation. Including:

• Availability of CT (specifically technical staff and interpreting physicians) within the hospital, particularly beyond daytime hours.
• Interpretation by qualified physicians. After hours coverage is particularly problematic and may require the use of a night read services, which increases costs.
• Development of protocols that highlight the indications and contraindications for the test, importance of heart rate control, administration of beta blockers and the like to obtain appropriate and assessable studies. Not every patient is a candidate for coronary CT. 
• Continuing quality audits that track the quality of the studies and pinpoint non-assessable studies, and continuous review of CT cases as part of appropriate monthly multi-disciplinary conferences.
• Often problematic reimbursement.

For further information on CT-STAT, CFA refers you to http://directnews.americanheart.org/extras/sessions2009/slides/159_sslides.pdf

2010 is Here and “Most Cardiologists Lose, Some Lose Big”

The CY 2010 Medicare Physician Fee Schedule (MFFS) Final Rule, as originally presented by the Centers for Medicare and Medicaid Services (CMS), passed into law January 2010 despite heavy lobbying efforts on the part of cardiologists, cardiac imagers and others. The new fee schedules, mandated by adjustments in the Sustainable Growth Rate (SGR) formula that governs physician payments, are phasing in sharp cuts in reimbursement for office-based imaging procedures; shifting payments from specialists to primary care practitioners; and changing coding and reimbursement for consultations, office visits and hospital visits; among other changes. The net result is an approximate overall cut of 21%. The RVU conversion factor drops from $36.0666 to $28.3895.

At the last minute, implementation of a portion of the reductions was put off until March 1, 2010. Intense lobbying and lawsuits questioning the rules methodology by the American College of Cardiology (ACC) and others are continuing in an effort to prevent full implementation. Only Congressional action can change the implementation schedule or the substance of the changes.

"Most cardiologists lose, some lose big," is a quote from a slide presentation put together by the ACC for its members before implementation was scheduled to take place at the beginning of the year.

As referenced in our last posting, a December 2009 a poll by the American College of Cardiology asked cardiologists to answer the question, "Did your practice integrate with a hospital in 2009?" As reported on the ACC website, www.acc.org:

• 13% said yes, my practice integrated in 2009.
• 23% said no, but my practice has concrete plans to integrate.
• 50% said no, but my practice is thinking about it in the next 1-2 years.
• 15% said no, my practice has no plans to integrate with a hospital.

A month or so into the new reimbursement climate, what would the answers be if the same question were posed today? One could conclude that these substantial reimbursement changes may tip the scale in favor of a more concentrated effort at integration between physicians and hospitals. Certainly, when and if the full fee schedule changes are implemented, the concern for future income and practice revenue stability of those affected will grow.

CFA is aware of cardiology groups that have been thrown into turmoil over these changes because of, among other factors, the way the group compensates its members; their respective work assignments and subspecialties, and associated reimbursement; which members own or otherwise control ancillary and testing equipment and services; and related issues. These changes can shake the very foundation of cardiology practice compensation methodology. Group practice compensation is a critical issue for member stability and the ultimate success of the group. Variation in compensation and perceived inequities under the pressure of reduced reimbursement could cause a group to become unstable, split apart or possibly seek closer integration with a hospital or health system as a strategy to return the group to a semblance of economic stability and harmony.

If the fee reductions are mitigated in the near term, as has frequently been the case in the past, there will still be erosion of the financial performance of cardiology practices. As healthcare costs increase, the assault on physician payment is anticipated to continue unabated. In the mind of most physicians, governmental reimbursement will inevitably be eroded at their expense and the overall reimbursement environment will remain toxic.

CFA recommends that cardiovascular physicians monitor their professional societies for updated information on reimbursement changes. These would include www.acc.org, www.scai.org and www.sts.org, among others.

It is critically important that cardiovascular management and hospital administrative staff monitor the situation with their cardiovascular physician colleagues' practice circumstances. Hospital management should be open to evaluating alternatives for collaboration and more effective alignment and integration with their cardiovascular medical staff.

Poll Indicates Cardiologists More Likely to Integrate with Hospitals

With the ongoing interest in physician and hospital alignment and integration strategies, this December 11, 2009 poll from the American College of Cardiology (ACC) is most interesting. Credit is given to our colleague, Walter Unger of Unger and Associates, for bringing this poll to our attention. The poll was conducted by Jim Fasules, M.D., FACC, ACC's Senior VP of Advocacy, and reported by ACC CEO Jack Lewin, M.D. Participants in the poll were asked, "Did your practice integrate with a hospital in 2009?" Here are the responses:

• 13% said yes, my practice integrated in 2009.
• 23% said no, but my practice has concrete plans to integrate.
• 50% said no, but my practice is thinking about it in the next 1-2 years.
• 15% said no, my practice has no plans to integrate with a hospital.

These results show just how strong the trend towards integration really is. A total of 36% of practices have integrated or have "concrete plans" to integrate. Another 50% of the respondents state that they are thinking about it. While the respondents are (presumably) only cardiologists, and the poll was not inclusive of other cardiovascular physicians (particularly cardiac surgeons) who may entertain the idea of integration, the poll is still a powerful indication of just how strong the integration movement is.

CFA is involved with clients where the circumstances leading up to interest on the part of cardiovascular physicians in integrating vary considerably. One would think the predominate reason for cardiologists and cardiac surgeons, among others, to consider alignment with local hospitals is purely economic. The initial stimulus frequently is; however, other factors come into play. It is logical to assume that physicians who have not been financially successful would be the first to consider an integration strategy. But this is not necessarily so. Consider the following:

Recently, in the southeast, a group of cardiovascular surgeons affiliated with the largest volume and most prestigious cardiovascular program in their state expressed interest in integration with their affiliated hospital. By every comparative metric applied, they were a highly financially successful group of surgeons with a significant geographic monopoly based on strong referral patterns. While their overall cardiac surgical volume had trended down, their group and individual incomes were stable as they aggressively managed their practice expenses and diversified into vascular surgery to maintain case volume and revenue. This group went to the extensive measure of taking one of their surgeons out of active practice and sending him for retraining in state of the art vascular procedures to build practice volume. Yet they still believed the overall, long term trends were working against them. The historical financial success of their practice did not preclude them from reconsidering their future direction.

Hospitals need to be prepared for this Physician-hospital alignment and integration movement by proactively thinking about their overall strategy and tactics before the issue arises. One of our senior staff attended a seminar on alignment this past year where a hospital administrator from the Midwest said that he lived in dread of any phone call or personal visit from one of his medical staff, because so many of them were asking to be bought out and employed! He was overwhelmed by the issue and knew that he needed to prepare a strategic response to this trend if he was going to keep his head above water.

CFA recommends that all hospitals and physician groups be prepared to deal with the issue of integration. With up to 50% of poll respondents actively considering integration with a hospital, it is imperative that each hospital and physician group understand the economic and political trends that promote alignment and integration, and the implications on their respective businesses.

To view the poll referenced in this posting, please refer to The Lewin Report

Advanced Cardiovascular Imaging (Cardiovascular CT Angiography) – A Critical Technology?

Three-dimensional imaging diagnostics-in particular, Cardiovascular CT angiography (CCTA)-have been widely touted as the next big thing in the diagnosis of CAD and PAD.  Nearly every day a new clinical article related to CCTA shows up in my inbox.  What's the current state of 3-D imaging?

While important, this technology has not proliferated as rapidly as many of us thought it would.  It is clear that the reason is largely (but not exclusively) economic:  the high cost of the equipment (beyond the scanners themselves, the workstations required to post-process and analyze results), the impact of the worldwide recession on capital purchases, lack of technological uniformity, lack of skilled technologists, the cost-related pushback by insurers (including Medicare) due to the proliferation of all types of imaging, fear of a negative impact on cardiac catheterization volumes, the time commitment and cost required for physicians to obtain proficiency, and so on.  Overall, reimbursement has been challenging, with ever-changing policies and payment inconsistencies among payers.      

Given the current challenges, what trends relative to CCTA does CFA believe will be important for hospital cardiovascular programs in the future?

• If you don't provide access to CCTA, your cardiologists and vascular specialists may be motivated to work with your competition that does. Or possibly to purchase it themselves (if they haven't already) and go into open competition with you (another reason for hospital/physician alignment strategies!). New regulation, including healthcare reform, could mitigate this issue, but it will still exist.
• The use of CT technology will continue to be shared between Radiology, Cardiology and others, except in the largest volume programs that can justify dedicated (and cardiology-controlled) cardiovascular CTA. This situation drives the need for inter-disciplinary collaboration and a cooperative model for sharing access to the equipment and completing comprehensive interpretation of the results.
• ED usage of CCTA for chest pain triple rule-out (because of its diagnostic capability to assess aortic pathology, coronary artery disease, and pulmonary emboli in one scan) may soon become the standard protocol for diagnosis of chest pain.
• As hospitals continue to develop stroke center capabilities, quadruple rule-out examinations, which extend coverage from the skull base through the thorax, may become useful in patients with syncope, transient ischemic attacks, and cerebrovascular accidents resulting from carotid stenoses. The so called "half-body scan" may become more commonplace.
• Automated cardiac CT-analysis software shows promise, has a high negative predictive ability and may facilitate utilization for smaller, community hospitals.
• The recent Texas law requiring insurance companies to pay for CV screening inclusive of non-contrast CT measuring coronary artery calcification (calcium scoring exam) will most likely not soon be replicated in other states.
• Use as a universally accepted (and reimbursed) screening tool for asymptomatic patients is highly unlikely as well.
• Highest and best use may be as a "filter" to avoid invasive angiograms where likelihood of CAD is not very high.
• Over time, CCTA will become part of the diagnostic work flow for many cardiologists, cardiac and vascular surgeons, and become an expected part of their clinical routine.
• As 3-D diagnostic imaging continues to develop, consistent reimbursement is established, drops in cost, and is generally accepted by other specialists (especially for surgical/procedural planning), it will become the standard. Payers will come to see it as possessing real value. The trend to promote all 3-D imaging will help promote CCTA for cardiac and vascular use as well.

The CFA team recommends that those interested in learning more about Cardiovascular CT contact the Society of Cardiovascular Computed Tomography (SCCT) at http://www.scct.org/.  This is the leading professional organization dedicated to CCTA and provides its members with regular updates on education and training programs and legislative initiatives.  SCCT publishes a journal devoted to the utilization of this technology.

 

Hospital and Physician Alignment in the Cardiovascular Enterprise

Hospital cardiovascular program managers and cardiology, cardiovascular surgery and vascular surgery practice administrators are well aware of the continuing evolution of cardiac and vascular medicine and the multitude of challenges facing each of us.  For cardiovascular program leaders across the country, the challenges of the past will continue into 2010, along with new circumstances requiring creative solutions.  The national debate over healthcare reform that is heating up is leading to more confusion and indecision about the future.  Hospitals and physician practices continue to be inundated with strategic, clinical, financial, operational, and competitive issues that require informed organizational responses.  The possible strategies to successfully address these issues are numerous and varied.

In such times, an approach that pools resources to solidify the program's foundation for the future is critical to short term and ongoing success.  Sound physician/hospital alignment has the potential to be a CV service line transformative strategy that can:

1. Align strategic, operational and financial incentives between physicians and hospitals
2. Provide a platform for developing customized integration strategies
3. Improve operating performance and profitability
4. Reduce/prevent competitive risk and predatory recruitment
5. Gain competitive advantage; retain and expand market share

Experience in the field of cardiovascular physician/hospital alignment projects, leads to several key conclusions when planning for a cardiovascular program's future:

• If you have seen one and done one, then you have seen just one and done just one. Unfortunately, what has worked in one city, for one hospital or group of physicians, may not work for you. A situation that seems similar to yours may be different in a crucial aspect that precludes your success.
• While there is a major trend towards hospitals employing specialists like cardiologists and cardiovascular surgeons, this is not always doable-nor is it frequently the best answer in all circumstances and in all communities.
• It isn't always about money. Yes, economics and aligned incentives are important, but a myriad of personal, political and other factors can impact physician thinking and hospital actions. How often has a physician said that he wishes he was in charge of the CV service line for just one day? Very often, the issue is the appropriate exercise of control and sharing of management responsibilities.
• Do not think that establishing a physician/hospital alignment model is simple, straightforward and completed quickly-it can be a contentious, problematic, sometimes meandering, and occasionally disappointing process.
• Incremental steps are not a bad strategy. Alignment options short of employing physicians offer hospitals and physicians a chance to work together more closely and experience a new collaborative business model. Experiencing what it is like to work together under a new arrangement can prove invaluable to both parties prior to employment should that be a consideration. This is especially true during this period of uncertainty about the implications of healthcare reform.

Interested in further information on the topic of Hospital and Physician Alignment in the Cardiovascular Enterprise?  Download a copy of CFA's article Physician and Hospital Alignment Strategies: