The CFA Perspective

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)

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.

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: