If you follow CFA’s blogs, you hopefully will have read our current and continuing series on low-volume cardiac surgery programs and the challenges they face in the evolving era of value-based healthcare (refer to Low-volume Surgery Programs: Parts One through Five). You may also remember our blog post from last year in which we asked the question, “Can Low-Volume Cardiac Surgery Programs be Excellent?” (posted November 15, 2016). We have received a great deal of response and feedback to this series, indicating that this issue is very much top-of-mind at many American hospitals. The release of the 2017 IBM Watson Health 50 Top Cardiovascular Hospitals listing published in the November 6 issue of Modern Healthcare focuses our attention on this subject again.
Basically, our position is that low-volume cardiac surgery programs are at increasing risk, and that difficult strategic and operational decision-making needs to take place to successfully address this issue over the long-term. CFA is poised to post its updated and expanded white paper, Self-Preservation Strategies and Excellence Expectations, in the very near future, to update and share our thinking on this critical subject.
Certainly, we have worked with many low-volume programs over the years that have had excellent outcomes, by any standard measures. But frankly, success under yesterday’s market conditions was generally easier, even at a lower volume, and today’s environment and the value-driven direction we are heading toward makes it much more difficult. The “average” low-volume cardiac surgical program may eventually be doomed, but can a program that maintains a low-volume perform well enough over the medium- to long-term to truly succeed and possibly even survive? Or are they ultimately candidates for consolidation or divestiture? These may be simple questions; but ones with very complex answers with wide-ranging consequences.
I am sure you are all familiar with the previous year’s Truven Health Analytics’ list of Top 50 Cardiovascular Hospitals in the U.S. The 2018 list was published in Modern Healthcare, November 6, 2017 under its new banner, IBM Watson Health. Hospitals make the list[i] by outstanding performance in areas of quality and cost measures applicable to heart attack, heart failure, CABG surgery, and PCI including:
- Risk-adjusted inpatient mortality rates
- Complication rates
- Clinical process measures
- 30-Day readmission and mortality rates
- Severity adjusted length of stay
- Average cost of care
- 30-Day episode payment for heart attack and heart failure (two new measures for 2018)
In summary, these seven measures focus on cost reduction, best practices, quality outcomes and reimbursement incentives. Hence the “value play” principle. What you do not see is case volume criteria. Therefore, by these measures, any program can be excellent regardless of volume. Yet volume mix is clearly a key factor (i.e., use of risk adjusted scoring).
Top Performers, Despite Low-Volume?
Last year, I looked at just the Community Hospital listing of fifteen hospitals and matched their cardiac surgical volumes for CY 2015, the latest year available, to see if any low-volume hospitals made the list. The combined volume for CABG and valve surgeries, the vast majority (80+%) of all “cardiac” surgeries, ranged from a hospital with a low of 46 patients to one with a high of almost 850 patients. Three of the fifteen hospitals were what CFA would define as “low-volume” programs; with 46, 53 and 59 patients respectively. And yet they made the list of 2017 50 top performing cardiac hospitals, in the Community Hospital category. By comparison, two “low-volume” hospitals made the 2018 list in the same category with volumes of 100 and 76 cardiac surgeries respectively. Perhaps the hospital with 100 surgeries is arguably on the “cusp” of low-volume – perhaps not.
By IBM Watson Health’s analyses, a hospital cardiac surgery program that performed as few as 46 surgeries is a top 50 hospital[ii]. By-the-way, congratulations to them, they have defied the conventional wisdom and should be proud of their accomplishment. They have beaten the odds by consistently tracking, monitoring and improving their clinical and operational performance through a systematic and multidisciplinary process incorporating evidence-based medicine (at least in 2017!). This proves that it not only can be done, but also argues the case that it must be done by every hospital attempting to stay competitive in an increasingly value-driven market. Of note is the fact that the three low-volume hospitals from the 2017 list did not make the 2018 top 15 list and the two low-volume hospitals on the 2018 list made the top 15 for the first time. This would seem to imply that excellence – at least as defined by IBM Watson – is not only challenging to attain initially, but equally or more challenging to sustain over time.
Succeeding at Low-Volume
Succeeding in improving performance to a high level, despite low-volumes, is an important achievement, and will be possible for some providers, but it cannot and should not be considered a virtual guarantee to save a program from the eventual need to seriously consider strategic and organizational options including consolidation or divestiture. The national trends are too formidable and the market can be unforgiving to even the best intentioned.
CFA estimates that there are somewhere in the neighborhood of 500 hospitals in the U.S. that operate low-volume cardiac surgery programs. There are about 40 in California alone. If approximately 30 percent are “Community” hospital programs (the same proportion as in the IBM Watson Top 50 Hospital designation), then there are an estimated 150 U.S. “Community” hospitals that will need to make substantial improvements to their overall cardiac performance to be able to qualify for the “Top Hospital” list, based on IBM Watson’s analyses and their definitions of what constitutes a top hospital. If five hospitals have done it during the 2017-2018 time-period, then there is at least the opportunity for others to try and be successful.
Focusing on performance and making significant efforts to achieve real progress in the typical cardiac surgery program takes focus, leadership and teamwork. This means constantly tracking data and assessing their performance to address unnecessary variation, evidence-based best practice, and enhance overall patient experience. As the average patient becomes more chronically or acutely ill, data generated from comparative databases, such as the Society of Thoracic Surgeons registry, becomes even more important to the ongoing analyses needed to enhance overall performance improvement across the continuum. CFA believes the demand for achieving a “center of excellence” status can be and, for many, must be a go-forward strategy to successfully compete in the cardiovascular marketplace.
In conclusion, low-volume cardiac surgical programs can be top performers in quality and cost measures – but they are the exception, rather than the rule. To be the exception takes a commitment to extraordinary vision, leadership, clinical expertise, collaboration and team-building, which many hospitals are challenged to provide. The majority of hospitals with low-volume programs will need to continue to strive for performance excellence, as a means of self –preservation in the short term. All the while recognizing that ultimate long-term success for the institution as a whole may lead inevitably to consolidation or divestiture of their cardiac surgery program simply due to the changing health care delivery and insurance markets and the need to successfully focus on attaining value-based status.
If you are interested in learning more about strategies to deal with low-volume cardiac surgery programs and/or programmatic consolidation for cardiovascular or other services, please contact CFA at (949) 443-4005 or by e-mail at firstname.lastname@example.org. Also, watch for our new, updated white paper, Low-Volume Cardiac Surgery Programs: Grow, Consolidate or Divest? Self-Preservation Strategies and Excellence Expectations in the near future.
CFA always appreciates your feedback and comments.
[i] In three categories: Teaching Hospitals with CV Residency, Teaching Hospitals without CV Residency, and Community Hospitals.
[ii] Recognize that this opinion is not informed by the specific mitigating local circumstances. There are many strategic and practical reasons a hospital would want to offer a low-volume program. In some areas of the country, issues of local access, travel times and/or sole provider status may be legitimate mitigating factors.