Over the past several years, the diagnosis and endovascular treatment of peripheral vascular disease has increased significantly in many hospitals. As cardiologists continue to expand their repertoires through endovascular training programs, as more vascular surgeons are formally trained in endovascular techniques, as interventional radiology groups continue to refine their capabilities, and as treatments for vascular disease expand into new arenas, peripheral vascular diagnosis and intervention continue to expand. Cardiologists, vascular surgeons and interventional radiologists working in harmony in multi-purpose cath labs and hybrid rooms should be the goal of every hospital wishing to call itself a comprehensive cardiovascular center.
So, from our perspective, it is very important to remember the “vascular” in “cardiovascular.” While the majority of the work CFA does is cardiac-related, most of our client engagements also involve vascular services. The vascular component can have a major impact on overall cardiovascular service line performance and your position in the local marketplace. While vascular care is generally lower volume than cardiac and typically represents far less revenue, it is nonetheless a vital and growing service that dovetails nicely with overall cardiac program development. Remember, vascular and cardiac disease are essentially the same – they just manifest in different parts of the body. The two have the same etiology: an aging and sedentary population, hypertension, obesity, diabetes, high cholesterol and smoking.
Here are six important considerations for ongoing vascular program design, development and management:
- Expanding Demand – Vascular disease is expanding with the aging population. Inpatient volume is declining, but not at the level of cardiac services. Outpatient volume is increasing at a higher rate than cardiac. Healthcare analysts predict by 2020, the global market for lower extremity stents, percutaneous transluminal angioplasty (PTA) balloons, PTA drug-eluting balloons, carotid stents, renal stents and other peripheral vascular interventions will increase to more than $4.6 billion, up substantially from last year. Unlike cardiac, vascular reimbursement is largely unchanged or increasing and subject to less scrutiny by CMS.
- Facility Dependent – Robust vascular programs require dedicated and/or shared space including vascular non-invasive testing labs, procedural facilities (i.e., cath labs, dedicated vascular interventional labs, and/or hybrid operating rooms), and the like. Access to CT-angiography is considered critical as is the ability of vascular specialists to read and interpret their own CT studies. Effectively, volume dictates shared or dedicated facility needs. In particular, dedicated facilities to support high volumes will require considerable resource investment. For example, an additional dedicated interventional vascular lab or a hybrid OR can cost multiple millions of dollars. (Refer to CFA Blog “What to do Before you Build that Hybrid OR.”)
- The Multi-Specialty Challenge – While cardiac procedures are essentially limited to cardiologists, vascular procedure privileges and credentialing is available to multiple providers – cardiologists, vascular surgeons, neurovascular, and interventional radiology. All compete for a smaller slice of the pie than cardiology and contribute to the challenge of developing an integrated program with a common strategy with multiple specialists and multiple agendas. Achieving a common vision, promoting teamwork and securing operational efficiency are challenges. Complicating this challenge is the basic fact that cardiology “controls” a significant volume of vascular patients by way of making the initial diagnosis and thus dictating who will treat them. Fully 25% of all cardiac patients also have peripheral vascular-related issues. Turf battles over this defined patient population are not uncommon.
- Technology Intensive - New, innovative endovascular technologies are rapidly changing vascular practice – pushing many inpatient procedures into the outpatient arena (e.g., transcatheter embolization, peripheral artery or venous balloon angioplasty and stenting). The multi-specialty provider challenge noted above encompasses issues of training and credentialing, new technology assessment, product selection and standardization of devices, documentation of best practices, standardization of procedures, cost and quality outcomes management, matching procedures with facilities to produce the best outcome at the lowest cost, etc.
- Screening is Vital in Building Referrals – Building referrals is vital for program growth as incident rates are lower than cardiac and vascular disease is not as acutely life-threatening and more often goes undiagnosed than most acute cardiac conditions. Traditional PCP-based referral network relationships and hub-and-spoke networks development are critical, but often less than optimal to build required program volume. Ongoing, comprehensive screening programs seeking to identify at-risk and already affected patients will be required.
Screening can be targeted at new patients through comprehensive programs in the targeted community and/or existing hospital groups such as diabetes or obesity clinics. Adding local and regional podiatrists to your program’s vascular network is important as these practitioners are frequently the only professional a patient may be seeing regularly. Such efforts require innovation, multidisciplinary participation and physician commitment, and a high degree of organizational commitment, resource allocation and managerial skill. Tracking patients’ downstream utilization through existing or custom-designed data systems is important to understand referral mechanisms and measure revenue impact to justify continuing resource commitment to screening.
- Facing the Vascular Value-Equation Challenge – Vascular care faces a similar value-equation challenge as does cardiac services, defined as managing the patient safety, quality outcomes, and patient experience, all divided by cost/price paid. While most of these factors present similar challenges to cardiac services, vascular quality outcomes in particular are less well defined, consensus-based and more challenging to manage given the multi-specialty participation (and unique specialty practice approach) in vascular medicine, intervention and surgery. There also exists an historical lack of focus on transparent and meaningful quality outcomes on the part of program management. Overall patient care costs are being adversely impacted by burgeoning technology and concomitant facility development requirements. Additionally, while cardiac providers are likely to have experience with bundled pricing and other value-based reimbursement models, vascular programs do not (once again, this inevitability will be complicated by the multi-provider nature of vascular disease treatment).
The vascular market is too important an opportunity to ignore. It is important to the patients with peripheral vascular disease in your hospital’s service area requiring well-coordinated diagnosis and treatment. And it is important to your cardiovascular program.
It is vital that hospital cardiac service lines continue to incorporate and grow their vascular services components into their overall organizational structure, strategy and tactics and manage their growth and development aggressively. There is no one single approach, structure or managerial tool-kit that will work for everyone; innovation and effective management will be required to optimize this important market opportunity. Remember the “vascular” in “cardiovascular.”
As always, CFA invites your comments, questions and suggestions.