Does Vascular Remain an Untapped Market?

David Fuller is a Senior Vice President at Corazon, Inc., offering strategic program development for the heart, vascular, neuro, and orthopedic specialties. Corazon provides a full continuum of consulting, software solution, recruitment, and interim management services for hospitals, health systems, and practices of all sizes across the country and in Canada. To learn more, visit www.corazoninc.com or call (412) 364-8200. To reach the author, email dfuller@corazoninc.com.

For many providers, the current state of vascular programming can most accurately be depicted as simply a collection of services provided within the hospital. Corazon’s experience at client sites across the country demonstrates these services are often uncoordinated among various specialists, and in some cases, could even be characterized as “fragmented” due to duplication of services in various patient care areas throughout the same hospital.  

Foundational elements that would assist vascular program growth are typically either incomplete or not in place at all. In fact, this current lack of structure and attention to a meaningful aspect of a cardiovascular service line is particularly confounding, especially given the opportunities at hand. The prospect of linking vascular program structure with the more fully developed cardiac service line can bring great value to both the program and the patient.

Although regulation impacting the development of new cardiac programming still exists in nearly half the country, there is an absence of similar regulation when it comes to vascular services provided within an acute care hospital setting. Providers are free to develop and offer interventional endovascular services in markets where they typically need to gain state approval for the same level of advancement in interventional cardiology. With that in mind, it is troubling that so few hospitals or health systems actually capitalize on this opportunity, as vascular services are consistently characterized as under-utilized in many regions of the country.

For years, vascular services were cause for uncomfortable encounters among physicians and hospital administrators alike. In a number of organizations, these services became a “turf war” between interventional radiology, interventional cardiology, and vascular surgery. Rather than working together towards a common goal, infighting existed among specialists, and a lack of clarity emerged regarding a vision and direction for the program.  

More recently, a number of successful providers built their vascular programs with a focus on just one of these three specialists, rather than working to bring them all together. Although on the surface this may appear to increase fragmentation, it has allowed providers to move forward and capitalize on at least part of the opportunity. However, Corazon continues to recommend the optimal approach of creating a vascular center concept by engaging all three specialists into a complete and integrated vision for the program.     

The potential for a vascular program may be difficult to estimate in a number of markets, particularly because these services are generally under-developed and thus under-utilized. For that reason, providers must work to understand the specific market dynamics that may have impacted the historic utilization of services, including availability of specialists, formalized programming in the area (in and outside the hospital setting), access to care, and regional demographics. In markets with a growing Medicare population, growth in the demand for treatment options for peripheral arterial disease (PAD) should be expected. The incidence of PAD increases with age, with almost 20% of adults older than 70 being afflicted.¹  

Generally, the vascular opportunity should at least equal that of the coronary disease opportunity for a hospital provider. In most cases, however, the market capture opportunity should exceed that of the cardiac program. In a recent review of national discharge statistics, Corazon estimates that current utilization of vascular procedures is at a ratio of 1.2:1 when compared to cardiac procedures. In addition, an estimated 75% of people with peripheral arterial disease have heart disease², and people with PAD are 4 to 6 times more likely to suffer a heart attack or stroke³. These statistics represent a significant opportunity for providers with a strong cardiac program and marginal vascular volumes, or vice versa.

For a number of markets, the potential for growth in vascular services falls short due to a lack of integration of referring physicians in the programming. A well-orchestrated and integrated non-invasive vascular program can make the difference between a marginal and successful performer. Primary care physician offices offer an attractive location by which to identify peripheral artery disease (i.e., through vascular screening programming), as patients are already visiting their family doctor for basic healthcare needs.  Corazon believes that integrating primary care and family practitioners into a vascular screening program can prove to be mutually beneficial. Since nearly half⁴ of all patients with PAD have no symptoms, it is important that programs reach out to the community in order to drive vascular screening initiatives and funnel appropriate patients into the vascular service line.

In many cases, the most significant investment involved in adding vascular programming is developing an infrastructure and adding the necessary physician manpower. This is not simply done, but can prove to be worthwhile, particularly at a time when hospitals and health systems are concerned with the return related to any investment. When evaluating vascular-specific additions to existing service line infrastructure, strong consideration should be given to the development and/or integration of a wound care program, diabetes clinic, and preventative/screening services, in addition to medical, surgical, and catheter-based treatment options. These elements of vascular programming do not necessarily involve facility changes or additions, but can many times impact processes and protocols, and also require additional time from key program stakeholders. Several turn-key options exist by which to develop foundational vascular program elements, all which may allow providers to focus resources elsewhere while leveraging proven programs with demonstrated return on investment (ROI).

For those providers with successful vascular programming, the financial impact is clearly significant. For example, a study published in the Journal of Vascular Surgery identified the division of vascular surgery and endovascular surgery as providing the highest gross margin per physician full-time equivalents (FTE) among all hospital-based specialty services.⁵ Although surgical treatment options are just one aspect of a comprehensive vascular program, they clearly have a positive bottom-line impact on a hospital’s finances. Additionally, when evaluating hospital reimbursement changes by DRG (diagnosis-related group) over the past few years, Centers for Medicare & Medicaid Services (CMS) reimbursement for inpatient vascular procedures is growing. Table 1 depicts this growth for all peripheral and major vascular inpatient procedures when reviewing two- and three- year averages. In our experience, a high-performing vascular program can function as a profitable aspect of the service line for a hospital.  

In situations where providers are dealing with capacity constraints in the cath lab(s) and operating room(s), the decision to expand vascular programming may be more complex. However, in instances where available capacity exists, expanded vascular programming may provide a mechanism to better utilize existing procedural space with a limited capital investment.       

Ultimately, a vascular program can function well both virtually or in a physical, branded environment. In either approach, providers considering an expansion should diligently focus on determining how this new (or expanded) programming works within the current program and governance structure. Additionally, consideration should be given to program outreach, locations, new infrastructure elements, and the specialists involved. 

As with any expansion, this cannot happen in a vacuum, as new services will no doubt have far-reaching impact across the service line and the hospital as a whole. Ensuring consistency in care delivery using evidence-based, best practice protocols is a must. At the same time, Corazon encourages providers to incorporate clinical, operational, and financial metrics specific to vascular programming into the cardiovascular service line dashboard in an effort to understand, monitor, and affect performance.

Through a well-planned and programmatic approach, providers can surely position themselves to capitalize on the often-untapped vascular potential and as a result, function as a cardiac AND vascular service line. Only then can the true potential of both specialties be realized, with the ultimate outcome being a healthier community at large as a result of expanded services and effective outreach efforts. 

References

1. The Society for Vascular Medicine. Who has PAD? Available online at https://www.vascularmed.org/pad/who.cfm. Accessed June 16, 2015.
2. Biomedix. Peripheral arterial disease. Available online at https://www.biomedix.com/peripheral-artery-disease.php. Accessed June 13, 2015.
3. The Society for Vascular Medicine. Why is treating PAD important? Available online at https://www.vascularmed.org/pad/important.cfm. Accessed June 26, 2015.
4. The Society for Vascular Medicine. What is PAD? Available online at https://www.vascularmed.org/pad/what.cfm. Accessed June 26, 2015. 
5. Taylor N, Lombardi JV, Toddes S, Alexander J, Trani J, Carpenter J. An all-inclusive and transparent view of a vascular program’s direct impact on its health system. J Vasc Surg. 2012;55:281-285.