State of the Union in Heart, Vascular, & Stroke: What’s Keeping You Up at Night?

As a leader in healthcare, do you often experience sleepless nights? Are you worried about decreasing volumes, increasing costs, and changes to reimbursement? Do you feel pressure from your physician partners as their professional fees continue to get ratcheted down? Is the cost of expensive new technology and soaring pharmaceutical costs eating away at your per case margin? Is the move to an electronic medical record (EMR) putting pressure on the organization to have a solid information technology (IT) implementation plan that is clinically relevant and timely? Are issues related to looming healthcare reform, and the uncertainty of the impact of the changes, causing unrest with the patients you serve, while wreaking havoc as you set strategic direction for your organization? WOW! It is no wonder that we can’t sleep! But, while the past year has no doubt brought many challenges, it has been balanced with progress on many fronts. So let’s acknowledge where we have been, and what our healthcare delivery future may hold. A look back — the good, the bad, and the ugly! As we survey the cardiovascular industry and interact with hospitals nationally, over the last year we have seen a focus on new options and standardization in stroke care, expansion of device implants for more effective management of congestive heart failure (CHF), and more widespread application of new, less invasive treatment options for vascular disease. We have also witnessed a growing trend that recognizes clinical standardization and practice rooted in evidence-based medicine, which are important to an effective care delivery process. From a regulatory standpoint, we have witnessed more states that have loosened regulations related to the provision of elective percutaneous coronary intervention (PCI) without surgery on site (SOS). For example, Georgia has granted permission for 16 additional hospitals to provide primary and elective PCI, without participation in the C-PORT clinical trial. Furthermore, the traditionally highly regulated state of New York now allows programs to provide primary and elective PCI while prohibiting the addition of any new “diagnostic only” catheterization labs. There are now 39 states that allow primary and elective PCI without SOS. On another regulatory front, many programs have already faced or are preparing to face the scrutiny of a Recovery Audit Contractor (RAC) audit that focuses on the demonstration of medical necessity. Cardiovascular services have been under the microscope, particularly for procedural patients with a one-day length-of-stay. Admission criteria for PCI, pacemaker and device implant/replacement, and CHF have proven to be important to the audit and RAC appeal process. Pay for performance (P4P) programs are evident across a variety of payors. Cardiac services have been used as pilot programs in the past for some of these initiatives, and continued attention to cardiovascular outcomes measures are seen with Core Measures focused on CHF, acute myocardial infarction (AMI), and a new 2010 stroke Core Measure. The industry is also focusing on the development of financial incentives to stimulate improvements in the quality of care while reducing costs for hospitals and physicians. For instance, the Physician Quality Reporting Initiative (PQRI) is providing a 2% incentive on allowed charges based on the Physician Fee Schedule for 153 quality measures and 7 measures groups. The PQRI added coronary artery bypass graft to the measures group in 2009. Physician alignment issues continue to garner much attention. Interventional cardiologists, electrophysiologists, and vascular surgeons are in short supply across the country. As Corazon provides recruitment services for these specialties, we encounter many who are seeking an employment relationship. Call and lifestyle issues are increasingly important to those newly out of fellowship and those winding down their medical careers. Recent payment reduction threats to physician ancillary office based-income continue to fuel physician interest in a more stable business environment. Furthermore, tax, malpractice, and regional payment rates likewise affect physician interest and commitment to practicing in a new location. In addition to an interest in employment, physicians continue to express interest in opportunities for joint ventures with hospital partners. There has been renewed activity in forming Clinical Institutes, Centers of Excellence (COEs), and management service agreements (MSAs). We believe these structures provide a framework for a new practice model — one that focuses efforts on driving practice standardization to improve quality and decrease costs — both of which are vital in today’s economy. P4P programs and predicted healthcare reform that contains bundled payment methods may drive some of the movement to new alignment models. The development of solid IT plans is particularly important for cardiovascular services, which are often THE most information-rich service in the hospital. An IT strategy that includes integration with aligned physicians has proven to be a very powerful link that can support efficient quality data tracking, remote access to images and documentation, and the ability to analyze cost and quality. In a new era of transparency in pricing, an organization’s ability to understand its case-based costs, rather than traditional procedure or unit-based cost, will become even more critical. We advocate a robust cost accounting system that is regularly updated with current supply costs, personnel wages, resource utilization, and time standards as a useful tool in managing and monitoring the care continuum. A look ahead – if we only had a good crystal ball! Only time will tell, but here are Corazon’s predictions for the future of our dynamic industry: • Accountable Care Organizations will be developed to administrate bundled payment demonstration projects that pay for “episodes of care.” Rates will be lower than current averages, and will provide payment for hospital and physician services that cut across the full continuum (pre- and post-acute care). Rewards will be provided for efficient organizations, while inefficient providers will be penalized. • A new focus on prevention and chronic disease management will surface, motivating the creation of more formalized programs that are funded to change the existing acute care paradigm. • Investments in IT infrastructure and the development of the EMR will continue. Physicians will begin demanding access and expect seamless IT system integration to support streamlined practice and timely clinical decision-making. Efficient real-time data collection to support real-time process improvement will become a reasonable expectation. • A continued focus on controlling costs will escalate as healthcare spending shifts to front-and-center. The implementation of the ICD-10 coding system will provide the ability for a more granular analysis of specific patient populations, and can become a useful tool for supporting efforts to achieve and demonstrate best practice standards for programs overall and certain procedures in particular. • The development of treatment protocols and services for stroke patients will mimic the broadly available services in place for AMI. Physician resources to support this effort will be developed to meet the growing need. Comprehensive stroke centers will migrate to the community hospital setting, mirroring the expansion of access to PCI service. • Technology advances will continue to drive new practice and will move more quickly from research or tertiary settings to community hospitals. Less invasive techniques and technology, such as percutaneous valve replacement, will become an expectation of the modern healthcare consumer, especially as they “shop” for services based on cost and quality outcomes. Concluding thoughts While the accuracy of these predictions remains to be seen, perhaps at this time next year, or even in five years, we’ll witness the fruition of these ideas. Regardless of specific changes, we believe the best means to approach the certainty of change is to focus, plan, prioritize, engage your physicians, and become an active voice for implementing best practice at your organization now and for the future. As the next decade stretches before us, we should all expect that change is coming — sometimes for the better, sometimes for the worse — but always on the horizon. So, our best advice: get some sleep tonight! And awake with the conviction to make your organization a better place tomorrow. Corazon specializes in consulting, recruitment, and interim management for the heart, vascular, and stroke specialties. For more information, visit www.corazoninc.com. To reach Susan, email sheck@corazoninc.com

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