Cath Lab Optimization: Improving Margins and Market Competitiveness in the Procedural Space

Cath Lab Survey & Results Opportunity

Would you be interested in comparing your current cath lab practices to those around the country?  Here is an opportunity to get some real-time benchmarking from other cath lab programs. Take 30 minutes to complete the following survey: 

https://surveys.medaxiom.com/s3/MedXcellence-Cath-Survey 

Within 30 days of completion, you will receive a summary of your current performance. 

The summary will include a full explanation of how to interpret your results. 

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As cath lab margins decline and competition grows, many programs are looking for ways to shore up business. Popular options for cath lab optimization include initiating a same-day discharge program for procedural patients, preparing for bundled payment models, and building radial programs. The decision to move forward on any of these initiatives will certainly add value to an existing program by: 

• Promoting safety through evidence-based care;
• Driving standardization;
• Expanding the care team beyond the procedural room;
• Generating throughput;
• Improving the experience for the team and the patient;
• Increasing financial benefit;
• Preparing the procedural area for future payment changes.

Of course, along with these benefits, there are challenges and barriers to work through. Understanding the benefits and challenges will help programs prioritize actions and prepare for successful optimization.    

Same-day discharge

Is same-day discharge the right move for your program? Same-day discharge will contribute to the defined successes listed above. First, and most importantly, the evidence of the safety of same-day discharge is growing every day. The Society for Cardiac Angiography (SCAI) originally published same-day discharge criteria in 2009. These criteria have been thoroughly tested and proven to be a safe screening tool for same-day discharge. The SCAI criteria are conservative and do screen out many elective percutaneous coronary intervention (PCI) patients. As some programs have grown in experience with same-day discharge, physicians are focusing more on the stability of the patient and the success of the procedure, rather than specific criteria such as age and body-mass index (BMI). It is anticipated that the number of patients eligible for same-day discharge will continue to grow. Programs that successfully implement a same-day discharge program should expect the following benefits:

• Improved capacity for inpatient needs;
• Reduced resource needs by decreasing length of stay (LOS);
• Cost avoidance of $800-$1200 per patient;
• Improved practices between office and hospital;
• Standardized practices for labs, NPO, arrival times, physical prep and recovery times;
• Enhanced patient satisfaction.

There are challenges in initiating a same-day discharge program that must be overcome. Most importantly, a physician champion is key to success. Any same-day discharge program will need a champion to educate on the safety of the program and promote the benefits to peers. This champion will help facilitate protocols, handoffs between office and hospital, set goals, and address barriers. Once a program has that key role in place, the additional work will include:

• Office coordination and education to the patient on same-day discharge;
• New protocols that are current for the elective PCI patient’s acuity;
• Standard work in the pre-procedure area (labs, electrocardiogram and assessment);
• Physical space for a longer recovery — avoid admission to inpatient units;
• Computerized order sets post procedure;
• Discharge instructions with follow-up appointments;
• Next-day, follow-up phone call;
• Measurement tools (selected metrics could include daily percentage of same-day discharge patients, percentage of outpatients admitted to inpatient beds, same-day discharge complications, same-day discharge patient satisfaction, and cost avoidance).

As an example, imagine your program overnights 3 outpatient status cardiology procedural patients every night at a cost of $800 per patient or $2400 dollars a day. If you did this 5 nights a week for 1 year, or 260 days, you would be spending $624,000 dollars in resources with no reimbursement. Not only is cost an issue, but if your system is struggling with capacity and holding patients overnight in the emergency department or with diverting patients, every bed begins to make a difference. Beginning a same-day discharge program is a considerable undertaking, but the rewards can be significant.

Radial program    

A natural question for programs considering a same-day discharge program is, how important is a radial program? Although a radial program is not a requirement for a same-day discharge program, it will help facilitate the growth of the program in several ways. A radial program, like a same-day discharge program, needs a physician champion. Once a program begins to offer radial service, the word spreads quickly and it soon becomes a preferred option for patients. Patients appreciate the privacy and comfort that the radial procedure provides. Clinicians understand the benefits around reduced access site complications, earlier time to ambulation, and pain management. A radial approach provides a greater sense of security in the same-day discharge process; eliminating the risk of a retroperitoneal bleed is peace of mind to many operators and staff. The barriers to beginning a radial program are not extensive. Leaders should expect longer procedures as physician and staff adjust to the new technique; this is generally 50-100 cases, but will vary with each proceduralist. Access site selection should be clearly communicated to avoid wasted product during set up and supply par levels may need to be monitored. Concerns about increased radiation dose and case length have resolved as expertise develops. It would be good practice to monitor case length, radiation dose, and complication events to accurately measure radial uptake and the safety of radial access.

Bundled payments

Should new payment models be a reason to look at cath lab optimization? Bundled payment models have been a hot topic over the past few months. This May, the Health Care Payment-Learning Action Network (HCP-LAN) released a white paper proposing a coronary artery disease (CAD) bundled payment. CMS followed this work by releasing a timeframe and specific content for the first cardiology bundle payment. If the timeline remains true, the data collection for payment adjustments will begin in July 2017. The CMS bundle will measure cost and quality for heart attack and coronary artery bypass graft surgery care. Accurately documenting and clearly understanding PCI cost and quality metrics will be critical for success in these new payment models. High quality and low cost programs will experience the greatest financial benefit.The cost will be measured by both historical and regional cost data. Historical costs are important, as this helps adjust cost based on the level of acuity and patient complexity that the system supports. Regional costs are needed to ensure programs that have worked toward efficiencies are not penalized by historical costs alone. Regional benchmarking recognizes systems will have different cost reduction targets. 

So, why prepare for a bundled payment now? The good news is this work will not be wasted energy. Preparing for a bundled payment helps identify high-cost patient populations, and allows a program to put in place screening tools or counter measures to capture and support these high-risk patients. A good example of this is in the congestive heart failure (CHF) model. Many systems have specific discharge processes for CHF patients. These processes ensure a timely evaluation, with the right clinical experts, timely post hospital discharge. Systems are risk-stratifying these patients and making sure the highest risk patients see a provider or physician’s assistant/nurse practitioner (PA/NP) in 2-5 days from discharge. This work has reduced readmissions while lengthening the optimized state of the CHF patient. This is a basic example of the type of work a bundled payment requires. Well-coordinated management of the patient for a designated period of time is a hallmark of bundled payments. Identifying the high-cost patients in each unique bundle will help physicians and systems understand if participating in a bundle is a good choice. It will also direct the focus and resources to the patients who can benefit the most.

Bundled payments are much more than just a single procedure episode. The purpose of an alternative payment model, such as a bundle, is to reward patient-centered care in patient-responsive delivery systems. This vision accelerates the move away from traditional fee-for-service models into the delivery of value, quality, cost, effectiveness and patient experience. The newly released CMS model is structured to incentivize the coordination of care for populations. The focus of this article is to drill down to how practices in and around PCI procedures can help support the success of a CAD bundle. 

Many cath lab programs currently focus heavily on supply cost management. There is no disputing that supply cost is an important piece of a well-run program. However, cost reduction opportunities are ripe in other areas. One significant challenge systems have is accurately measuring cost per case by procedure type — this need will intensify in a bundle environment. It will be an important discussion to have with your cardiovascular service line finance or business partner. Preparing for this work will require a method for not only cost assignment, but review with providers for relevance. It is very difficult, if not impossible, to engage clinical teams in cost management if the data is suspect or outside their control. In addition to implementing same-day discharge criteria and growing radial access, programs should consider the following approaches to program safety and success in future alternative payment models:

• Standardize the care from the office: prep, procedure, discharge, and follow-up;
• Reduce redundancy in data entry by using one source for prep, procedure, charging, structured reports, and registry documentation;
• Adherence to appropriate use criteria;
• Streamline or eliminate the day prior/pre-procedure call for low-risk outpatients;
• Review your sedation practices: minimal sedation needed to maintain patient comfort reduces recovery time, care, and is better for patients;
• Understand the cost per case in your system;
• Identify your high-cost patients and put resources around them;
• Provide cost per case by procedure type and provider;
• Overlay safety, quality and cost by provider — share best practices;
• Registry participation and review;
• Work toward transparency in reporting safety, quality, and cost with the team.

Because the day-to-day operations of a procedural area can seem to absorb all the team’s and leadership’s energy and time, it is difficult to imagine carving out resources for this level of program redesign. Optimization is not about cost avoidance and enhanced revenue. These are two outputs frequently measured, but should not be the primary intent. Programs that strive for true optimization and redesign find this work promotes quality, safety, and cost metrics. For healthcare leaders and care teams who choose to own patient quality, team-based care and cost measures is where the greatest level of transformation can occur. Consider how all these steps expand ownership beyond the traditional cath lab room and procedural team. Patient-focused optimization around these steps begins the journey from isolated episodes of care to caring for the patient across the condition of CAD, and involves:

• Pre-operative diagnostic and care planning — ensure patient education is comprehensive and work meets appropriate use criteria;
• Appropriate use of drugs and devices;
• Discharge planning — medication education and timely follow-up appointments;
• Care transition support — consider care coordinators for a consistent point of contact;
• Post-acute care — cardiac rehab and other behavioral support programs.

Beginning to create true care teams that support the patient throughout the disease process will position a program for success in new, alternative care models. Preparing for new payment models creates significant disruption in the workload and priorities of cardiovascular service line leadership. However, along with this disruption comes the opportunity to extend care teams with the goal of enhanced, patient-centered care.

Anne Beekman, RN, Vice President, Consulting, MedAxiom Consulting. Anne has extensive experience in new program development in interventional cardiology, peripheral, electrophysiology, and structural heart, as well as working with programs on cost management, updating staffing models, and office-to-hospital efficiencies. Anne’s experience also includes opening and managing multiple cath and EP labs, prep and recovery departments, and cardiac care units. She has focused on process improvement as well as expense reduction through program redesign and resource allocation with a focus on quality and safety.

Using various methodologies, Anne has improved core measure performance, patient satisfaction scores, and redeployed full-time employees based on streamlining processes. Recently, Anne has become dedicated to improving the safety in cath labs by reducing radiation dose to providers, staff, and patients through a variety of approaches. Additionally, she has been the lead on two successful Accreditation for Cardiovascular Excellence (ACE) accreditation reviews over the past 2 years.

Anne has a bachelor’s degree in nursing and is credentialed as a Nurse Executive by the AACN.

Bibliography

Mehta SK, Frutkin AD, Lindsey JB, et al. Bleeding in patients undergoing percutaneous coronary intervention: the development of a clinical risk algorithm from the National Cardiovascular Data Registry. Circ Cardiovasc Interv. 2009; 2: 222-229.

Rao SV, Ou FS, Wang TY, et al. Trends in the prevalence and outcomes of radial and femoral approaches to percutaneous coronary intervention: a report from the National Cardiovascular Data Registry. JACC Cardiovasc Interv. 2008; 1: 379-386.

Jolly SS, Yusuf S, Cairns J, et al. Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): a randomised, parallel group, multicentre trial. Lancet. 2011; 377: 1409-1420.

Shroff A, Kupfer J, Gilchrist I, Caputo R, Spencer B, Betrand D, Rao S. Same-day discharge after percutaneous coronary intervention: current perspectives and strategies for implementation. JAMA Cardiol. 2016 May 1; 1(2): 216-223. 

Cath Lab Survey & Results Opportunity

Would you be interested in comparing your current cath lab practices to those around the country?  Here is an opportunity to get some real-time benchmarking from other cath lab programs. Take 30 minutes to complete the following survey: 

https://surveys.medaxiom.com/s3/MedXcellence-Cath-Survey 

Within 30 days of completion, you will receive a summary of your current performance. 

The summary will include a full explanation of how to interpret your results.