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Cardiac Cath Lab Economics in a Public Hospital of a Developing Country
Introduction
Managing the planning, operation and results of a cardiac catheterization laboratory in a general public university hospital is definitely an enormous task, especially when the hospital budget does not include the cath lab. We are reporting the financial results of our first 1,000 cases in the university public hospital, Hospital Civil de Guadalajara “Fray Antonio Alcalde,” serving a population of approximately 6 million people in the northwestern part of Mexico. Our hospital is the largest hospital in our country, with 1500 beds for the main areas of medical treatment and 67 subspecialty areas. The cardiology department has 30 beds for adults, more than 8000 outpatient cardiac consults, more than 1,500 admissions and 1,700 echocardiograms per year, along with 2 interventionalists and 9 cardiology fellows. The cath lab team is composed of Luis Jauregui-Plascencia, MD, F. Petersen-Aranguren, MD, FACC, Ignacio Campos-Becerra, technician, and Maria Luisa Segura, RN.
At Hospital Civil de Guadalajara “Fray Antonio Alcalde,” we based our program on the use of lease agreements and purchased material as described previously in other institutions1,2 so that we could provide the mechanisms to enhance revenues, utilize new resources, improve patient care, and avoid costly and duplicate capital outlays. Since the hospital budget does not pay for the material, there is no legal imposition as to offer in public license the amount of budget necessary for the investment.
The Cath Lab and Getting Started
We first realized it was necessary to develop an interventional cardiology program in our facility when the cardiac surgery department opened in 2002. The cath lab opened three years later. Prior to opening, patients traveled to a private hospital for procedures, which brought the risk of transportation and the higher costs of procedures with it. Management of the cardiac cath lab was handled without a single catheter being provided by the hospital. Our ultimate goal was to perform high-quality invasive cardiology procedures with highest levels of safety. The cardiac program had to meet the needs of the following three groups:
1. The industry
2. The physician (cardiologists)
3. The patient
The patient had to be provided with the best materials for the procedure at the lowest price. The physician had to have the best possible material that would allow him to be comfortable and secure at the time of the procedure. The industry had to give their best material at a price to make a profit and be happy serving our purposes.
At this time, our sponsors are still Cardiopace (Medtronic, Santa Rosa, CA) and Promedica Garcia (Cordis Corporation, Miami, FL) which work on our inventory supply method: bringing to the hospital the necessary material for the procedures, deploying it and charging the patient for the material used. The representative, either from Medtronic or Cordis, arrives each day bringing catheters, guidelines, balloons and stents. Most of our patients are elective procedures, but emergency procedures are done as well. The representative charges the family the previously communicated amount (depending on the procedure) and gives the family a receipt. The representative leaves the cath lab when all procedures are finished for the day. They then take the money to their company, deduct expenses and deposit the rest in a bank account under the name of Cardiology Hospital Civil.
We calculated the initial costs for 3 main procedures:
• Diagnostic cath, which includes all angiographic procedures permitting the physician to obtain a proper diagnosis, including all vascular beds.
• Cardiac angioplasty, which includes only the diagnostic study and necessary material for a percutaneous transluminal coronary angioplasty (PTCA) and 1 balloon.
• Coronary stents: All the above, plus 1 stent.
The rest of the material was added through individual costs at a previously agreed price. All the costs were calculated to be at least 25% cheaper than the less expensive private hospital costs. Prices can be seen in Table 1.
The decision to implant a coated (drug-eluting) stent was made by the attending cardiologist caring for the patient and the interventional cardiologist who performed the intervention.
In all procedures, the full cost was paid to the appropriate vendor representative. The vendor paid all the expenses and the rest was deposited on a bank account. The patient paid nothing else for the use of the cath lab.
A social worker was pivotal in getting the proper information to the family or payer, and arranging to have the amount described paid by the patient and/or his/her family before the procedure so that we had no problems financially.
Procedures
Our first 1,000 patients are divided into the following groups: male (646) and female (354).
From the procedure standpoint, numbers are as follows:
• Diagnostic Caths 533
• PTCA and stents 261
• Biopsies 4
• Valvuloplasties 5
• EP studies 20
• Pacemakers 177
Regarding pacemakers, since Medtronic provides our facility with permanent implantable devices, seventy-two of the 177 pacemakers were generously donated by the company to patients who lacked economic funding. All other pacemakers provided no revenue for the hospital. All of the devices have been dual chambers, except for seven bi-ventricular pacemakers which were implanted in patients with congestive heart failure.
Of the global management income (See Table 2), there have been revenues of USD$771,930 ($7,719,300 pesos). Of these global incomes, in the setting of these first 1000 procedures, the cath lab has earned USD$192,982 ($1,929,825 pesos), 25% of the income, for maintenance and the future acquisition of a new lab.
Discussion
The daily minimum salary in Guadalajara is USD$4.90 ($49 pesos). In order to pay for a cardiac diagnostic study, a person would have to work 83.6 days. Like the United States, the Mexican population has increased its percentage of older population, which is elevating the costs of medical care for cardiovascular disease. Medical treatment for patients over 85 has more than doubled the proportion of health expenditures from 17% of the average population to 35%.3 Among the challenges of the new millennium will be trying to find creative and innovative ways to bring efficacy, efficiency, safety and equal opportunity to expensive issues such as cardiovascular disease. In our efforts, we have found teamwork to be the glue of success, basing our structure and development on the needs of our three components: patient, physician and industry.
We have not yet received a budget from the hospital for the daily performance of the cath lab. Nevertheless, we have completed than 1000 procedures at our institution through the application of our own methods. As a result, vendors, physicians, and patients have been kindly rewarded with the use of new catheters and devices. Patients are provided with the same devices they could receive in a private hospital in the city and the vendors are being paid fair prices for their products in cash.4
Conclusion
We wish to motivate and share our strategy with all of those unable to perform diagnostic and interventional cardiology due to budget deficits. If properly arranged, leasing and direct purchases can strengthen relationships and provide financial rewards for vendors and physicians. Twenty-five percent of the global revenues is achievable if the project is properly managed. Support from the hospital board of directors is essential for the proper spinning of the wheel. Financial, labor and legal advice should always be involved.
The authors can be contacted at fpetersen2003@yahoo.com.mx
References
1. Holloway D. Cath Lab management. Cath Lab Digest Nov 2006;14(11):1-10.
2. Czarnecki R. Supply inventory models for the cardiac catheterization laboratory. Cath Lab Digest Dec 2004;12(12):24-28.
3. Steinwachs DM, et al. The future of cardiology: Utilization and costs of care.JACC 2000 Mar 15;35(4):1092-1099.
4. Williams J. Cutting Cath Lab Supply Costs. Managing the Margin Oct 2006:1-3. Available at: provider.thomsonhealthcare.com/uploadedFiles/10_06_MTM2_Cath%20Lab.pdf. Accessed March 19, 2008.
