The Dynamics of a Quality-Driven Cardiovascular Interventional Program: Physician-Hospital Integration

Various factors impact the utilization of a cardiac cath lab:  ownership, location, the physicians’ philosophy of care, their capabilities, and even the culture of the organization overall. These and many other dynamics affect cath lab volume and procedure mix, and can explain why cath lab utilization varies so much from region to region, hospital to hospital, and even room to room within the same hospital. By looking at these critical factors, hospital or program leaders can gain some valuable perspective about what it takes to realize optimum results. 

How a cath lab should be utilized by providers to ensure best-practice clinical outcomes and top-notch financial performance can be demonstrated through the formal alignment of physicians and hospitals. Alignment can mean a fully integrated position of employment, a co-management arrangement, or a more simple financial collaboration.

The clinical case for integration

In the growing industry trend of patient ‘appropriateness’, one should ask, “do individual hospitals and physicians have tracking and reporting mechanisms to validate the diagnostic results at their own hospitals?” And if so, do they use them and inform their patients, referring parties, and the public about why an intervention was the best approach and how other treatments could have provided equivocal or better benefit?  

Now that the cardiovascular field is faced with increasing scrutiny on appropriate use criteria (AUC), particularly in the cath lab, basic measures to drive processes towards compliance with initiatives like AUC can often come from physician-hospital integration.  

Integration comes when two or more parties “work in harmony” with each other, and this dynamic must be realized in the cath lab setting. Integration must involve hospital management, the physicians, technologists, nurses, and other administrative and clinical staff who touch or influence the patient. Integration not only will promote a shared vision for the procedural work in the cath lab, but it will ensure standardization of processes to ensure compliance and quality outcomes. 

More efficient operations 

Corazon continues to witness patient access bottlenecks in cath labs across the country that compromise operational outcomes when more than enough capacity should exist.  Operational issues include scheduling problems, inventory problems, staffing issues, transportation bottlenecks, communication voids, and so on. Unfortunately, this list is just a small sample of the operational issues that we have encountered in our cath lab assessment work.  

Physicians often relay how disgruntled they are with the operational aspects of the cath lab environment, especially if they have little or no authority to manage these operational issues. In fact, those physicians viewed as customers of the cath lab space usually offer the best solutions to repair operational issues. 

In a physician-hospital integration approach, management of operational concerns in the cath lab can be shared jointly by both departmental managers and key physicians. If physician behaviors (i.e., late case starts due to physician delays) are a persistent issue that impacts operations, then an integrated approach to managing behavioral solutions will promote the most “buy-in” and lead to a solution that positively impacts the care process. 

The financial case for integration

There is little doubt that monetary incentives play an important role in the delivery of cath-based services. Monetary incentives can also have an effect on the clinical outcomes and revenue performance of the cath lab. Aside from reimbursement, the direct costs of providing the service, the compensation of the physician, and operational efficiency affect the overall financial performance of the lab and related services.  

In general, physician ownership of certain diagnostic and treatment modalities remains a variable today, though not as prevalent as in the past, and this can include cath labs.  Technical fees may drive the likelihood of the physician to use a modality he or she owns, especially if it is readily accessible. This is justified by the clinical efficacy of the procedures, but also the cost of the equipment, supplies, staff, and space. As reimbursement continues to be reduced for many of these modalities, it becomes difficult to justify physician ownership. Thus, many physicians are selling their diagnostic services to hospitals, becoming employed, and/or “integrating” their practices with the hospital.  

This practice of absorbing physician diagnostic services by hospitals may be considered to be a model of true integration. Some theorize that by taking on these services at the hospital level, everything else will improve, including operational efficiency, clinical outcomes, and program growth. However, our team has witnessed examples wherein employment of the physicians, or even a simple ancillary partnership where diagnostics are now considered “hospital-based,” can actually erode service growth, if the incentives are not aligned during the negotiation phase.   

In order to control growth, an increasing trend is the full employment of specialists, particularly cardiologists. Our team often finds that hospitals fail to recognize the complexities involved with employing a cardiologist, an entire practice, or group. Employment arrangements become much more complex as the number of involved stakeholders increases. Many hospitals do not have a full understanding of cardiology practice dynamics, and unless the practice acquisition or other integration strategy structure is accompanied by a comprehensive practice plan, including compensation with incentives, the productivity of these physicians typically falls dramatically.

The case for true integration

Corazon believes that cardiovascular hospital-physician integration is mandatory in the age of healthcare reform, which includes acute care organizations, medical-centered homes, appropriate use criteria, and declining reimbursement. This is further exacerbated by the fledgling value-based purchasing arrangements coupled with the potential influx of patients, as more are deemed ‘insured’. Developing true integration involves much more than an employment agreement or implementing a single model.  

Concluding remarks

The bottom line for true integration of a cardiovascular program (or a component) is the willingness of the hospital and physicians to have more than just financial considerations as the driving force — clinical and service issues must be paramount, as well as initiatives to create a positive patient experience. Indeed, the cath lab operation is the “hub” of the wheel from a cardiovascular perspective, regardless of the depth and breadth of services provided. The leadership of the hospital and cardiovascular medical staff must be committed to the growth and improvement of patient outcomes and access. It starts with how quickly, easily, and efficiently the cath lab operation accommodates patients. And, how the cath lab “hub” is integrated with the full continuum of care provided both before and after patients visit the cath lab.

Conrad is a Vice President at Corazon, Inc., offering consulting, recruitment, interim management, and physician practice & alignment services in the heart, vascular, neuro, and orthopedics specialties for clients across the country and in Canada. To learn more, visit www.corazoninc.com or call (412) 364-8200. To reach Conrad, email cvernon@corazoninc.com. 

Did You Know?

• Cardiologists can be a significant driver of admits to a hospital. Most full-service hospitals have one-third of their census under a cardiovascular code in their critical care units.
• Cardiology practice dynamics and characteristics can affect the hospital’s overall quality outcomes more than any other subspecialty group.
• More cardiologists are leaving the field than entering it, which will further upset the supply and demand balance.  
• There are more sub-specialties within cardiology than any other physician category, including general cardiology, coronary intervention, invasive diagnostics, non-invasive diagnostic, nuclear medicine, echocardiography, electrophysiology, heart failure, heart transplant, etc.
• Depending on market dynamics, hospitals can discover that their overall economic situation is closely linked to their cardiology economics.
• Today, about 60% of cardiologists are employed by hospitals, due mainly to the decline in diagnostic reimbursement for physician-owned imaging, increased need for recruiting cardiologists, economic security, and the increasing costs for maintaining a practice.