Integrated Delivery: The Key to Vascular Program Success

Vascular services represent a dynamic and progressively important component of the cardiovascular continuum in programs across the country. Fueled by improved disease awareness, better patient accessibility and education, fiscal appeal, rapid technological advancement, and multidisciplinary physician interest, hospitals continue to actively pursue vascular services expansions…as they should!  

Eroding procedural volumes both in the invasive and non-invasive departments within cardiovascular services persists, causing physicians and administrators to collaborate on ways to protect declining volumes. As a result, vascular has emerged as an attractive growth opportunity.  

But, based on Corazon experience, many hospitals still have not fully recognized the market share potential despite the large population of vascular disease patients. There are two fundamental obstacles:

• First, most patients do not experience classic symptoms until they reach a crisis point, and/or symptoms are often mistaken for common aches and pains of aging. Typically, vascular disease is not considered “acute” like its cardiac counterpart.   
• Second, vascular conditions are mistakenly deemed to be of secondary importance to heart disease.  Primary care physicians, and even some specialists, are unfamiliar with peripheral vascular disease and its consequences, and often lack the tools to make an accurate diagnosis that would ultimately lead to a more collaborative treatment plan for the patient. 

There is tremendous variance in the degree of success hospitals have in capturing the vascular market. Vascular procedure utilization across communities varies because of access and referral patterns for follow-up testing. Each community has different expectations for care and physician supply is often variable as well, especially for those appropriately credentialed in the vascular specialty.  

Capitalizing on vascular opportunity

As witnessed in our work around the U.S., many physician specialists — interventional radiologists, interventional cardiologists, vascular surgeons, and in some cases, cardiothoracic surgeons — believe they are equipped with the knowledge, skillset, and tools to treat the vascular patient. However, the efforts of interested programs and physicians are often thwarted by limited access to necessary technology or a focus on other patients or clinical duties, which makes it exceptionally difficult to expand an existing or new vascular program, even with a qualified physician available.

The desire to expand services now comes with an increasing awareness that the quality of medical care delivered in the United States is variable and lacks a coordinated approach. The Institute of Medicine credits as much as 33% of the nearly $2.6 trillion the United States spends on healthcare each year as potentially “wasteful.” While unnecessary care represents the largest contributor to unnecessary spending, inefficiencies in administrative processes, clinical care, and provider communication represent a sizeable share as well. Nearly 25% of wasteful spending is linked to poorly-timed care, delayed decision making, missed opportunities to coordinate care, and inefficient clinical and operational processes. 

The clinical argument for pursuing the vascular patient population relates to the significance of peripheral artery disease (PAD) as a marker of systemic atherosclerosis, and also the likelihood that a patient diagnosed with cardiac disease also has some form or PAD. Approximately 8 million people in the United States are afflicted with PAD — that is nearly 12% of the adult population, with men affected slightly more than women. However, this percentage is age dependent; almost 20% of adults over the age of 70 years have PAD. Further complicating diagnoses, the clinical presentation of PAD varies along a continuum from no symptoms to intermittent claudication, atypical leg pain, rest pain, ischemic ulcers, to gangrene. Claudication is the typical symptomatic expression of PAD. However, asymptomatic disease may occur in up to 50% of all patients with PAD. 

PAD has two major consequences: the first is a decrease in overall well-being and quality of life due to claudication and atypical leg pain, and the second is a markedly increased cardiovascular morbidity (myocardial infarction and stroke) and mortality (cardiovascular and all-cause). We believe that treatment should be directed at each of these facets. The risk of cardiovascular events has been found to be similar between PAD patients with claudication and PAD patients without any symptoms.

If intending to capitalize on vascular opportunity, hospital leaders are wise to set goals for the vascular program. The ultimate clinical intention of a vascular subspecialty program is PAD management, including limb salvage, symptom relief, improving functional status, and preventing cardiovascular events (acute myocardial infarction [MI], stroke, and vascular death). Since all PAD patients require intensive cardiovascular risk reduction, they should be referred to a supervised exercise program. Limb revascularization procedures should also be offered for select patients. Thus, there are many and varied components of a vascular program — establishing the structure and overall offerings with the intent to grow market share and improve community health should be the ultimate goal. 

Despite the overwhelming evidence that patients with PAD are at a markedly increased risk of myocardial infarction, stroke, and death, these patients are often undertreated, or even undiagnosed.  Further, they typically do not receive antiplatelet therapy or statins with the same frequency as do patients with the more recognizable coronary artery disease. Because these patients may or may not be optimally medically managed, providers must be diligent in documenting indications for non-invasive testing and any follow-up revascularization. Indeed, PAD patients add a new wrinkle of complexity when matching appropriate care to symptoms (vs. in response to incidental findings) in order to prevent future procedural denials or auditing.

Physician collaboration

Corazon has found the most successful vascular centers address physician issues proactively and create a collaborative model for addressing changes in practice. It is impossible to be all things to all players; however, creating a culture of trust and flexibility is crucial. 

Our recommendations to achieve true physician collaboration in the vascular subspecialty — where many physicians may lay claim to a “turf” — include:

• Create transparent privileging criteria. Traditionally each specialty area establishes its own credentialing and privileging standards. We believe that consensus-driven, equitable standards eliminate variance and secure physician support.
• Facilitate referrals. Ensure that fair and equitable reading panels exist so that all providers work to grow the business instead of creating work-arounds that could lead to the outmigration of patients.
• Perfect physician handoffs. Primary care physicians need strong communication with the specialists caring for their patients in order to create a seamless care continuum. Longitudinal vascular care requires that all physicians be on the ‘same page’ regarding a treatment plan, including medications, exercise rehabilitation, future procedures, etc.  

Hospitals are also faced with the challenge of monitoring and tracking vascular service quality, especially in today’s era of increased healthcare industry, government, and media focus on care outcomes and metrics. Including selection criteria and outcome data as part of the vascular services multidisciplinary team meetings is crucial. This group should be responsible for evaluating new technology and discussing roadblocks in care. We usually recommend that hospitals treat participation in the group as a mandatory component for re-credentialing.

Cost/reimbursement impact 

Notably, there have been increases for all procedures and DRGs, excluding peripheral vascular without stent. Also worth noting is that the procedure costs for each of these categories has increased each year as new technology has reached the market. The positive financial situation within vascular is another reason why this subspecialty is prime for procedure growth in nearly all markets. Particular attention to the financial aspect of a program is always worthwhile. In fact, opportunities to reduce costs and maximize margin on these procedures most certainly exist.

Corazon believes achieving a more favorable bottom line in vascular can be the result of eliminating redundancies, especially if procedures are performed in multiple areas. Consider the following strategies:

• Shared inventory with only essential items stocked in the room(s). Keep low par levels since other areas carry if needed.
• More efficient staffing and scheduling procedures, including the cross-training of staff and the creation of collaborative cross-departmental schedules. Both can serve to prevent wasteful downtime and ensure room availability during peak times.
• Use of purchasing groups to get the best pricing with variable market share/volumes.
• Required physician participation on a new/existing product review committee.

In addition to managing procedural costs, vascular cases are notoriously difficult to document and code. Staff that is unfamiliar with the diverse anatomy to master, varied catheter placements, numerous technologies to consider, and incomplete physician documentation all contribute to potential lost revenue. Investing in structured education for staff that will be entering charges is a must.

Corazon also advocates creating a financial review committee as a forum to discuss the entire revenue cycle for these and other complex patient types. Members should include finance, coding/billing personnel, case management, clinical staff selecting procedure codes, and the physician specialist on an ad hoc basis. Responsibilities of the group should include:

• Chargemaster updates as new procedures are added;
• Billing sheets (physician and hospital);
• Denials (authorization or post procedure);
• Communicating any changes in practice. 

Indeed, vascular growth opportunity abounds. Understanding the defined treatment strategies and developing cohesive and collaborative systems of care among providers and facilities will ensure future success and profitability — though these are not easy tasks to accomplish! Untapped clinical and financial opportunities exist in almost every market, but requires creative strategies to capture. Beginning with strong physician collaboration, from primary care through the vascular specialists, is an essential first step to meeting patient needs in a constantly changing healthcare environment. From there, the possibilities are endless… 

Kelly is an Account Manager at Corazon, Inc., offering strategic program development for the heart, vascular, neuro, and orthopedics specialties, consulting, recruitment, interim management, and physician practice & alignment services to clients across the country and in Canada. To learn more, visit www.corazoninc.com or call (412) 364-8200. To reach Kelly, email knealwilson@corazoninc.com.  

References

1. Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. National Academy Press, Washington, DC: 2001.
2. Dormandy JA, Rutherford RB: Management of peripheral arterial disease (PAD). TASC Working Group. TransAtlantic Inter-Society Consensus (TASC). J Vasc Surg. 2000; 31(Suppl): S1-S296.