Expanding Patient Care to Out-of-Hospital Settings

In this video, Dr. Jim Melton discusses his motivations for entering the out-of-hospital space and expanding his practice to include cardiac care within a hybrid office-based lab and ambulatory surgery center service model. Dr. Marcus Smith discusses his role at the clinic and dive deeper into the cardiac procedures performed at the hybrid lab. Both doctors discuss industry trends, access to care, and the improved patient experiences from their perspectives.

This discussion is sponsored by Philips OBL and ASC Solutions. To learn more, please visit philips.com/SymphonySuite

The transcript below has been lightly edited for clarity.

Jim Melton, DO:

Welcome to Cath Lab Conversations. Today, we're discussing the expansion of patient care to the out-of-hospital setting. We're in Oklahoma City today. I'm Jim Melton, a vascular surgeon, co-founder of CardioVascular Health Clinic in Oklahoma City. I'm with my partner and colleague, Dr. Marcus Smith, an interventional cardiologist, also at the CardioVascular Health Clinic here in Oklahoma.

I would like to thank Philips for their support of the presentation today, and I would like to just march forward with some points on why we think it's so important to talk about a lot of cases that are moving out of the hospital setting and into the surgery center setting, and go from there.

Our facility is a 20,000-square foot facility with an office on the second floor and a 10,000-square foot surgery center on the bottom, with expansion of another 9,500-square foot surgery center on the bottom. Probably a total of around 19,000-square feet of surgery center 100% dedicated to vascular surgery and cardiovascular health care prevention, as well as interventions and care for lots of different disease processes, which we'll get into later.

Our practice opened in May of 2016. We moved from a hospital system at that time, and our surgery center opened approximately one year, maybe 10 months, later, in April of 2017. We are a Joint Commission-accredited facility and, again, currently about 9,000 to 10,000-square foot is accredited, with another expansion already accredited by the state.

We have two procedure rooms. One is a fixed-unit room where most of the cardiovascular procedures are done, to include heart caths and interventions on the coronary arteries, which Dr. Smith will go into a little later. We have another operating room where we do a lot of procedures for end-stage renal disease, fistula creations, and other procedures to include peripheral arterial disease interventions for amputation prevention and limb salvage.

Our procedure types in the surgery center are diagnostic and interventional coronary; diagnostic and interventional vascular, arterial and venous; cardiac rhythm management, which includes pacemakers, defibrillators, and loop recorders; dialysis creation and management; and neuropathy management with peripheral nerve stimulation. All of these procedures are done in an outpatient setting, and all the patients go home the same day.

Why did we move to the out-of-hospital care setting? In 2013 or 2014, we started seeing some of the outpatient hospital procedures that were being sent home the same day being identified and recognized on the surgery center fee schedules, and we decided to make a leap at that time to try to give the patients the benefit of a low-cost center, low infection rate center, as well as very high patient satisfaction scores.

The benefits of a hybrid model, which is defined as an office-based lab and a JCAHO-accredited surgery center, are numerous, which we'll get into, but the flexibility that gives the doctors and the patients is tremendous. It gives us a lot of flexibility on what procedures we're doing, and that's why we chose to proceed with the hybrid model.

Again, the impact of procedure trends: we think it's the future of cardiac care, regarding all types of procedures. I would think with time, more and more procedures will be moving from the hospital to the outpatient setting in the surgery center.

Improving the patient experience was mentioned earlier, but one of the main reasons is we have a model in our practice where we have rural clinics, and have better access to care for our patients in the out-of-hospital setting, complementing what is happening in the hospitals today, of course, for more complicated procedures. Again, it's markedly increased patient satisfaction, personalized care, and a concierge type of feeling when the patients arrives and leaves. It's much more inviting. Again, lower infection rates just because it's a lower square footage facility and very, very cost transparent.

Patient selections are very important in this space, and it takes a very special group of docs, which we think we have accumulated here at the CardioVascular Health Clinic. We have to decide in the clinic side the comorbidities of the patient and if they are good candidates to do on an outpatient basis, just like we would do in the hospital.

Obviously, cost is a big issue with our patients in rural Oklahoma and Southwest United States, in that they really need to know that their cost to the procedure markedly decreases in this space compared to the hospitals.

Our most thought-of consideration is obviously outcomes. We watch outcomes very closely, and we're very proud of our outcomes here at CardioVascular Health Clinic. We keep a close eye on that data and present it any time we get the chance to do that.

We have some cases today, and I was going to let my partner, Dr. Marcus Smith, an interventional cardiologist who I'm very proud to call partner and colleague. Dr. Smith has been with us since 2017 and has been very instrumental in building the cardiovascular program from the cardiac standpoint to include risk factor modification and just everything involved with taking really good care of yourself from the cardiovascular standpoint.

Marcus Smith, MD:

Thanks, Jim. When we were putting this together, I thought I wanted to pick a case that exemplified a couple things. We could've gone down the road of looking at complex anatomy and a really intricate case. But I said, "Well, I wanted to show something that showed a little bit more about our facility and what brings to light some of the benefits of what we have here."

This guy actually came to my care within the last three or four months. As it says here, he's a 64-year-old man, has a history of some risk factors of cholesterol issues. In the last three months, he developed some CCS III angina.

Here at our facility, we have the capabilities of doing in-house PET and nuclear stress tests. Luckily, when I saw him, I believe it was on a Monday, I was able to work with our team to get him authorized and get him on the schedule for a Tuesday PET stress test. The beautiful part about that PET stress test is the accuracy. We've got about 90% sensitivity on these PET stress tests.

I was in the building when this stress test took place, and they called me and said, "Listen, this gentleman's having quite a lot of chest pain and feeling like he may pass out when he's having the stress test." So I went over there and I saw him. I reevaluated him, I was able to read the stress test on the spot and saw there's a really large anterior defect on the front part of the heart that was definitely concerning, given his symptoms. Now we're correlating with an abnormal functional study. So we again worked with our team, which is great here. We have all in-house coordinators here, and were able to get him preauthorized and on the cath schedule in the next 48 hours.

He went from being a new patient, to getting a stress test, which was abnormal, to getting a heart cath all within about a three- or four-day period, which lo and behold ends up being a very important thing, because when we did the angiogram, we were able to find that he had a very tight proximal left anterior descending (LAD) lesion that we were able to fix with a drug-eluting stent. We did this radially, and he went home the same day. I've seen him in follow-up now about a month ago, chest pain-free, doing well, living life, saying he's got many more years with his grandkids.

So I thought that was a really cool story just to exemplify the flow that we have here, which is very unusual. I think a lot of patients [instead] will experience something like, "I saw the doctor. I got a stress test in a couple of weeks. I saw him back after the stress test. He said it was abnormal. It took him a couple more weeks." Who knows what kind of outcomes you're going to have in the meantime if you're delaying care on a really tight proximal to mid-LAD lesion like my patinet had. Then to do it radial, go home the same day, I thought it was a really nice example of how we're able to do what we considered years ago, hospital medicine, in an outpatient basis and doing it very effectively, efficiently, and cost effective on top of all that.

Jim Melton, DO:

That was a very good case. Thanks, Marcus. I appreciate you going through that.

I think I'd really like to hear from you, being obviously a lot younger than I am and having the capability of practice anywhere you wanted to, as to why you chose to join CardioVascular Health Clinic and your vision versus a hospital setting and just the old “go to work, clock in, and clock out” type of model.

Marcus Smith, MD:

I think that's a great question, because I, like most people out of training, thought, “All right, I'm getting out of training. I have to join one of the local big hospitals.” And I did, and I did it for about a year. I quickly found out that for me personally, it just didn't fit in my style of medicine. I felt like many people do in that situation, you're a cog in a wheel. You don't have much say in how the future is for that facility or for your own self, for that matter.

Oklahoma City is a decently small town. I knew that this facility, ironically, was about three miles from my house, and I drove by it every day. So I knew it was being built, and I knew when it was functional. I started talking to reps and started talking to other people, and they're like, "Hey, Schmidt and Melton are doing an outpatient center." I have an entrepreneurial spirit, and I realized that I saw the landscape of medicine and cardiac medicine very much merging towards the outpatient sector. So I thought getting ahead of it would be ideal.

I cold-called you and Dwayne one night and just said, "Hey, I'm a local guy in town. I'm young, but I really am interested in the model that you guys are implementing over there." Within a week, I want to say, we sat down at a dinner. We hit it off for about two and a half, three hours, and I think I was ready to ink a deal in the next week.

I think the best business advice that you can take is to find the smartest people in the room and hang on to their coattails, and let them take you on a ride. I knew what you had done locally building hospitals, and I knew that the next chapter of this would be something really special.

Here we are five years down the road, and I could tell you honestly, the best call I ever made, the best decision I ever made, I guess outside of marrying my wife, is to make sure that I'm with people with whom I truly 100% agree. We have the same vision. You have been pioneers locally and nationally, so I feel extremely honored to be under your tutelage from a medical standpoint and from a business standpoint.

It's been really rewarding, because I grew up in Oklahoma, to give healthcare back to Oklahomans, both in the city I grew up with and in rural Oklahoma, which one-third of all Oklahomans live in rural markets. To be able to give affordable healthcare is a really, really rewarding thing. One of the most rewarding things I've done in my career is to be able to provide healthcare to people that couldn't get it because they couldn't afford it.

We talk about the Hippocratic Oath, speaking of the first line that says, "First do no harm." I think the new iteration should be, first do no financial harm. When you give somebody a diagnosis of heart disease or cancer, unfortunately their first reaction is, "What's this going to cost me?" It shouldn't be that way. We should be able to give affordable healthcare, and I think that's exactly what we're doing here. To hear and to feel that we can do that, I rest my head on the pillow very comfortably at night knowing I'm doing what I intended to do in medicine from the get-go, and that's help people and get access to care for my fellow Oklahomans.

Jim Melton, DO:

I second a lot of what Marcus said. I think we were very stable in a hospital setting and, again, had built two pretty big hospital-based or physician-owned hospitals, cardiac hospitals in town, and just saw that the amount of cases that we were seeing move to the outpatient surgery center, or at least have a chance to, was going to grow with time. We still think that that list of CMS-approved procedures is going to grow significantly over time.

Like Marcus, I'm in the limb salvage/amputation prevention business. It became frustrating to try to get an angiogram done and then not get on the schedule for another week or two, and see patients lose tissue and lose the possibility of saving a limb at a hospital. It's not necessarily the hospital's fault. It's just a big place, and it's a lot of people trying to do things. Scheduling-wise, it's difficult. So those are all issues.

What we did find when COVID hit was that we were looked at as a place to stay open to help patients with their cardiovascular care. They reached out to us from the state to try to keep us open when everybody else was forced to close in order to maintain cardiovascular care. While people continued to have heart attacks and continued to have limb-threatening issues, we were on the front line trying to stay open. We really never saw much dip in business. So I think that that was a really important way to see the outpatient space and its value with the terrible, terrible epidemic that we all faced.

Marcus Smith, MD:

That's exactly right. I think when we started seeing national trends, whether it be a 40% reduction in things like screening mammograms or colonoscopies or, from my line of work, just people needing to get their echocardiogram or their stress test or whatnot, we saw that nationally those numbers were dropping drastically. It wasn't because those people didn't have a need to do it. They had a fear of doing it, fear of environments that they thought were higher risk for contraction of COVID.

Of course, when you have an outpatient environment like we do that has basically all the utility of an inpatient environment, without the risk of overnight COVID patients and some of the exposure risk, it allowed people to continue their healthcare in a pandemic without that fear.

I had a lot of feedback in the last couple years about how good people felt coming into our environment. It allowed them to continue their care because, again, these trends are really scary nationally in terms of these preventative measures. Even people with MIs are down at some point in time during the pandemic, 20% to 35%. That doesn’t mean MIs were not happening. It's people weren't presenting and getting the adequate care because of fear of the environment that they had to go into to get that care.

Jim Melton, DO:

Marcus, thanks for the case presentation. Final thoughts tonight, advice for physicians on opening their own lab. I think that it's really important to have people that know what they're doing with surgery center openings and accreditations, and all you have to go through to get that done. It's a lot easier to open an office-based lab only, but the trends, as we know today, are heading towards surgery centers. A lot of the procedures that we've talked about today, cannot be done in an office-based lab. So the surgery centers are an important part of that build, and I think it's important to get consultants that know what they're doing and have done this before.

Predictions on out-of-hospital trends are that more and more cases will be moved to the outpatient space, there's no doubt in my mind, because we can show them outcomes and we can show them the same outcomes they're getting from sending those patients home at the hospitals the same day also.

Personally, from the CardioVascular Health Clinic standpoint, we plan on growing this platform across the country: to the southwest, west, east, north, everywhere. We want to have partners with like minds and like practices that treat their patients like we do, so we can scale the business and have a lot more impact on patient care going forward. We're excited about mergers and acquisitions in the present day and going forward. That's a big part of what we do now, and we're very excited about that part of the business.

I think that the out-of-hospital care setting obviously impacts not only business, but our community at large. Again, the COVID example was a great example of state representatives reaching out to us to say, "Please help us. These patients need help, and we can't get them in the hospital because of certain limitations because they are full." We took that as a challenge and definitely stepped up to the plate. So I think that community care and also having the patients have access to care is our mission statement. I think those are final thoughts going forward. Marcus, do you have anything else?

Marcus Smith, MD:

From my perspective, I agree with everything you are saying. It has been rewarding personally and the future looks bright. I think you've got to look at the landscape of healthcare and realize that a lot of healthcare dollars are being spent on cardiovascular care, and we know that many hospitals strive to achieve 80% to 90% same-day discharge on their procedures. If you could segue some of that money and some of those procedures into our space or spaces like ours, the savings is going to be giant. So in order to save some of the dilemmas that we've had in healthcare, we've got to start being forward-thinking, which I think our group locally and nationally has been a great example of. I hope we encourage people to feel entrepreneurial, that they can do it, and they can exist outside of the confines of big hospital systems.

Big hospital systems are important. We're not saying that they're not. We all have patients that have acute needs that need to go to the hospital, but for that 80%+ that could be on an outpatient basis, why not do it on an outpatient basis? In terms of an outpatient setting, I think we're showing that patient satisfaction, cost, and accessibility are all huge advantages to what we can offer.

Jim Melton, DO:

Thanks, Marcus. With this final discussion, we'll wrap it up today. Thank you, and thank everybody for listening. We would also like to thank, obviously, Philips for their support of today's discussion.

To learn more, please visit philips.com/symphonysuite.