Getting to the Heart of Cardiology Alignment

This article appears in the January 2012 issue of HealthLeaders magazine.

Like the rhythm of the beating heart, there is the steady drumbeat of knocking on the hospital's doors.

It's those cardiologists.

With declining reimbursements and eroding practice income, cardiologists are increasingly seeking hospital employment, prompting health systems to consider an array of possibilities for physician alignment.

Most hospital systems are using the standard employment model as they bring physicians into their systems, but others are using comanagement or other paradigms, such as professional services or business enterprise systems, for invigorated cardiology programs. In the process, they are improving internal committee oversight and management structures, and influencing changes within group practices.

"Physicians are sitting alongside the administrative team at all levels of the heart institute," says Lisa Shannon, COO of Spectrum Health's Grand Rapids, MI, hospitals. "So many times an administrator is unable to move things forward to change quality or decrease costs unless it is physician-led." Spectrum Health has employed, integrated physicians, and also those who are not salaried within the system. Physicians who aren't employed are included in the committee structure, says Shannon, noting, "We certainly have room and need their input."

As the nation moves toward value-based purchasing, hospitals are evaluating systems such as bundling for episodes of care, which is shown to improve efficiencies, according to Nancy Harrison, director of the acute care episode project for the 681-licensed-bed Hillcrest Medical Center in Tulsa, OK, which is part of Ardent Health Services, a Nashville-based system that owns nine acute care hospitals and one rehabilitation hospital with a total of 1,731 licensed beds.

Healthcare leaders are considering prospects for new payment systems, for value-based efficiencies, and possible accountable care organization structures, says Tim Attebery, system vice president for cardiovascular services for the Wellmont Health System in Kingsport, TN.

"We want a seat at the table as we talk to physicians and physicians are coming together; they may be in several ACOs," says Attebery. "Cardiology and heart disease is the No. 1 subspecialty of any population."

Roger Noble, RN, director of cardiovascular services for FirstHealth Moore Regional Hospital in Pinehurst, NC, says the 395-licensed-bed hospital is evaluating several employment models to hire cardiologists, who are now under contract with the hospital. One of the models being considered is an integrated plan, such as a professional services agreement in which a hospital or health system operates a physician clinic and contracts with an independent group to provide professional services.

The hospital, part of FirstHealth of the Carolinas,  a private, not-for-profit system with 582 licensed beds, may decide to diversify its employment models and not just stick with one, Noble says.

"Because of our geographic location, we have a market lock that allows us to do something we maybe wouldn't be able to do in an overly competitive environment," Noble says.

Success key No. 1: Overcoming alignment challenges
Two years ago, the leadership team at the 422-licensed-bed Borgess Medical Center in Kalamazoo, MI, moved toward a full-employment model for physicians in cardiology programs, but hospital officials figured out quickly they had to confront some significant obstacles to attain their goal.

As they negotiated with physician groups, they realized there was a lack of alignment in the doctors' goals, and different expectations for compensation. Hospital officials knew physicians sought a degree of control of their day-to-day operations and did not want to lose autonomy, says J. Patrick Dyson, executive vice president for strategy and corporate services at Borgess Health, which includes the Borgess Heart Institute, where most cardiology and cardiac surgery services are centered.

One of the most important system changes was to create a cardiovascular leadership council to oversee overall performance of the Borgess Heart Institute. The council consists of physicians—both employed and in private practice—from various groups that comprise the institute. The groups represent various cardiac subspecialties, such as surgeons and hospitalists.

Dyson says the hospital system ensured that the employed cardiology medical groups retained oversight of day-to-day clinical operations and had a role in governance of the service line. Although the hospital system did not have a comanagement model in which physicians and administrators have joint ownership, the leadership council system was important to maintain and develop a stronger, more representative leadership structure for physicians employed by the system, says Dyson.

Another key component centered on citizenship.

"These citizenship expectations are what is expected from physicians—behaviors on a day-to-day basis," Dyson says. Among the rules that are unique to one particular group: Nobody is late to start a clinic; if someone has a concern about an issue, how do you voice that concern? Do you get your billing done on time? How is your documentation? Is it done in time?

M. Sue Anderson of ECG Management Consultants, Inc., in Arlington, VA, who has worked with Borgess, says that the framework of operating councils has "really transformed the relationship between the hospital and physicians, and has empowered the cardiologists, allowing them to move forward to not only focus on operational issues, but also to target strategic initiatives.

"With many cardiology groups, the opportunity to play an active role in management and governance is just as important as compensation," says Anderson. When Borgess incorporated a newly employed cardiology group, it was incorporated into an existing physician structure, but was able to operate as a "separate and distinct practice," she says.

Dyson says the hospital system is using the physician alignment structure to improve the hospital clinical outcomes. Borgess has focused on various aspects of cardiac care, he says, with good results. The hospital system's 30-day readmission rate for patients admitted with heart failure is 21.4% for 1,800 Medicare patients, compared to the national 30-day readmission rate for heart failure at 25%, according to Centers for Medicare & Medicare Services data from 2007 to 2010. 

Success key No. 2: Prospects for bundling
Hillcrest Medical Center has embarked on shared savings with physicians as part of a bundled payment program demonstration project in cardiology, and it has seen reduced costs and improved efficiencies, says Harrison.

The three-year Medicare Acute Care Episode demonstration project for Hillcrest Medical Center began in May 2009. The demonstration was to test the effect of bundling Medicare Part A and Part B payments for acute episodes of care, with the effort designed to improve coordination, quality, and efficiency. Five sites in a four-state area were selected as value-based care centers for designated cardiovascular or orthopedic procedures.

Under the payment methodology, CMS would share 50% of its savings with Medicare beneficiaries, not to exceed their annual Part B premium. The selected set of procedures included 29 cardiac inpatient surgical services.

Hillcrest doctors have been guaranteed regular surgical fees as part of the pilot project, but they can also receive a provider incentive from Hillcrest for keeping costs down and maintaining high-quality scores, such as low infection and readmission rates, says Harrison. Hospital officials have not disclosed payments, but Harrison notes that "participating facilities can arrange provider incentive payment methodology under their program with CMS approval." She emphasizes that physicians would have to meet "the predetermined and agreed-upon savings criteria and quality measures as defined by our agreement." The maximum cannot exceed 25% of their reimbursement for these cases, says Harrison.

Bundled payments are among the models being considered under healthcare reform to replace fee-for-service.

"The most important thing with cardiology is going to be bundled payments, with the ACE demonstrations really pointing the way where CMS will be pushing hospitals," says Anderson.

There have been satisfactory results not only with the scores, but also with physician involvement, linking them to the gainsharing initiatives, Harrison says. There has been "better coordination with our physicians and collaboration on episodes of care," she adds.

Over a 15-month period, scores on several quality measures increased, while supply costs decreased. The hospital saved up to $750,000 in Medicare payments on 37 diagnosis-related groups, according to hospital officials.

Another important area focused on improved product management and cost controls with physician involvement, she adds.

As the program began, hospital officials realized that many surgeons didn't know "the actual cost of the products they used," Harrison says.

The hospital examined "a supply list and standardized the products for quality and reduced costs," she says. "We didn't go to a sole source and didn't dictate [products] from a certain supplier. We left the decisions to the doctors. We were working with physicians from the start, involving them in the decision."

Among the benefits: 11% defibrillator implant savings, 9% stent implant savings, and 25% stent supply savings.

"We're feeling good about the results, and we think we've learned more working with physicians and quality improvements," she says.

Success key No 3: Same-day discharge
As it began focusing more on cardiac care with development of a new heart institute, Spectrum Health, a 1,370-licensed-bed system, ensured physician and administration partnership to improve clinical outcomes, targeting same-day discharge for angioplasty patients in cardiology programs.

The program highlighted specific metrics that must be reviewed and benchmarks to be achieved as part of a coordinated effort between physicians and administration, says Richard McNamara, MD, interim comedical director of Spectrum Health Frederik Meijer Heart & Vascular Institute and chief of cardiology at Spectrum Health.

"We put this in front of physicians, that these are the metrics we are going to identify and focus our efforts on," says McNamara, referring to the angioplasty and other programs. "We are engaging physicians a lot more consciously about identifying goals. And we have incentive pay to meet those goals," McNamara says.

"We went across the board, looking at clinical problems that required a lot of cooperation with administration and physicians," he adds.

The program is part of the institute's executive leadership council, whose subcommittees examine research, education, business, and medical programs.

The hospital has focused on improving efficiencies in a same-day discharge program for percutaneous coronary intervention patients, McNamara says. The procedure used to carry out the PCI process is coronary artery stenting. Nationally, at least 1 million PCI procedures are performed annually among Medicare patients.

In a review of low-risk Medicare patients who underwent elective PCI, same-day discharge has been rarely used, with only 1.25% of 1,339 patients discharged on the day of their procedure, according to an independent study from the Duke Clinical Research Institute in Durham, NC.

PCI has not been associated with an increased risk of rehospitalization or death, the institute states. 

While Spectrum Health is still compiling data, its preliminary reports show that it averaged same-day discharge for 16 patients each month, representing about 30% of all scheduled elective PCIs, says Patrice Villemure, executive director of the Fred and Lena Meijer Heart Center.

Overall, the hospital database shows 281 PCI patients who had same-day discharge. "We have no major complications, which have been measured as bleeding, reinfarction, stroke," says Villemure. "Patients have been highly satisfied with the program," she adds.

"There were PCI patients stable enough to go home the same day of the procedure," says McNamara. "We felt they were responsible for a large number of beds used in the hospital. We were not getting the utilization that we wanted; there were unnecessary expenses, and that's what we wanted to change."

Success key No. 4: Collaboration
Scotland Health Care System, in Laurinburg, NC, an affiliate of Carolinas HealthCare System, joined with FirstHealth, based in Pinehurst, NC, to build the $2 million Scotland Cardiovascular Center on the outpatient wing of the Scotland Memorial Hospital campus in 2011.

The hospital systems are separated by 45 minutes, and sometimes compete for patients. Yet they joined together to build the cardiovascular center with a catheterization lab for improved patient care, a move that each hospital's leadership says can be replicated successfully elsewhere, for cost savings.

"As a small community hospital we have always been proactive in creating alliances with regional partners to bring the best technology and services to our community to allow patients to remain close to home," says Greg Stanley, director of cardiovascular services for Scotland Memorial Hospital.

The new relationship evolved from a long-standing, albeit much smaller, partnership. Over the past decade, FirstHealth managed a mobile cath unit that Scotland Health Care rented twice a week to perform diagnostic cardiac catheterizations.

The new cath center includes the catheterization lab as well as four preparation and recovery rooms. By having the cath lab on site, Scotland Health Care can serve patients each day, instead of only twice a week.

The lab allows the Scotland medical staff to transmit images from the procedures directly to FirstHealth, where doctors can review results and decide whether the patient needs additional care or services. Patients who need additional percutaneous transluminal coronary angioplasty or coronary artery bypass graft would be transferred to FirstHealth, which provides around-the-clock coverage for such cases.

"Scotland provides follow-up care to the majority of these patients—if we transfer for intervention or surgery, we get many of those back into our cardiac rehab program," Stanley says. "And the physicians at FirstHealth work well with Scotland cardiologists so patients can receive the advanced care when needed in Pinehurst and then return to their Scotland physicians," Stanley says.

Noble, of FirstHealth Moore Regional Hospital, agrees. While the part-time mobile lab provided some benefit to the community, "what was really needed was something five days a week," he says. "We want to improve access to care and improve the mortality rates. We'd like to deploy the lab to other areas and help people in other areas. We're lockstep in this."

The mobile lab, originally based in Laurinburg, has been replaced with a fixed lab available to patients five days a week, he says.

Under the joint-venture agreement, Scotland Health Care and FirstHealth invested $750,000 each to "purchase the fixed procedure room and support equipment," says Stanley. Scotland Health Care added another $1 million to renovate a hospital wing and then "relocated a couple of departments to make space for the new cardiovascular center," he adds.

Stanley described management of the center as a "team approach from both organizations." Stanley and Scotland Health Care's vice president of patient care services partner with administrators at FirstHealth. As for the day-to-day operations, "We utilize some of their staff on the procedure side, and we pay their organization per procedure," Stanley says.

Although there is no firm data because the project is relatively new, Stanley says more than 30 patients can use the new cath center each week, easily more than doubling volume.

Scotland Memorial Hospital statistics show that one in five emergency room visits has some sort of cardiac issue from either chest pain or high blood pressure.

"We are getting a better snapshot of cardiac disease in our county and in our region," Stanley says. "As we see it, our volumes will continue to grow on the cardiac side, and we are going to take care of more patients in a more timely manner. Patients will be getting started on the road to recovery quicker, getting cardiac rehab and some kind of medicine regimen.

"In this corner of North Carolina, there is a lot of cardiac and vascular disease, with diet, lack of exercise, food options, and smoking," says Stanley. "We can make inroads on this."

This article appears in the January 2012 issue of HealthLeaders magazine.