Roundtable: Cost-Control Strategies in the Cath Lab
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Roundtable Speakers include:
- Peter L. Duffy, MD, Interventional Cardiologist, FirstHealth of the Carolinas in Pinehurst, N.C.
- Joseph D. Babb, MD, Interventional Cardiologist, East Carolina Heart Institute in Greenville, N.C.
- Michael J. Lim, MD, Interim Director, Division of Cardiology, St. Louis University in St. Louis
- J. Jeffrey Marshall, MD, Interventional Cardiologist and Director of the Cardiac Cath Lab, Northeast Georgia Medical Center in Gainesville, Ga.
- Cathy (CJ) Hosea, RT, BS, Cath Lab Manager, Citrus Memorial Heart Center in Inverness, Fla.
Could you provide a cath lab strategy that resulted in cost savings?
Duffy: It was our transition from a mostly femoral lab for diagnostic and interventional cases to the transradial approach. Two years ago, 2 percent of our cases were transradial, now it represents 15 percent of our interventions. About 80 to 85 percent of my cases are transradial. This shift has facilitated faster turnover times, as we have the capability of same-day discharges for cases performed earlier in the day.Babb: Our facility is probably doing 2 to 3 percent of our cases radially, which represents the tension of evolving technologies. While radial access has many advantages, including lower complication rates, it has some disadvantages, including more radiation exposure to the operator and a higher failure rate to engage the vessel. Also, the learning curve for radial can turn off conventional interventionalists. Some have suggested that even seasoned interventionalists need about 150 to 200 cases to feel really comfortable. It could be a cost-savings strategy, but even if we performed radial procedures, we couldn’t discharge patients the same day because of our rural location, as many patients drive an hour-and-a-half to two hours.
Lim: It’s hard to measure the cost savings of a radial program because very few radial programs have hit that magic number to realize savings. Decreasing complications in patients who you catheterize—either diagnostic or intervention—will decrease costs, but when you’re only using the approach on 15 percent of your cases, you might not recognize savings yet.
Our system has adopted a systematic approach. Last year, we used the radial approach on all of our elective outpatient caths that could be cathed radially. This year, we’ve moved to all of our outpatients and inpatients who could be cathed radially. Then, our last step will be to transition the emergent cases to radial access. However, the learning curve is a lot higher in our institution because we’re training fellows to perform them as well.
Babb: It depends a great deal on the practice setting. Cost savings are not going to be as easily recognizable in a structured teaching environment, as it would be when you are in control of your own practice and you are personally performing these cases.
Has the dawn of the drug-eluting stent (DES) era resulted in a decrease in readmissions? If so, how are you compensating for those revenue losses?
Marshall: The use of DES has reduced restenosis, and everybody has seen that in their lab. However, our lab is located in an area where the population is growing. Our cath lab numbers for the last three years are up about 6 percent per year. In fact, we’re building a new cath lab. Also, we’ve been involved with peripheral and carotid and other types of intervention for a while. As the cath volume has grown, so too has the peripheral intervention work. We now have a hybrid OR where the vascular surgeons are performing stent graphs instead of in the cath lab. Fortunately, we have been somewhat insulated from the drop-off.Hosea: It’s a little different here. We have one of the oldest populations in the U.S. and the second oldest in Florida. Our physicians thoroughly evaluate the patients, along with their ability to be compliant with post-stent implantation prescriptions. Unlike most facilities, we stayed at a 50/50 mix of DES and bare-metal stents [BMS]. Even if the companies are going to give them a year’s supply or the 30-day supply, some patients are not going to take the medication. Our patient population also is keeping us busy, as we’ve grown a couple of percents every year, and we’ve expanded our peripheral stent usage. Also, we implant cardiac devices and ICDs to help supplement any losses.
Babb: We had a fellow methodically assess compliance, and the data were not pleasing. When our DES use dropped dramatically in 2006 in the wake of the upheaval over late stent thrombosis, use actually stayed at that lower rate. We’re using DES about 70 to 75 percent of the time, but the decisions are being made based upon the patient’s ability to comply with the directions. We developed a detailed questionnaire to assess compliance, which is documented in the patient’s record, to avoid liability issues.
Duffy: The Medicare or uninsured populations less often comply with antiplatelet therapy during the first month, so physicians are faced with the double-edged sword of them returning to the lab with acute thrombosis or restenosis.
To cut costs, have you eliminated/cut back the use of certain products?
Babb: When iso-osmolar contrast [Visipaque; GE Healthcare] was introduced, many of our operators adopted the agent, which made the costs go through the roof. Later, evidence emerged that in patients without renal failure and a higher risk profile, there was no reduction in contrast-induced nephropathy.As a result, our group created metrics to justify the use of the iso-osmolar agent, including evaluating whether the patient meets certain criteria of EGFR [estimated glomerular filtration rate] and other risk profiles. This decision saved money, and did not compromise patient outcomes. Also, our IIb/IIIa inhibitors usage has declined, while the use of bivalirudin [Angiomax, The Medicines Company] has risen significantly based on the new data.
Duffy: Joe [Babb], since the majority of your operators are community-based practitioners in an open lab setting, how do you get buy-in from physicians you don’t have direct control over?
Babb: We have a cath lab users group, which is chaired by the medical director of the cath lab, through which we discuss many of these issues. We make it a point to get buy-ins from the community physicians by not issuing edicts, but instead, using group discussions and consensus development to make our lab as evidenced-based as possible. This attitudinal shift in the academic setting has been drastic over the past 15 years. Now, the community-based physician is much more valued and included in the decision making.
Hosea: For contrast usage, we’ve implemented the Acist injection system, which has reduced our contrast usage about 30 percent. This has made a big difference to the bottom line.
Babb: We have an Acist device, but feel it is difficult to implement in a training environment. Most of the community-based physicians were offered the educational opportunity, and have chosen not to utilize it.
Marshall: Over the last several years, the hospital has been more cost conscious. As a result, we have made a concerted effort to cut back on the amount of different aspiration catheters in each lab. You really don’t need them from two or three companies. We’re not a sole vendor lab, but we don’t buy three different products that have the same functionality simply because of a particular doctor’s preference. We all agree that they’re essentially equivalent, and then choose the product that costs the least.
Have you engaged in a competitive bid initiative with certain vendors?
Duffy: Competitive bidding has been our major strategy for cost containment over the past several years because we have a robust electrophysiology [EP] program to complement a busy interventional practice. We perform approximately 3,000 diagnostic and 1,500 interventional procedures this year—and that does not include the work of our three EPs. We have coupled our vascular contracts with our EP contracts to appreciate significant cost savings. Many vendors want all the business, but a provider shouldn’t have one vendor. For most needs, you can have two vendors, and we’ve been satisfied with our cost savings.Babb: We sent out RFPs to various companies asking for their best prices. They requested 90 percent of our market, which is unreasonable, and we settled around the 60 percent range. Now, we have some selection, whether with DES, balloons or guidewires, but every option is not on the shelf. It’s just not cost effective to do that.
Hosea: We’re working with SouthEast Supply Solutions, which is comprised of larger hospitals and smaller hospitals that work with the major vendors to attempt to consolidate with one or two vendors and get the best pricing. The pacemaker/ICD contract was recently signed. The next undertaking is interventional equipment, such as for PTAs with CTOs.
We have an established Heart Board of physicians from all groups, which governs all aspects of CV services from policies to products. We bring our proposals to the board, seeking their thoughts and acceptance before we engage in negotiations because if we don’t get their buy-in from the beginning, it could defeat everything we attempt to negotiate on the back end. This seems to have been a successful endeavor.
Marshall: Our hospital has formed a technology committee. Now, all cath lab requests have to go before the committee, which is comprised of people with no bias from other disciplines. For example, if a physician desires a new radiofrequency ablation wire, he or she has to make a case before the committee in a comparative effectiveness manner. Unless the case is proven or the physician is involved in a research trial, it’s hard to get approval. It has really slowed down new technology adoption, but this approach might be the wave of the future.
What are the economic considerations of the new PCI imaging technologies?
Lim: With IVUS [intravascular ultrasound] and FFR [fractional flow reserve], it depends on one’s perspective. From a patient/payor standpoint, the FAME study showed that physiologic evaluation of lesions was not only a way to improve patient outcomes for elective PCI, but it was exceptionally cost effective. It saved money on the initial procedure and subsequent revascularizations. From a physician’s standpoint, however, the professional reimbursement is woefully inadequate based on CMS’ system. Regardless of whether FFR or IVUS lead to better outcomes, the reimbursement for stenting is much higher. Despite the lack of reimbursement, our FFR/IVUS use is several standard deviations above the national average because we challenge our operators to take care of their patients as though they are family members, recognizing that stents aren’t the answer to everything and can have their own problems down the road.Duffy: The irony of it is we’re in the same situation as a general practitioner who feels pressured to prescribe antibiotics for a virus because referring physicians are telling us to fix the situation. Some of my patients with negative FFRs have come back to demand stents because in their mind something was wrong. We’re going to have to change patient and referring physician culture to properly utilize the fantastic tools of IVUS and FFR.
Lim: The concept really lays in our internal biases and society’s biases, which focus on a quick fix. A physician sees a problem, like an angiographic stenosis, and feels compelled to fix it. Is that the right thing? The COURAGE study was so polarizing because it challenged this fundamental concept. As a result, interventionalists challenged the premise and the enrollment of the study. Yet, we failed to challenge ourselves by questioning whether the study’s findings—fixing a lesion might not always improve outcomes for elective PCI—was correct. When we come to grips with that, either as physicians or a society, it will result in a major cultural shift. But it is a big challenge.
Babb: Mike [Lim] is exerting strong leadership by asking people to justify their procedures. It requires a painful change in culture, and one that is causing battles within my institution right now. The current culture says you’ve got to fix a problem. The patient isn’t happy. The referring physician isn’t happy. So, we just fix it. And, by the way, we get paid to do that. This is part of the illness that we have to address.
Duffy: We have misaligned incentives because it’s so much easier to place the stent, and make everyone happy. If they still have chest pain, we learn the problem wasn’t solved and move onto the next solution, as opposed to spending time to assess the situation properly, explaining the rationale to your patient, then getting less reimbursement for your system. Misaligned incentives are the major barrier in turning around our whole cath lab culture.
Marshall: One of the issues is that payors actually don’t recognize quality. When the government tries pay-for-performance, it doesn’t know how to measure quality. This will be a quagmire as long as I practice. It would be nice if people who are thinking and doing the right thing got compensated for it, but it’s too difficult for payors to figure it out.
Duffy: I’m the co-chair of the Medical Directors Institute, which is an American College of Cardiology [ACC] committee. Our focus is to bring payors and cardiologists together to look at that very issue, finding out if they will pay for meaningful patient care. We are assessing what in cardiology practice brings value to patients and to the system, and how practices would respond if there were consistent pay-for-performance measures, as well as appropriate incentives.
Lim: Getting out in front and encouraging alignment of incentives for better patient care is a more appropriate method, rather than watching every year pass by with decreasing reimbursement because Medicare’s pot is emptying. We can complain about continued decreased reimbursement or try to realign the incentives so the reimbursement makes sense for appropriate care or even that appropriate care gets reimbursed at a higher rate.
Marshall: The disparity on the number of stents used per patient or the number of nuclear stress tests per patient is quite obvious. People know who is over utilizing. Yet, instead of going after those individuals, payors punish everyone. In our 23-physician practice, about 11 percent of the patients receive a nuclear stress test, and certain practices in the country surpass that by five times. I hope that the Medical Directors Institute is addressing this problem. While it would be difficult and uncomfortable to reprimand a practice that’s conducting too many tests, if we don’t improve our methods of dealing with our own colleagues, somebody else is going to tell us what to do.
Duffy: Quality experts call this “unexplained clinical variation,” and that’s the biggest challenge that we have to address with physicians. Payors are not trying to assess whether 55 percent or 11 percent is correct usage, but instead, they deduce that one of them has to be wrong, and want clinicians to figure out the proper usage. Also, this is where business comes into play. There is an inherent conflict of interest when a physician can order a study for which he or she will be reimbursed.
Under healthcare reform, there could be a larger Medicare population. How does your current Medicare population affect your practice management, and how would more patients affect your practice?
Duffy: Reimbursement will be the ultimate determiner. All institutions have to run on some profit. Even nonprofits need to have an operating margin. However, if we get Medicare rates from uninsured patients who will now be insured, and we get a lot more volume, it may not help our ability to deliver quality care.One game changer will be bundled payments, and we’re going to have to work much more tightly with our hospitals to be able to manage patients appropriately. If we have to go to the hospital for fees, which is scheduled to start in 2014, then much closer alignment with hospital administration will need to occur. We will have to learn more how to administrate cath labs, and cath lab administrators will have to give us more leeway to affect cost containment, while still improving quality care for patients.
Hosea: As administrators, we have to improve patient flow. The more we can get in, the more we can get done and the less physicians and patients will have to wait. We need to use as much standardization as possible. Plus, we should scrutinize what is being used in each room, to reduce waste.
Duffy: Basically, there’s still waste in the system despite the fact that people claim we’ve cut it down to the bone.