What Plagues the Cardiothoracic Surgery Administrator?
While cardiothoracic surgery continues to have improved patient outcomes—particularly with decreasing stroke rates associated with CABG procedures—practice management considerations, such as greater utilization of EMRs and hospital employment, often receive less attention in this specialty. However, those tides may be turning.
To address these considerations, the Society of Thoracic Surgery (STS) recently appointed Vinay Badhwar, MD, as chair of the STS Workforce on Practice Management and included a summit on practice management at the past two annual meetings. “Cardiovascular surgical administrators require a national forum for education, and to discuss the issues that impact their day to day,” says Badhwar, a cardiothoracic surgeon at the University of Pittsburgh, who adds that these administrators have turned to the Medical Group Management Association. Yet, the specialists may require increased representation.
Cardiothoracic surgeons cannot currently attest for meaningful use, because, according to the Centers for Medicare & Medicaid Services (CMS), they will not “enter enough data and charges through the EMR in the inpatient setting,” Board explains. “At CVT, we still use hard copy documents. However, having come from a previous setting that used EMRs, I am trying to convince our surgeons of the tremendous benefits of employing EMRs.”
Board suggests it is challenging to win physician support for EMR use in independent practices because direct benefits to the physician are not always apparent. Surgeons are not opposed to health IT altogether, though, as indicated by widespread participation in the STS database. “If the STS database could somehow automatically tie into whatever EMR the hospital system is using, then that would be a big benefit because we have almost 1.5 full-time employees solely dedicated to the STS database, which could assist with the conversion,” he says.
Others see the decision as more integral to healthcare quality at large. “The fundamental reason to implement an EMR is to minimize medical errors, to maximize quality and to improve documentation,” Badhwar says. “It is not a personal choice, as it’s becoming a federally mandated initiative. If the medical record is complete and all of the patient history is electronic and accessible, then it will prove beneficial for the surgeon to be part of that cycle of improved documented care in an EMR.”
However, surgeons may suggest they are too busy and are used to doing things a certain way. Badhwar counters the transition is “inevitable, as we all have to go toward the EMR. The sooner we embrace it, the better off we will be.”
Of course, becoming a hospitalist is never an easy decision. There are pros and cons from the hospital/surgeon perspective. “The hospital benefits from prohibiting a nomadic heart surgeon in the community. For instance, a surgeon can come into hosptial for just for one day a week, and go to other hospitals for other services,” Badhwar says. “This could result in an inconsistency in volume, outcome and dedication to an institution, which could affect the leadership of the program as well as the outcome reporting and achievement of core measures.”
From a surgeon’s perspective, giving up independence, or the perception of independence, can be upsetting, Board notes. But Badhwar has a more positive outlook. “If a surgeon gets hired, that person can remain successful yet participate in a leadership capacity in hospital and business operations, while remaining independent and professionally stable and secure,” Badhwar says.
Board sees regional patient volume as the biggest driver of hospital mergers. As long as practices can stay afloat while providing services to the surrounding providers, they can stave off hospital employment, for now. However, in more competitive markets, merging seems like an inevitable outcome.
Regardless of unique merger choices, Badhwar says that administrators and surgeons need better guidance. “We need to help cardiothoracic surgeons navigate this escalating issue,” he says. “Five to six years ago when the first cardiothoracic surgeons were becoming employed, there were more definitive challenges as hospitals would only offer short-term contracts, and after a year or two, they would cancel the contract with all the benefits of an independent practitioner.”
More recent hospital employment contracts are more of a win-win for surgeons, according to Badhwar. “We, as a specialty, have to weigh in to provide education and help surgeons with their contract negotiations in order to provide information and education as well as the pros and cons of hospital employment.”
To address these considerations, the Society of Thoracic Surgery (STS) recently appointed Vinay Badhwar, MD, as chair of the STS Workforce on Practice Management and included a summit on practice management at the past two annual meetings. “Cardiovascular surgical administrators require a national forum for education, and to discuss the issues that impact their day to day,” says Badhwar, a cardiothoracic surgeon at the University of Pittsburgh, who adds that these administrators have turned to the Medical Group Management Association. Yet, the specialists may require increased representation.
EMR tundra
While cardiac surgeons may initially resist EMR adoption, they might reconsider when the benefits are explained. “While we don’t currently have an EMR, we have the digital capability on the lab studies. Therefore, the next logical piece is to implement an EMR that ties directly with the PACS,” says Lyle E. Board, COO of CVT Surgical Center in Baton Rouge, La., an independent practice with five cardiothoracic surgeons who serve three hospitals.Cardiothoracic surgeons cannot currently attest for meaningful use, because, according to the Centers for Medicare & Medicaid Services (CMS), they will not “enter enough data and charges through the EMR in the inpatient setting,” Board explains. “At CVT, we still use hard copy documents. However, having come from a previous setting that used EMRs, I am trying to convince our surgeons of the tremendous benefits of employing EMRs.”
Board suggests it is challenging to win physician support for EMR use in independent practices because direct benefits to the physician are not always apparent. Surgeons are not opposed to health IT altogether, though, as indicated by widespread participation in the STS database. “If the STS database could somehow automatically tie into whatever EMR the hospital system is using, then that would be a big benefit because we have almost 1.5 full-time employees solely dedicated to the STS database, which could assist with the conversion,” he says.
Others see the decision as more integral to healthcare quality at large. “The fundamental reason to implement an EMR is to minimize medical errors, to maximize quality and to improve documentation,” Badhwar says. “It is not a personal choice, as it’s becoming a federally mandated initiative. If the medical record is complete and all of the patient history is electronic and accessible, then it will prove beneficial for the surgeon to be part of that cycle of improved documented care in an EMR.”
However, surgeons may suggest they are too busy and are used to doing things a certain way. Badhwar counters the transition is “inevitable, as we all have to go toward the EMR. The sooner we embrace it, the better off we will be.”
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| Source: Circulation 2009;120:488-494 |
Hospital employment
With decreasing reimbursement and changes in volumes, there is a trend across the U.S. for independent practices to merge with hospitals.Of course, becoming a hospitalist is never an easy decision. There are pros and cons from the hospital/surgeon perspective. “The hospital benefits from prohibiting a nomadic heart surgeon in the community. For instance, a surgeon can come into hosptial for just for one day a week, and go to other hospitals for other services,” Badhwar says. “This could result in an inconsistency in volume, outcome and dedication to an institution, which could affect the leadership of the program as well as the outcome reporting and achievement of core measures.”
From a surgeon’s perspective, giving up independence, or the perception of independence, can be upsetting, Board notes. But Badhwar has a more positive outlook. “If a surgeon gets hired, that person can remain successful yet participate in a leadership capacity in hospital and business operations, while remaining independent and professionally stable and secure,” Badhwar says.
Board sees regional patient volume as the biggest driver of hospital mergers. As long as practices can stay afloat while providing services to the surrounding providers, they can stave off hospital employment, for now. However, in more competitive markets, merging seems like an inevitable outcome.
Regardless of unique merger choices, Badhwar says that administrators and surgeons need better guidance. “We need to help cardiothoracic surgeons navigate this escalating issue,” he says. “Five to six years ago when the first cardiothoracic surgeons were becoming employed, there were more definitive challenges as hospitals would only offer short-term contracts, and after a year or two, they would cancel the contract with all the benefits of an independent practitioner.”
More recent hospital employment contracts are more of a win-win for surgeons, according to Badhwar. “We, as a specialty, have to weigh in to provide education and help surgeons with their contract negotiations in order to provide information and education as well as the pros and cons of hospital employment.”
| Shortage Will Lead to ‘Inadequate’ Surgical Care |
| The U.S. is facing a shortage of cardiothoracic surgeons within the next 10 years. This could diminish quality of care if non-board-certified physicians expand their role in cardiothoracic surgery or if patients must delay appropriate care because of a shortage of well-trained surgeons, according to 2009 study findings (Circulation 2009;120:488-494). Using a simulation model, Atul Grover, MD, PhD, director of government relations at the Association of American Medical Colleges, and colleagues projected the future supply of cardiothoracic surgeons under alternative assumptions about the number of new fellows trained each year. By 2025, the demand for cardiothoracic surgeons could increase by 46 percent on the basis of population growth and aging, if current healthcare use and service delivery patterns continue. The study included people covered by both Medicare and private insurers; however, the study was conducted prior to the passage of the Patient Protection and Affordable Care Act, which will result in a large expansion of U.S. insurance recipients in 2014. Thus, the study’s shortage prediction is “underestimating the demand for some of those services, given that expansion in insurance,” Grover says. At the time of the study, there were fewer than two cardiothoracic surgeons for every 100,000 people, and most were concentrated in urban areas. Compared with other physician specialties, cardiothoracic surgeons were older and more likely to be men; more than 50 percent of active surgeons were 55 years of age or older, compared with 33 percent of all physicians. “As the baby boomer population continues to cross the 65-year-old threshold, there will be a greater need for CABG, resulting in a real concern for being able to provide proper cardiothoracic care in the U.S.,” says Grover. “The physician shortage is going to be felt most strongly in places that are already underserved, including rural communities and also financially underserved urban communities.” “Many patients will require cardiac surgery in the near future, yet with the economy and the years of education required, there will be a crossing of the line,” says Vinay Badhwar, MD, a cardiothoracic surgeon at the University of Pittsburgh. Grover and his colleagues predicted that the future supply of cardiothoracic surgeons is likely to be sufficient only if all three following conditions are met:
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