Redefining Cardio

Elyas Bakhtiari, for HealthLeaders Magazine , April 9, 2009
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Joseph Knapp, MD, works as the physician half of a dyad model for the heart institute at St. Patrick's Hospital, a 213-bed hospital in Missoula, MT, and says the one-two clinical and administrative punch makes it easier to evaluate potential investments on both their clinical and financial merits, leading to wiser final decisions.

"We needed not only a sense of where it makes sence clinically to invest our time and energy, but also the business case for where it makes sense to invest. It didn't make sense to not do both of those simultaneously and give both of those an equal footing when it comes to long-term decisions," he says. "The simple fact of having bean-counter, administrative folks and the doctors sitting down and talking to each other when making decisions is the crux of what we're doing."

Before restructuring the management organization, cardiovascular services were handled by various administrators who separated aspects of the service line—imaging, cardiac catherization lab, and cardiac services—into "fiefdoms" in the larger world of cardiology, which created conflicts of interest and slowed down the decision-making process, Knapp says.

"Hospitals are big, hierarchical structures, and if you don't turn on a dime you can lose leverage in the market," he says.

The physician involvement reaches even higher, to a six-person board of directors for the service line that is evenly divided between administrators—the COO, CNO, and the vice president of physician services—as well as three practicing physicians.

However, Knapp cautions that St. Patrick's hasn't been operating under the dyad model long enough to conclude whether it will present a problem for daily operations. "I'm a little leery about the buck not stopping at one individual," he says.

Key No. 4: Control operating costs
Cost control is always a factor in any service line, but at the height of cardiovascular's rapid growth phase, it was lower on the list of priorities for service line managers. The poor state of the overall economy has changed that.

"The economy right now is one of our biggest challenges," says Alonzo Lewis, vice president for pediatric and cardiovascular service lines at Beaumont Hospital. "There's a lot of stuff that's on hold from capital spending and trying to organize a structured way to make the right decisions."

Supply costs, such as the number and type of stents used, are also getting more attention, and curbing costs cannot happen without physician involvement. "Before, when cardiology was always the No. 1 income driver for the institution, people didn't pay as much attention to supplies," Hollingsworth says. "Now we're trying to get the physicians more engaged and more involved in understanding the reimbursement to the hospital."

The two cost centers—investments in technology and supply costs—are linked, and making that connection clear to physicians can improve participation in overall cost control.

Beaumont provides printouts to surgeons after an operation detailing the costs in comparison to average direct and indirect costs, so physicians can get a real time assessment of their performance. Afterward, physician leaders are willing to sit down with members of the department to discuss product utilization.

Although some private practice physicians are indifferent to hospital facility fees, many make the connection between their own supply costs and their organization's ability to invest in the technology they want, and that's when real cost savings are seen, says Hollingsworth.

"Some physicians say, ‘Wait a second, if we can't make this a profitable area, then we don't get new equipment,'" she says. "They understand how revenue is tied to their capital needs."

Elyas Bakhtiari is an editor with HealthLeaders magazine. He can be reached at
Jumping Jupiter

In 2008, the Justification for the Use of Statins in Primary Prevention: An Intervention Trial Evaluating Rosuvastatin—also known as the Jupiter study—stirred up the field of preventive cardiology with new data suggesting that treating healthy patients with a statin cuts their risk of cardiovascular disease morbidity and mortality by almost half.

Just a few months earlier, the American Academy of Pediatrics caused a mini-controversy by suggesting statins could be used to treat hypercholesterolemia in children, reducing their lifetime risk of cardiovascular disease.

These cases illustrate the evolving role of statins and similar drugs in treating heart disease, but they also raise questions about the future of cardiovascular care. Medical management, early detection, and prevention will continue to play a more prominent role in cardiovascular care, yet many hospitals still center service lines around surgical procedures and reactive treatments. How will hospitals reconcile the financial incentives with the evolving treatment methods? Will the market shift away from a procedural-based model?

Savvy service line directors are preparing for that future already.

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