PROCEEDINGS
OF THE 30TH BETHESDA CONFERENCE. THE FUTURE OF
ACADEMIC CARDIOLOGY. BETHESDA, MARYLAND, OCTOBER
26-27, 1998.
JACC Vol. 33, No. 5, April 1999:1091-1135
30th
Bethesda Conference:
The Future of Academic Cardiology*
Task
Force 1: Clinical Care
Henry
DeMots, MD, FACC, Co-Chair, Gilbert H.
Mudge, Jr., MD, FACC, Co-Chair
POTENTIAL
SOLUTIONS/OPPORTUNITIES
Academic
medical centers are poised to redefine their relationships
with the community and the departments of medicine/pediatrics
in a fashion that can be instrumental to their
long-term viability (6,9-11).
Geographic differences and rapidly moving market
forces make a standardized approach impossible,
but a number of different strategies have already
proven to be successful. Whatever solution or
opportunity is identified, academic medical centers
must be proactive in its initiation.
External
Relationships
Acquire
primary care practices. The acquisition of
primary care practices has clearly channeled specialty
care to a number of academic medical centers.
This has allowed them to maintain a high census
during times of declining specialty care needs.
However, such acquisitions have been a financial
burden, and are now being reconsidered by a number
of integrated health care systems. Moreover, shifting
an acquired practitioner from a private practice
model to a staff model for remuneration purposes
has consistently resulted in reduced provider
productivity. Academic cardiovascular programs
have benefited from these department/institutional
initiatives, but should not rely on them as their
sole future strategy.
Develop
primary care networks. Although such networks
have usually been directed toward the development
of a system capable of accepting large managed
care contracts, their intended consequence has
also been to rechannel specialty care to the academic
medical center associated with such networks.
Moreover, the investment in the infrastructure
of such networks has primarily benefited the primary
care physicians and only indirectly the specialists.
Subspecialty
care clinics/outreach programs. Establishing
subspecialty clinics in conjunction with community
physicians has been welcome in many regions. Although
some community specialists will certainly view
this as direct competition, the ability of academic
specialists to work closely with community physicians
will often be perceived as enhancing the capabilities
of community physicians. The academic medical
center benefits because new sources of potential
patient referrals are created. These relationships
can often be established based on "goodwill"
without formal contracts. This is in keeping with
traditional referral patterns that are based on
mutual respect and personal relationships and
not exclusive contracts. However, it is important
to note that one means of changing referral patterns
is providing financial incentive. Moreover, inviting
community specialists to participate in other
missions of the academic medical center (teaching,
clinical research protocols) serves to enhance
their participation/affiliation/allegiance to
the long-term mission of academic medical centers.
Partnering
of community hospitals and academic specialists
serves a similar need. This outreach provides
community hospitals with sub-subspecialty care
that might not otherwise be available to them.
Subspecialty
carve outs. There are a number of potential
carve-outs that may emerge in managed care for
subspecialty care and will depend upon the degree
of managed care penetration. Such carve-outs might
include diabetes, hypertension, end-stage renal
disease and congestive heart failure. They offer
the ability of an academic cardiovascular program
to offer cardiology capitated carve-out products
as managed care evolves. This model requires the
ability to offer regional cardiology services,
which can be capitalized by the large academic
medical center, and provides high quality practitioners
for managed care providers. It also potentially
provides for cost saving, since a single employer
is identified so practice patterns can be uniform
and respond quickly to the rapidly changing environment
of health care reform. Additional cost savings
can also be realized because this model allows
shifting of procedures such as stress tests, echocardiograms
and diagnostic catheterization to community hospitals
where they may be able to be performed at lower
costs, while shifting more complex procedures
to the academic medical center, fostering mutual
benefit. Such carve-outs by definition require
a broad geographic distribution of academic center-related
cardiologists and are an important outgrowth of
long-term specialty outreach strategies.
Leasing
arrangements. Full-time interventional faculty
or sub-subspecialists in the academic division
of cardiology are leased to community clinical
cardiologists who wish an affiliation with the
academic medical center but do not wish to be
purchased. The community cardiologist pays a portion
of the academic salary and in exchange, the academic
clinician/interventionalist receives patients
for interventional procedures or clinical care.
The academic medical center gains new referrals
and associated referrals to other cardiology services
while the patient is in hospital. The community
cardiologist can then legally receive part of
the professional fees from the interventions or
other procedures performed, since the academic
cardiologist is a part-time employee of the community
practice.
Purchase
of cardiology practices. Due to falling reimbursements
and excessive numbers of cardiologists in the
community, high quality community cardiologists
may consider being purchased by academic medical
centers. In exchange, they expect regional exclusivity
within the academic cardiology network and full
membership in any network products. They are also
provided with long-term contracts with minimum
salary guarantees. Once purchased, these groups
include the academic center as a site for interventional
procedures. Because most academic medical centers
expect minimal numbers of interventional procedures
to be performed in their facilities, these purchases
increase the academic centers' interventional
patient volumes and associated inpatient admissions.
Once these physicians develop relationships with
other academic specialists including electrophysiology
or congestive heart failure/transplantation, additional
referrals to the academic medical center may occur.
However, preexisting referral patterns may abrogate
the ability of purchased practitioners to move
their cases to the academic center if the groups
referring primary care physicians demand that
their patients remain at the nonacademic medical
center.
Internal
Restructuring
The
future success of the academic cardiovascular
division depends on its ability to leverage a
number of the potential market advantages that
it possesses in a business-like fashion to maximize
their impact. These include:
Broad
clinical strength. Community hospitals often
possess cardiologists with skill and technical
expertise equal to the faculty in academic divisions.
However, academic programs often have greater
breadth of expertise with sub-subspecialists in
congenital heart disease in the adult, electrophysiology,
congestive heart failure/transplantation and outcomes
analysis.
Align
incentives. The academic medical center should
foster an environment that is conducive to alignment
of incentives among physician groups (e.g., cardiology
and cardiothoracic surgery divisions) and between
physicians and hospitals. Such alignment may be
instrumental in augmenting revenue and managing
down institutional costs to maximize profitability
of the entire system. These factors--academically
credible clinical strengths and an environment
conducive to aligning incentives--are often not
adequately leveraged by academic centers, in large
part because of bureaucratic obstacles, a lack
of mutual trust among the various parties and
fear, on the part of departments of medicine/pediatrics,
of losing control.
Become
cost-competitive. It is imperative for survival
that academic medical centers provide care at
costs that are competitive with surrounding community
hospitals. The academic medical center faces this
challenge with a number of intrinsic disadvantages
and some advantages which have not been adequately
developed and deployed. In many instances the
faculty practice only at the academic hospital,
and practice at the academic hospital is dominated
by faculty members. This facilitates aligning
financial incentives to reduce cost. When patients'
length of stay is reduced, the reimbursement to
the physician correspondingly drops. But the physician
effort required to produce the shortened length
of stay may increase. If physician and hospital
incentives are allowed to conflict, improvement
in performance can be achieved only by imposition
of rules, guidelines and threats; and success
will be limited. In creating a funds flow process
in which the academic departments benefit as the
hospital thrives it becomes possible for the faculty
member to provide the extra effort required for
good fiscal results. Because the faculty may be
employees of the health system, novel financial
arrangements may be constructed between the hospital
and the academic practitioner. Cost-competitive
care can be delivered by other means; the academic
medical center is an ideal environment to standardize
purchasing and inventory items; physician involvement
can produce substantial savings through bulk purchases
of high-end technical equipment.
Minimize
variation in practice patterns. Variation
in practice patterns increases cost of medical
care without measurable influence on quality.
Although one can argue which group of physicians
is offering procedures at the "correct"
frequency, there is rarely evidence that the general
health of the population treated with the higher
number of procedures is better. Academic medical
centers might prefer to consider their practices
evidence-based, but this may not always be the
case. The same clinical history, stress test result
and stenosis identified by coronary angiography
may trigger variations in coronary intervention
or medical therapy.
The
value of variation in patterns of acceptable practices
must also be readdressed. The educational mission
traditionally requires proof that more than one
direction of care is acceptable. A standard approach
to care may reduce inventory costs and provide
routines that allow nursing and technical personnel
to become very skilled and efficient in providing
care. However, such an approach is viewed by many
as antithetical to the academic environment in
which the trainee is traditionally thought to
benefit by observing multiple paths to the same
end. The trainee is considered to be in a better
position to judge the best way after this varied
experience. This precept must be reconsidered,
for this educational approach is prohibitively
expensive and scientifically flawed. To propose
that the educational "best way" can
be determined by a trainee based on uncontrolled
experiments in which patients vary, entry criteria
are not defined and end points often are not collected
or analyzed except in an anecdotal fashion is
inconsistent with our collective scientific heritage.
Define
training/workforce. Unlike our colleagues
in many of the surgical subspecialties, adult
cardiologists have failed to limit the number
of physicians that are trained in cardiovascular
disease each year. Legal concerns about restraint
of trade are usually articulated as justification
for lack of action. This fact, more so than any
other, has negatively affected the economics of
cardiovascular care in the U.S. and might well
contribute to the actual or perceived overuse
of cardiovascular services in many geographic
regions. Although many academic cardiovascular
programs have substantially restricted the number
of fellows that are enrolled each year in their
cardiovascular training programs, nonacademically
affiliated and smaller training programs have
failed to alter their enrollments. In fact, any
reduction in the smaller training programs threatens
their viability with regulatory bodies and the
institutional purpose that they serve. Furthermore,
many of these community-based training programs
barely meet or fail to meet the basic requirements
provided by the American College of Cardiology.
Their clinical volume often precludes adequate
training in sub-subspecialty areas, including
electrophysiology, preventive cardiology, heart
failure and cardiac transplantation and adequate
six-month research experience resulting in scholarly
publications. Although there are many examples
of excellent non-university-affiliated programs
that meet these requirements, many more cannot.
Since such training is a requirement of certification,
it is imperative that the academic cardiovascular
programs, the American College of Cardiology and
the Accreditation Council for Graduate Medical
Education address this issue.
Nonphysician
extenders. Academic cardiovascular programs
have often been slow to optimize the value of
physician extenders to improve efficiency of clinical
care. Residents and fellows are traditionally
integrated into the continuum of clinical care
as part of the teaching mission, whereas community
providers have markedly improved their efficiency
with nurse practitioners, clinical nurse specialists
or physician's assistants. It now becomes a challenge
to the academic program to incorporate these valued
nonphysician colleagues in a fashion that compliments
the educational mission.
Advocate
change in payment policies of the Health Care
Financing Administration. Current and proposed
payment policies of the Health Care Financing
Administration should be revised to diminish their
adverse effects on clinical practice at academic
medical centers. Specifically, the policies should:
- Recognize
uncompensated care as a legitimate physician
practice expense.
- Provide
adjustments to the outpatient prospective payment
system to recognize the added costs of teaching
and providing care to populations with a disproportionate
share of Medicaid recipients.
- Extend
the exception for teaching physician supervision
of residents to all specialties that provide
evaluation and management services.
- Provide
payment to teaching physicians for the services
of medical students provided under direct physician
supervision.
- Reduce
the physician presence requirements of the teaching
physician rules for private practitioners willing
to teach residents in their offices.
- Provide
adequate payment to support the care of children
and adults with congenial heart defects.
Any
future discussion of payment of graduate medical
education by payers other than Medicare should
recognize that the current level of funding may
be inadequate. In other words, some of the contributions
to the funding of graduate medical education by
payers other than Medicare should be in addition
to, not as a substitute for Medicare funding.
Relationship
between the academic cardiovascular division and
the departments of medicine/pediatrics. The
academic mission of the departments of medicine/pediatrics
is essential, but academic cardiology programs
have a traditional relationship with their department
of medicine that needs to be reexamined. Although
the departments of medicine/pediatrics continue
to be central for academic recruitment and credentialing,
there are other constituents and partners for
the academic cardiovascular programs, which include
hospital leadership and integrated networks among
others, whose needs must be addressed. A restructured
academic cardiovascular division will ultimately
be of more benefit to a department and its other
subspecialty divisions than the current fragmented
approach.
The
present alignment of the various subspecialties
into departments of medicine, pediatrics, surgery
and obstetrics and gynecology dates back to the
late 1800s, a time when cardiologists' primary
tools were their hands and their stethoscopes.
However, like all of medicine, the practice of
cardiology has changed dramatically. Indeed, cardiologists
are sub-subspecialized with independent board
certification in at least two of these highly
specialized areas, electrophysiology and interventional
cardiology. Furthermore, the primary point of
service is more often an interventional laboratory
than an outpatient clinic, and the practice of
cardiology has far more in common both intellectually
and technically with the surgical subspecialties
than with traditional medical subspecialties.
Despite these differences, cardiology divisions
are still expected to support less remunerative
divisions of the departments of medicine/pediatrics,
and meet more robust productivity standards. However,
this disparity is far from novel. Over the past
several decades, similar disparities existed between
the goals of the surgical subspecialties and those
of the department of surgery, resulting in the
development of departments of otorhinolaryngology,
neurosurgery and cardiothoracic surgery. Even
in schools of medicine, divisions of neurology
and dermatology have become independent departments.
However, perhaps the most relevant models for
the cardiology programs of the future are the
50 centers of excellence in oncologic disease
that have been developed at academic centers across
the U.S. These centers of excellence, funded both
privately and publicly, have had substantive effects
on the care of patients with malignancies and
have provided multidisciplinary and collaborative
centers allowing for outstanding levels of patient
care, rapid transition of new technology to the
patient and interdisciplinary collaborative research.
These stand-alone facilities compete effectively
for patients with community hospitals and practitioners
and in some ways exist as economically independent
entities. By having administrative responsibilities
to a larger health system, they are able to bypass
much of the academic bureaucracy that has slowed
the ability of these academic divisions to respond
to change.
A
number of different and successful models should
be considered by the academic cardiology division.
Cardiovascular specialists at the Washington Hospital
Center have developed a superb organization structure
for cardiovascular care outside the traditional
department of medicine. Their clinical trials
in interventional cardiology are leadership investigations,
their commitment to basic research is expanding
and their outreach/merger with other institutions
or individuals makes them competitive with the
most prestigious institutions in the mid-Atlantic
States. In other regions, for-profit ventures
in cardiac catheterization have proven to be fiscally
sound and serve as an example to academic cardiology
programs for their efficient business-like clinical
care.
Several
cardiovascular centers have been successfully
integrated into the academic mission of their
respective institutions; Mount Sinai Medical Center's
Cardiovascular Institute and the Cardiovascular
Institute at the University of Pittsburgh Medical
Center are perhaps the most compelling current
examples. Common characteristics of these efforts
include advisory boards responsive to the governing
health care system, horizontal multidisciplinary
integration across clinical care and all research
endeavors and independence from their traditional
departments to forge new community relationships
and to develop marketing and philanthropic strategies
while maintaining fiscal responsibilities to and
academic credentialing by their respective departments
and medical school.
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