Building Rural Interventional Programs with CardioSolution

CardioSolution offers a “hybrid” solution to rural or regional hospitals with diagnostic-only cath labs. What does that mean?

[1]Perrin Peacock, CEO: We guarantee comprehensive interventional cardiology service lines, specifically to rural and regional hospitals. Our unique model allows us to attract the most talented and experienced interventional cardiologists in the country, and we bring those physicians to rural hospitals. We have the ability to move quickly, modify our service line where needed, and most importantly, we put our hospital clients and their patients first. Unlike a traditional physician practice, we drive patient loyalty to our hospital clients, not to our company or physicians. Also, unlike a locums firm, our physicians are proactive. We strive to improve upon the care our patients are receiving and improve upon the processes of the hospital. We also partner with the hospital to do marketing and outreach to let the community know that the hospital is now capable of delivering a much higher level of cardiology care.

What are some of the challenges experienced by more remote facilities that don’t offer interventional services?

[2]Dr. Lou Vadlamani, chief medical officer: Many smaller hospitals have witnessed a drop in their diagnostic volumes as patients have become more and more informed, asking, why do I need a diagnostic procedure first and then be shipped out somewhere else for an interventional procedure? It is also difficult to recruit interventionalists to these smaller places and in addition, doing angioplasty without surgical backup has been historically taboo. Fortunately, over the last few years, with the release of the C-PORT trial data and the American Heart Association/American College of Cardiology’s change in the guidelines, that taboo has gone away.

The CardioSolution model brings experienced interventionalists to these hospitals. Certainly, the hospital can recruit a cardiologist coming out of fellowship, but in these remote locations, you want an experienced person, because there is not going be another cardiologist to consult with if a complicated case arises. Doing angioplasty without any on-site surgery, you obviously want to take an extra level of precaution on each case, and understand which patients are less likely to experience complications. Yet recruitment at this level is much more difficult for a rural hospital. Experienced, middle-career physicians are mostly settled with families. CardioSolution is able to solve both issues by bringing in experienced interventionalists, and, in turn, these interventionalists do not need to relocate permanently.

Once hospitals begin to do interventions on-site, diagnostic volumes will also increase, because now patients don’t need two sticks and they know this going in. There is also a non-direct increase in volume, what we call a halo effect. High-risk patients who are undergoing orthopedic surgery or an elective procedure can now stay at the hospital. Also, ER patients who historically were transferred out because they might have possibly needed an angiogram or angioplasty, will now stay at the hospital.  Half of these patients may not have had coronary disease; it might be a GI issue or musculoskeletal, for example, but now we have the capacity of answering the question, and then sending the patient home or fixing the problem in the cath lab.

If someone comes in with a ST-elevation myocardial infarction, that can be a huge issue in terms of transfer time and cost.

Dr. Lou: Absolutely. To be using lytics in the 21st century, in the United States, seems archaic. There have been many retrospective studies showing that angioplasties do better long term than patients who get lytics. Many smaller towns have disproportionately older populations, and typically they don’t do well with lytics, being at a higher risk of bleeding complications. I believe numbers have shown 10% of the patient population has a contraindication to lytics, so this is 10% where we would have wasted hours shipping them somewhere else, with really just heparin or aspirin, because you can’t thrombolyze them.

What about getting staff ready for interventional procedures?

Dr. Lou: We have relationships with larger centers that do high-volume angioplasty. Our client hospital might also have a relationship with a particular hospital and may choose to send staff there for training. Two or three cath lab team members will spend a month going back and forth getting experience and training on procedures, scrubbing in, etc. In the past, we have also recruited technologists with a great deal of experience who then trained staff. Once you do a few cases, then the staff feels much more comfortable and facile. ICU staff also needs to be trained, because they will be taking sicker patients, who have balloon pumps, are hypotensive or hypertensive, etc., so we have done the same thing with ICU staff.

You meet with various groups and departments prior to starting a program at a facility.

Perrin: One of the first things we do is go visit with local physician practices — the internal medicine and family docs that will be referring patients to us.  Our cardiologists give them our cell phone numbers and encourage them to call us with questions. We make ourselves available to answer those questions readily. We seek out emergency care professionals as well and make ourselves available to them. We simplify the referral process as much as possible.

In the case of a hospital we just implemented recently, we were up and running immediately. We did a stent the first day we were there. Within six weeks, we had done 15 stents, installed a handful of pacemakers, and done a great deal of diagnostics. The hospital was happily surprised that we were able to get started so quickly. We did a conservative forecast for quarterly and yearly PCI volume that the hospital thought was overly optimistic, but we have already met our first quarter forecast in the first six weeks — and we hadn’t even fully kicked off our marketing and outreach program.  The community just really needed this service.

CardioSolution is very conservative in our approach. All of our cardiologists must have done at least 500 cases (after fellowship), so they are very experienced, but if they feel that a patient would be better served in a larger facility, we will never hesitate to ship those patients out. We always put the patient’s care first.

Dr. Lou: The process begins at least two months before we take a patient to the cath lab. We also meet with the ER physicians, and discuss the process of pager activation in order to keep our door-to-balloon times low. We try to shoot for less than an hour, less than 45 minutes if we can, because it is a small town and there is no reason why we shouldn’t be able to show up at the hospital in 10 minutes and take care of the patient. So we meet with ER physicians to learn about the process. With nursing staff, we meet at least a couple of months before we start the process, just so everyone is on the same page, and then we look at what the nursing staff feels comfortable with: do you know what a sheath is? Do you know what heparin is? We take nothing for granted. We see their comfort level and then go to an education level involving our cardiologists, who are coming to educate, as well as other experienced nursing staff who come in and educate about balloon pumps, what you need to look out for in a patient who experienced an acute myocardial infarction (MI), what kinds of arrhythmias are concerning, when should you call the doctor, that kind of thing.

Perrin: We believe very strongly in being available to other doctors, to primary care doctors, to nurses, and emergency professionals as well, so they can have easy access to ask those questions. People appreciate that willingness to be available to them. It is a huge aspect of what we bring to the table and in a lot of cases, is something they are not getting.

Your model has interventionalists doing 7 days on and 7 days off, with at least two cardiologists who stagger their shifts so there is constant coverage.

Perrin: Our model would typically call for at least two interventional cardiologists that we would assign specifically to one hospital client. In some cases, it would be more.  Our hospital clients want consistency, and we provide that by assigning specific physicians to specific hospital clients. Above and beyond that, we have at least two other physicians that we designate as alternates, if there is any weekend coverage or vacation that we need to cover for. We guarantee 365-day, 24/7 coverage to our hospital clients.

Dr. Lou: The whole interventional portion is almost the icing on the cake. Many of these places do not have general cardiology, and if they do, it’s outpatient based. So there is no cardiologist readily available on site and the hospital has no say or stake in it. We build the cardiology department, essentially. We do a great deal of outreach. Part of that is being available for the much smaller hospitals, which are often 10- to 12-bed outposts run by mid-level providers. We are always available for them to run a case by us, and it might not be an acute MI; it might be some kind of arrhythmia, it might be someone who is hypotensive. We give them our cell phone number and say, call us no matter what. We work to establish a relationship and take care of their sick patients, and then we also set up an outreach clinic for outpatient work, so the hospital gets to expand the scope of services it offers to these small areas. We find that after establishing these relationships, we see more pneumonias coming in, gallbladders, and so on.

I used to work in a big medical center, and now, being in smaller places, I have found the biggest impediment to transferring from location A to location B is, how easily can I get it done? If I can pick up the phone and say, “Jim, I’m going to transfer this patient,” and Jim says, “Done! Give me the name of the patient and the date of birth, and it’s taken care of,” that’s what I want to hear. That’s the kind of service we try to provide.

How do you handle the transition period with the week on/week off schedule?

Dr. Lou: There is at least a day of overlap. If you are leaving tomorrow morning, the next physician comes in the night before. We typically have two physician assistants as well, and they know the patients. It’s no different from when I was at Fairfax on the weekend and rounding on Monday to check out to the physician who is on duty Monday. We are always available via cell phone. We also prepare the patient’s family and let them know, “I’m off call starting Monday morning, and my partner is going to take over,” so the patients and the family aren’t saying, where’s the physician who was seeing me yesterday? They are not surprised. We try to make that transition as smooth and seamless as possible.  We are actually more aware of the need to keep our patients in the loop — even more so than in larger hospitals.

Can you share some of your experiences at your current hospitals?

Dr. Lou: At our first hospital in South Dakota, our program is now about 4 years old. It has gone beyond what we expected. CardioSolution is extremely transparent. All our data is on the American College of Cardiology’s National Cardiovascular Data Registry (NCDR). At this program, our interventional volume is about 350 percutaneous coronary interventions (PCIs) per year and about 50-75 peripherals per year. We also do about 100-110 devices per year.

Perrin: Before we got started at our second hospital, which is in Idaho, we forecast 125 stents in the first year. The director of cardiology told us it was optimistic from his perspective, and he said, “If we get to 75 in the first year, I will be ecstatic!”

For the first quarter, we conservatively forecast 15 stents. We have already met that forecast in the first six weeks. At a minimum, we will have doubled our stent forecast.

Dr. Lou: I want to emphasize that when we project these numbers, we are not held to our forecast, so it’s not that we stent when there is no call for it. As I said, we are a transparent organization. Our cases can be and are reviewed. We review them internally and externally. If it is a complicated case, meaning there is a calcified lesion, risk of perforation, patient at risk, renal failure, cardiogenic shock, multivessel disease, left main lesion, etc., but the patient still needs PCI for some reason, then we will transfer the patient to an appropriate facility. If the patient is better served being surgically revascularized, then again, that is what we will do — send them to a cardiac surgeon. There has to be an indication to perform PCI. We do not stent just to meet our numbers and there is no pressure to do so.

Perrin: Yes, the arrangement we have with the hospital is not based on performance. We have a fixed fee, negotiated up front, that is completely independent of any kind of a performance measurement. (Certainly outcomes are considered!) Hospital contracts are 3 years, and in some cases, we are talking to hospitals about a 5-year commitment.

Dr. Lou: We don’t want anything hidden. Let’s look at our outcomes out in the open. Our program in South Dakota was rated number one in South Dakota by HealthGrades, an independent organization (see sidebar). They looked at our Medicare coding and our outcomes based on Medicare codes.

It is important to note that we do not pick programs that are a stone’s throw away from The Cleveland Clinic or The Mayo Clinic. If there is a huge PCI center 10 miles away, that’s not the place we want to be. We want something that is at least 1.5 to 2 hours away, or typically 40-50 plus miles away. Distance and weather often play a role in time to transfer as well. In some cases, a hospital might be geographically close to another larger facility, but it still takes over an hour to get there.

Data regarding cost in our South Dakota location was presented at the February 2012 CRT meeting in Washington, D.C. On average, per patient, we saved about $15,000 in transfer fees. Just firing up the helicopter to transfer the patient can be $7,500 to $15,000 or more, not to mention the additional costs. That is for an acute MI patient. Ground transport for stable or unstable angina may cost even more.

I was at our Idaho location for 2 weeks when we first started the program, and the CEO told me that during that time, they had 18 patients who historically would have been transferred out, but who ended up staying at the hospital. Not all 18 needed an angioplasty, and it was unclear initially when they came in whether the issue was cardiac or non-cardiac. In the past, these patients would have been transferred out because the hospital did not have a cardiologist. Now, we can sort through these patients, do a non-invasive study or cath them, and most likely fix the problem. I think the ER and primary care physicians now feel much more comfortable keeping these patients in the hospital, rather than saying, well, it’s beyond my expertise, let’s transfer them.

Perrin: The director of cardiology told me that they have had an average of at least 1 patient/day that has come to the hospital that would not have come to the hospital prior to us having been there. That’s the halo effect Dr. Lou was speaking of.

How did you start the company?

Dr. Lou: While I worked at Emory in Atlanta, I became acquainted with Dr. Thomas Aversano and eventually started working with the C-PORT trial, which studied programs doing angioplasty without on-site cardiac surgery. I worked on starting interventional programs and then hospitals would recruit their own staff. Sometimes they were not very successful in recruiting. One hospital recruited an interventionalist who started doing things he shouldn’t, and the hospital got into trouble and almost had their trial participation pulled.

I wanted to provide service to these smaller hospitals and still offer expert care. Even though these are not major metropolitan areas, people should have access to good physicians. I wanted to find a way to get well-trained, experienced doctors to go to these places, but everyone I talked to said, “I’m not moving! You’re crazy.” They were all established in Orlando or New Orleans, or wherever. Now, under the CardioSolutions model, we offer a schedule of work for one week and home for one week, with no pagers and no work responsibilities. Take your kids to school, take them to taekwondo or Kumon. When you are at work, you are at work, but when you are at home, you are at home and mentally present. It is a model that works for many cardiologists.

Perrin: Dr. Lou and I planned for a solid year before launching CardioSolution. We found a 75-million dollar, privately-held travel nurse staffing firm in Ohio and set up an LLC with them. Even though CardioSolution itself is a young company, Dr. Lou has been working in this model for several years, and while the scalability is new, the concept has proven successful over the past 3 years in South Dakota. Basically, we hit the ground running at 100 miles an hour, because partnering with the travel nurse staffing firm gave us accounting, IT, and a marketing department. We also have a logistics department that is used to handling 500 nurses out traveling at any given point, so to get an extra 30-50 cardiologists out on the road is an afterthought for them. Interventionalists absolutely love our model and are coming to us. We now have a full roster of cardiologists that are ready to go. The immediate, most obvious hospital client for us is a small rural or regional hospital with a cath lab doing a little diagnostics.  We can make a dramatic and immediate impact with hospitals like that.

Dr. Lou: When I first pitched this idea in South Dakota, they initially said, well, we want our physician to be local. My response was, are you sure that matters? Do you go out to dinner with your primary care physician? Do you socialize with them? Being local or not is irrelevant in this day and age, although you can say our physicians are, in fact, local, because we are there 7 days a week. We do reach out to the community. I do presentations to Kiwanis and the Elk Club, for example, because along with the hospital support, the community also has to embrace the program.

I have found working in these small towns incredibly rewarding. When I left Fairfax Hospital in northern Virginia, I’m sure there were 5 people lined up to take my job. But now, I may be out at a Wal-Mart, and someone will come up to me and say, “Hey, you saved my wife’s life!” I feel good. I feel important. It’s an intangible benefit.

How is CardioSolution an improvement on a locums setup?

Dr. Lou: The big difference is that we provide the hospital with physicians who have ownership of the program. I have done locums in the past. When you come in as a locums physician, your attitude tends to be, well, this isn’t my gig. I am just here temporarily filling in and then I am gone. CardioSolution builds a program with physicians who feel ownership of that program. We have a commitment of building the program for the hospital, because it is a three-year contract. We want the hospital to come back and say, you have done so well for us that we just want to continue. That is our goal. We want to continue to build the relationship and run the program for these hospitals.

Perrin: Unlike a doctor’s practice, our goal is to drive patient loyalty to the hospital itself, versus driving patient loyalty to CardioSolution or to any of our individual physicians. Of the regional hospital CEOs I have spoken to, one of their biggest complaints is that while they are using an individual cardiology practice, that practice can send patients to other hospitals if they choose to do so. Our goal is to put the hospital back in the driver’s seat, where they have the decision-making ability. If we need to change our model, if we need to pull a cardiologist for any reason, then we do. Whereas if the hospital has two cardiologists and one of them doesn’t work out or has to leave, half of their revenue goes away and may not return for 6 to 12 months. CardioSolution will have someone there the next day.

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