John R. Florio, Executive Director, Cardiovascular Services, University of Kansas Hospital, Kansas City, Kansas
John R. Florio, Executive Director, Cardiovascular Services, University of Kansas Hospital, Kansas City, Kansas
They had not seen each other since the meeting last year, but as good long-time friends, their conversation flowed spontaneously, as if they saw each other every day. They are: Bob, a senior cardiovascular product line manager from the southeastern part of the United States; Bob’s cath lab manager, Susan; Mary, an administrator from New Hampshire; Jack, a vice-president and executive director of a large program in the midwest, and Gina, a former heart program executive director, now CEO of a large cardiology group in Tennessee. Most of the time they are truthful and candid with each other, especially since they are not competitors. However, on occasion, some have been know to stretch the truth a bit. The views expressed are their own, told in their own words. Bob (A senior cardiovascular product line manager from the southeastern part of the United States) I am comfortable in the large chair as I loosen my tie and stretch out the kinks in my legs. It’s great to see everyone. Hopefully, they will be able to help me with my problem. Well, not really a problem, but rather an issue that I am struggling with at my hospital. Up until this year, our growth in the cath lab has been strong. But for whatever reason, this winter our business slowed down just enough to make me question whether we should add our next cath lab. I have great physicians who are very loyal to the hospital, and I don’t have any staffing issues. I was lucky to hire Susan, who had relocated to the area along with her husband, who is a senior manager at one of the large computer research firms in our area. When there is a pause in the conversation, I jump in and say, So what do you think about me adding another lab? Think the timing is right? These people are very sharp, and I hope that they will validate my inclination to add a lab. But knowing them, they will touch on the pros and cons of such a decision. As they ponder my question, I can’t help but think about the shell space next to the existing labs, which is all ready to finish out and to add the equipment. I even have the construction and equipment budget approved, but still have not had the nerve to pull the trigger and proceed. Gina (a former heart program executive director, now CEO of a large cardiology group in Tennessee) I am glad I came to the meeting, even though it now seems I may be on the other side of the fence, so to speak, working directly for cardiologists. I loved working in the hospital and especially enjoyed the cardiologists, even though we had our moments. I guess they really valued my experience and expertise because they made me an offer I couldn’t refuse when they expanded their practice and added a cath lab in their office. The rest, as they say, is history, and when the CEO retired, I was asked to fill that role. Have any of you guys heard about Cardiology Services of America? I ask. You need to check them out. They are an incredible company out of Tennessee that helps groups build cath labs or advanced imaging suites through a unique partnership. Our group entered into an agreement with them, and with their help, we recently added a 64-slice CT scanner. I pause for a minute and then add, The images from the 64-slice are awesome, and we are even starting to get paid for them. That is a good thing, I think to myself, especially since the quality is so great that it is eliminating the need for some diagnostic caths. I glance at Susan, Bob’s new cath lab manager, and smile as I ask her, Susan, so how is Bob to work for, and what do you think about adding a new lab? Susan (Bob’s cath lab manager) Bob was really great to bring me along on this trip. His friends are awesome, and they seem to know so much about cardiology and our business. Gina, I say, smiling, Bob has been great to work for because he is so supportive. He is actually having me do quite a bit of research on many of the issues you all have raised. Speaking from my perspective, perhaps the greatest challenge I will face is finding the technical staff and nursing team members to cover an added lab. Even though we have a great lab and team, several of our longer-term employees are closely watching for openings in new start-up labs at some of the smaller regional hospitals that are planning to do interventional procedures, even though they have no on-site surgical backup. In most cases, they will probably get the same salary, but they can work in their own towns and not have to face the longer drives in our traffic, not to mention the cost of gas. For a long time, interventional programs were more or less protected under the existing CON rules, but now hospitals can apply to expand their cath lab programs to do interventions. Jack (a vice-president and executive director of a large program in the Midwest) Bob, I can see why you brought Susan along. She is right on target with the staffing issues and the smaller interventional programs. I continue, In order to preserve our surgical volume, we recently entered into an agreement with a smaller hospital to provide interventional services. It reduced our volume of interventions but preserved the more difficult cases for our lab, along with surgical procedures. Mary (an administrator from New Hampshire) You know what really has me worried? I ask the group. There are some terrible payment rule changes proposed by CMS that are going to dramatically reduce payment for inpatient procedures. If you haven’t yet heard about them, the stent companies are helping to spread the word and you can always log onto the CMS sites to read the proposed rule changes. If only they knew how mad my CEO was when I let our Heart Center advisory group know about the numbers! I thought I was going to have to take her to the cath lab. You know, Bob, I say, looking at him and Susan, One of the things that you must factor into your thought process regarding another lab is vascular procedures, which we forecast to steadily increase in the years ahead. Our cardiologists have started to aggressively screen for this disease in their clinics, and now we’re starting to see increased peripheral interventions. Our cardiac surgeons are also starting to do more endovascular procedures along with the cardiologists in the cath lab. Susan (Bob’s cath lab manager) The group has really seemed to accept the comments I have made, so I hope I don’t go overboard by continuing. I look at Bob, and he seems to know I am about to add something more to the conversation. Guess I was never known for being bashful. Bob had me read quite a few books and talk to some of my friends in other hospitals about typical cath lab volumes. Most agree that you can do about 1,700 procedures in a lab, which equals about seven cases per day. I think those numbers may not reflect the more complex nature of cases we seem to be doing today. Isn’t that right, Bob? Jack (a vice-president and executive director of a large program in the Midwest) Bob, as always, has picked a very bright individual to work with him. Before he can respond, I say, Susan is right. Our interventional procedures are longer and more complex than before. With an aggressive group like ours, well, the old formulas are out the window. Just before coming here, one of the acute procedures in the hospital lasted almost four hours, and I hate to tell you how many stents were used. I look at Mary and ask, Do you think your hospital will ever pressure physicians not to perform some interventional procedures if the stent usage is projected to be too great? Mary (an administrator from New Hampshire) Jack is trying to bait me a little, as he always does when he knows that there may not be a correct answer to his question. Let me see if I understand what you are asking, Jack. You want me to tell physicians what is right for their patients? How many stents did your physician put in that patient? Sounds like it might have been a full metal jacket! Bob (A senior cardiovascular product line manager from the southeastern part of the United States) I jump in before Mary and Jack can get started on one of their famous debates. So let me see if I understand some of the issues you have raised in response to my original question about when to add a cath lab. I pause for a minute, until I see I have everyone’s attention and then summarize the discussion. I need to carefully watch for increased competition not only from other hospitals starting programs, but from large physician groups starting labs and CT testing outside of the hospital. Generally, I also need to realize that our own CT scanner may cut down on the number of diagnostic caths done in our labs. As if that weren’t enough, I have to worry again about staffing issues if I do expand a lab. If that is not enough, I have to worry if we are going to make a profit. I pause and add, Actually, thanks for being helpful, and yes, I will not forget about vascular. You can see we have a lot on our plates even without considering lab expansion. About this time, I am on overload, and I look at the group and say, So what are our plans for dinner? Any suggestions? Later that night. The group somewhat easily agrees upon a time to meet for dinner and even a restaurant. They leave the lobby to go back to their rooms to freshen up before meeting in front of the hotel. Later during dinner, Bob is uncharacteristically quiet and begins to look downright uncomfortable. Gina notices him perspiring and asks if he is all right. Bob acknowledges that he is not feeling well and is, in fact, having an irregular heartbeat and some pain in his shoulder and tightness in his chest. Bob argues somewhat half-heartedly with Gina when she suggests that he needs to be seen in the emergency department at the nearby medical center. The medical center has an accredited chest pain program, and Bob’s EKG leaves no doubt that he is having an acute problem. He is rushed to the cath lab where a team quickly diagnoses the blockage, which is opened and a drug-eluting stent is deployed. Bob tolerates the procedure well and is kept overnight, his friends by his side. After all, what are friends for? John Florio can be contacted at jflorio@kumc.edu