The New Vascular Interventional Center An Interdisciplinary Organization that Facilitates Collaboration Among Peripheral Int

Many hospitals and physicians are feeling the impact of changes that are taking place within the field of peripheral intervention. Many of these changes are directly related to technology and the physician component. John Goodman & Associates (JG&A), Inc.’s most recent audio conference entitled The New Vascular Interventional Center addressed the current status of the peripheral interventional field relative to these changes, and the need for programs to become more fully integrated in order to effectively diagnose and treat vascular disease. The following synopsis highlights some of the information that was shared during that enlightening discussion, which included John Goodman, JG&A President, Conrad Vernon, JG&A Executive Vice President, and James Williams, MD, specialist in cardiac, thoracic and endovascular therapy. Vascular Disease Statistics JG&A President, John Goodman, offers this analysis of the vascular market: There are 70.1 million people in the U.S. today with cardiovascular disease as identified by the American Heart Association. Roughly 18 million of those 70 million people have ischemic disease. Minimal attention has been focused thus far on the 52 million people who have vascular disease, but are not being treated until they are in the end stages of their disease. This oversight is very costly to the hospitals and groups that have to manage these patients. Understanding the Vascular Market Potential On a national basis, approximately 25% of the total symptomatic vascular population are receiving treatment for their disease. In JG&A’s opinion, this represents a tremendous opportunity for expanding a cardiovascular program. Hospitals and physician groups who recognize this market opportunity early on, and who can successfully integrate the various interventionalists (e.g., cardiologists, radiologists and vascular surgeons) and consolidate their facilities and services will have successful programs three to five years from now. Twenty years ago, John Goodman was considered a bit of a futurist when he made some predictions regarding cardiovascular service industry trends predictions that turned out to be very accurate. Now, two decades later, he believes that the cardiovascular service industry is once again entering a new era. Mr. Goodman states, The diagnostic and treatment potential relative to the vascular market is as great now as it was in the mid-1980s and early 1990s with respect to cardiovascular services. Dr. James Williams had this additional perspective to offer: Physicians must come to grips with the fact that the vascular market is five times larger than the current cardiac market, but it is served at only one-tenth or one-twelfth the rate as the cardiac market was served twenty years ago. Defining the New Vascular Interventional Center The New Vascular Interventional Center refers to integrating the services of peripheral interventionalists from various disciplines in order to effectively diagnose and treat vascular disease by using a total cardiovascular system approach. As a consulting firm that works with cardiovascular programs across the country, JG&A is finding that many hospitals, whether tertiary centers, community hospitals, or academic centers, are not organized in an integrated manner with respect to their vascular services. However, a small number of centers have taken the initial steps toward integrating their vascular services. Conrad Vernon states, We are currently working with a couple of clients who are developing what we call the ‘total interventional facility approach’, which means consolidating cardiac catheterization, endovascular therapy, noninvasive diagnostic modalities and computed tomography departments by housing all services in one location. This arrangement very efficient and very attractive to the physicians and to the entire market. Requirements for Developing an Integrated Program According to Conrad Vernon, there are several requirements to develop a more fully integrated program. First, integration requires a review of facilities and services in order to determine how they can best be consolidated. In working with centers throughout the United States, it is not unusual to find cardiac catheterization, percutaneous coronary intervention and heart surgery programs, but no peripheral vascular intervention program. When reviewing the facilities, it is very important to evaluate the services offered and determine how they are physically and logistically located within the hospital. It is also important for the physicians to work with the hospital because they can offer valuable input regarding how facilities, services and equipment should be consolidated to create maximum efficiency. Second, it is critical to define the market in terms of patients and procedures, which translate into revenue flow. Mr. Vernon states, If you are looking to grow your program both from the vascular and the coronary side, addressing the total cardiovascular system in an integrated fashion will definitely drive major revenues for the hospital and the physicians alike. Third, integration requires outreach. Since vascular disease is underdiagnosed and undertreated, developing an outreach program is key to reaching the market. What is outreach? Outreach means offering services as close to one block away from the hospital or up to 100 miles away from the hospital. Regardless of proximity, the modalities for screening and diagnosing disease and educating patients need to be made available in outreach locations and physicians need to participate. Mr. Vernon adds, The key to marketing an outreach program is to define it as part of the overall cardiovascular institute or heart institute and to develop a marketing strategy that is targeted at the entire vascular system. Thus, if a center screens for coronary disease, the protocol for total cardiovascular disease screening must be expanded to include the whole body, which means from the legs up to the torso and the head. Another requirement for integration is organization. This includes not only the physicians in the hospital, but the facilities, services, outreach and marketing programs as well. Mr. Vernon recommends that If your center features a heart institute organization or a section of cardiology, a section of radiology, or a section of surgery, you need to evaluate how to bring all of those physicians together in a formal organizational structure that addresses the entire cardiovascular system. Obstacles that Must Be Overcome Typically there are turf battles among radiology, cardiology, and vascular surgery departments relative to duties, credentials, qualifications and territory. These conflicts inhibit a program’s ability to optimally capture the market. Another challenge involves facilities and services that are configured in separate areas. Dr. James Williams speaks with the voice of experience; he offers the following case example to show that effectively integrating various peripheral interventionalists is definitely achievable. Case Example of Successful Integration Dr. James Willliams of Peoria, Illinois, originally trained as a cardiac surgeon. However, as a cardiac surgeon, approximately 80 to 90 percent of his work involves interventional procedures. He freely chose this path a number of years ago, and has been involved in interventional work for over fifteen years. This year Dr. Williams is well on the way to performing 600“700 interventions. He has been involved in many political battles, but has managed to achieve a workable level of compatibility with his colleagues from other departments. Dr. Williams has become a strong advocate of credentialing and believes that hospitals play a critical role. He states, The first thing that the hospital must do is to level the playing field. If you have a large facility, it should be available to those who want to use it. If you have very expensive imaging equipment, that equipment should be maximally utilized not just 30 or 50 percent of the time, but 100 percent of the time. Then, when the equipment is utilized at 110 percent of capacity, more equipment can be added. Dr. Williams further states that It is extremely critical for the hospital to make the decision to level the playing field and then develop credentialing guidelines that cross over specialties. These credentialing guidelines must achieve two things: protect patients and be attainable by the physicians who are well-intentioned and well-trained in their particular vascular discipline. I am referring to interventional radiologists, vascular surgeons, cardiac surgeons, cardiologists and nephrologists. Our lab, for example, is an endovascular suite that is truly integrated. It’s not integrated from a financial standpoint, it’s not integrated in terms of all physicians being employees of our center, but all physicians have an equal opportunity to work. This lab is equipped with a Philips 15-inch image intensifier. We can image from the top of the head to the tip of the toes. Physicians at our lab can perform coronary and peripheral interventions, and our lab is utilized now at near or above capacity. Two cardiac surgeons at our center have acquired endovascular skills, myself included. We also have two vascular surgeons, one fellowship-trained physician, and one who was trained by myself and other physicians. Our lab has three cardiologists and an interventional nephrologist who peforms hemodialysis access. The credentialing issue merges with the quality control issue. At our institution, an Endovascular Committee was formed; the committee is comprised of those individuals who practice in the endovascular lab. To be a member of that committee the physician must commit to train others. That is, the physician should be willing to proctor others, though it is not mandatory. Training others to help them become credentialed in the area of vena cava filters or simple angiography, for example, helps break down many of the existing barriers. Also, the integration of multiple specialties into one site allows for a very efficient, centralized inventory system, as well as cross training of personnel. Furthermore, it allows for staff reductions because practitioners now have the skills to open an abdomen or to pass a wire or a catheter. Integration allows for all of the expensive technology to be located centrally where it can be apppopriately managed. Integration also allows for control of access to the center by industry representatives, and more importantly, it facilitates the development and maintenance of relationships with industry. Physicians must learn that industry is not the enemy. Rather, industry is responsible for funding most of the research and development that provides the latest technology. A center will not have a good relationship with industry, however, if its staff members are not credentialed and if the facility does not have quality control, or its physicians are constantly squabbling. The Health Care Landscape Shifts John Goodman believes that the changes that have occurred just in the past two years are primarily due to the emergence of new technologies and devices. He states, Today, over seventy percent of vascular procedures can be performed using an endovascular approach. This approach results in less trauma to the patient, a significantly shorter hospital stay, and an overall use of fewer resources. Dr. Williams concurs: I’ve been a practicing surgeon for twenty years. As recently as five to seven years ago, the ratio was about 80 percent open heart surgery procedures to 20 percent interventional procedures; today, that ratio has clearly been reversed. Strategic Planning Is Essential JG&A’s Conrad Vernon believes that strategic planning is a must for developing a more fully integrated program that facilitates collaboration among interventionalists. Strategic planning entails the following: Evaluation of resources and capabilities; Market assessment; Definition of the center’s vision; Feasibility analysis; Comprehensive business plan. Evaluation of resources and capabilities. In order to successfully design and implement an integrated approach, a center must first evaluate its current resources in terms of facilities, equipment and staffing. Simply stated, if a center lacks the appropriate imaging equipment, it cannot achieve its goals. Also, staff capabilities must be evaluated, which includes the physician component. Are the center’s physicians trained in peripheral vascular procedures? Are the surgeons trained in endovascular therapy? What, if any, are the issues concerning turf battles? How are the center’s cardiologists addressing the market, if at all? All of these questions are important to ask when evaluating a center’s resources and capabilities. Market assessment. Conducting a current assessment of the market is an integral part of strategic planning that will help the center to accurately understand and define its true market potential. Definition of the center’s vision. After a center has evaluated its resources, capabilities and target market, it can then move on to defining a vision for capturing that market. The center should define its full potential through that vision. For example, how does the center expect to handle expanding patient and procedure volumes over the next three to five years? To answer this question, the hospital’s administration and physicians must collaboratively develop a vision based on the information that was gathered in the initial evaluations. Feasibility analysis. A center must determine exactly how its unique program will be set up in terms of facilities, equipment, organization, outreach and marketing programs, clinical credentialing and protocols. All available options should be evaluated, as there are likely to be financial constraints, manpower constraints and various logistical issues. Comprehensive business plan. Preparing a comprehensive business plan is the final component of strategic planning. A comprehensive business plan will provide program guidelines and serve as a roadmap for the center. The business will also provide direction and strategies for future program development. Look To the Future John Goodman offers this enlightening viewpoint on the future of vascular services: To those who are currently providing cardiovascular services that primarily target the heart, you should be experiencing a revenue effect that yields anywhere from a low of 25 percent to a high of 45 percent of your overall revenue coming from that one area. In the next three to five years, vascular services will equal what is seen today in the cardiac services area. Vascular services represent a new frontier, and it is critical that centers develop and implement an effective strategy to capitalize on this quickly expanding frontier. If you would like to receive additional information about any of the topics discussed, please contact Deborah O'Dwyer at dodwyer@jga-net.com or call 800-542-5435.