Terumo Business Edge is excited to have the opportunity to interview the former CEO of the American College of Cardiology (ACC), Timothy W. Attebery, DSc, MBA, FACHE, who also has a long history with the cardiovascular service line and being the CEO of a hospital. Drawing on Tim’s recent tenure with the ACC, his perspective on the cardiac service line amidst the pandemic will be especially helpful in shedding light on currently existing challenges. We talk about what will need to change if our healthcare system is to learn anything from this situation, and more importantly, what the future may hold for those institutes and providers that resist this change, believing it can and will be a version of business as usual.
— Gary Clifton, Vice President, Terumo Business Edge
From your previous experience with the American College of Cardiology (ACC) and as a former hospital CEO overseeing a service line, what were the major issues facing the cardiovascular service line prior to the COVID-19 pandemic?
Prior to the pandemic, most cardiovascular service line leaders were focusing on growth, cost reduction, and quality improvement. Growth entailed items such as capacity planning and physician recruiting, expanding ambulatory offerings, new program development, addressing the emergence of advanced tomographic imaging (both cardiac PET and CT), and integration of telehealth and virtual services. Cost reduction focused on implantable and consumable pricing, throughput and productivity improvements, decreasing length of stay, increasing same-day status, and reducing complications. Quality improvement encompassed all efforts to improve quality and safety outcomes, which enable hospitals to succeed under value-based reimbursement.
As we begin to see states trying to resume non-emergent procedures, what does cardiology, and specifically the procedural areas like the cath/electrophysiology lab, need to evaluate as essential to their future, long-term survival?
I think we may see a significant overhaul of cath lab operations as we emerge from the pandemic. Patients are more aware of the risks associated with being in the hospital and they won’t want to be in the hospital any longer than they need to be. As we all know, the vast majority of cath lab procedures are elective and most of those are in the ambulatory status. If cath lab operations are going to return to their pre-pandemic volume levels, leaders must evaluate and implement a set of measures aimed at maintaining a safe environment for the patients, physicians, and staff. Pre-procedure screening methods, including the use of telehealth or televisits, will be paramount. However, those methods must be efficient and implemented in a way to avoid adversely affecting capacity and throughput. I think the post-pandemic focus will be how to transform cath lab operations using all the evidence and tools at our disposal, and moving more procedures to same-day discharge. Let’s face it, prior to COVID-19, many cath labs were operating not much differently than they did 5 to 10 years ago. Many programs grew complacent and settled into a routine that resulted in suboptimal throughput, unnecessary time in the hospital, and a general lack of innovation.
Some would say (and we agree) that this is an opportunity for the cath lab to conduct a hard reset as it relates to managing the business of delivering procedural care. What has been your experience and how would you characterize the challenges and considerations for a reset?
The first challenge is coming to the realization that we need big change, not minor or incremental change. Physician and non-physician leaders must unite in the conclusion that “business as usual” will not work. Competition for elective procedures is going to become much more intense, particularly in those states allowing for the development of ambulatory surgical centers (ASCs) with cath lab services. Cardiovascular service line leaders may need to consider collaboration with cardiologists for an ASC (a joint venture ASC). Next, cardiovascular service line leaders need to review their cath lab operations from top to bottom, map the workflows, review all existing order sets, etc. Take out the waste and inefficiencies. It’s a “no stone unturned” approach. Then, leadership must have the discipline and sustained focus to implement the transformation. This may require changing the physician compensation model to include some form of gain-sharing incentives for the employed and independent cardiologists.
As a former cardiology service line leader and hospital CEO, where would your energy and efforts be focused to ensure the success of the cardiology service line?
I strongly suggest that all hospital CEOs and boards understand the huge threat and opportunity they are currently facing in the cardiovascular service line. For most hospitals, the cardiovascular service line is their #1 source of operating margin. As I’ve often said, “if the cardiovascular service line gets a cold, the hospital is on life support!” After a 15-year wave of integrating cardiovascular practices into the health system (with cardiologists and cardiovascular surgeons becoming hospital employees), I think we are at an important inflection point. Continuing to pay the employed cardiovascular specialists on a per work RVU (wRVU) basis is not going to bring about the type of change needed. As a matter of fact, I would argue that it serves as both an impediment to change and a moral injury to the employed physicians. Physicians generate much more value for the health care system than simply producing a wRVU. I think it is time for hospital leaders and physician leaders to consider the tremendous opportunity for a transformation in the services offered, how we provide those services, how we generate value for patients and payers, and how the physicians should be incentivized around that new model.
Will this pandemic impact hospital volumes and procedures with respect to what some would consider the ideal opportunity for ASCs to step in and not only fill the gap, but perhaps become the prevailing site of care for elective procedures?
Absolutely, the expansion of cath lab services outside the “on hospital campus” setting is going to pick up speed in the post-pandemic world. The reality is that most cath lab procedures, both cardiac and non-cardiac, can be performed safely in the non-hospital setting. Hospitals with mostly employed cardiologists need to evaluate the opportunity for joint venturing an ASC. Independent cardiologists located in non-certificate of need (CON) states, and those in CON states with no requirement for a CON for a cath lab, should pursue discussions with potential partners (hospital or others) for developing an ASC option. Payers and patients are looking for more value, and the ASC setting can offer more convenience and lower costs without compromising quality or safety.
Over the last decade, we have seen significant migration of cardiology practices into hospital employment. Having led a group through and after integration, what is your perspective on how this has worked out for both physicians and hospitals? How does the pandemic and recovery impact this relationship moving forward?
In general, I think the integration migration has been positive for both the hospital and cardiologists. It has provided a high level of stability and certainty. However, from this point forward, just being an employee of the hospital is not a long-term strategy for success. Who pays your compensation as a cardiovascular specialist doesn’t address the bigger, macro-environmental issues we now face. Surviving and thriving in the post-pandemic world will require a new way of thinking about hospital-physician integration. As I previously stated, compensating employed cardiologists on a per wRVU basis is simply flawed. It doesn’t fully align the incentives around the outcomes that are most important. For example, if I were a hospital CEO and I wanted to implement an overhaul of cath lab operations, continuing to pay the integrated cardiologists on a pure production model (paying on a per wRVU basis) becomes a potential obstacle to my performance improvement and cost-reduction efforts. I suggest all cardiovascular service line leaders and hospital CEOs work with their integrated and independent cardiologists, and explore ways to align financial incentives around the new imperatives.
Will this pandemic, and the huge economic burden being placed on hospitals help them to rethink and engage in risk-sharing opportunities? Similarly, does it force hospitals to rethink how they will compensate providers?
If we were thinking it may take a virtual earthquake to shake us out of the rut we’re in, it just happened. COVID-19 has served as a big wake-up call. Returning to business as usual in the post-pandemic era will not work. We need innovation, re-alignment, new ways of creating value, new ways of delivering our services, new risk-sharing arrangements, etc. With all of that new thinking, we need to change the compensation and financial incentives for both integrated and independent cardiovascular physicians. Finally, hospitals with limited financial resources have several options for partnering with new players in the marketplace who can make significant capital investments. This form of risk sharing enables the hospital to optimize the use of its capital.
One would anticipate this will further exacerbate the need to migrate to value-based care. How do you see this happening and who are the various stakeholders who will need to do the heavy lifting?
The appetite for value-based care will intensify. This may become a “survival of the fittest” world for a while. Some large cardiovascular service lines operating in a bureaucratic, lethargic, and reluctant-to-change environment will lose market share to others who are more nimble, innovative, and willing to change. Patients, purchasers, and payers will reward those who can figure out a way to offer better outcomes at a lower cost. Risk will continue to shift from payers to providers. Those providers who can accept and manage risk will survive. Those who cannot, or will not, will lose market share, revenue, and operating margin from their cardiovascular service line.
As for the heavy lifting, I strongly urge my cardiologist friends and colleagues to step up and drive the change. Nothing substitutes for a high level of physician leadership and engagement. Without that ingredient, the recipe simply will not work.
Timothy W. Attebery, DSc, MBA, FACHE is on Twitter @TimAttebery