Author + information
- Received January 31, 2011
- Accepted February 10, 2011
- Published online May 24, 2011.
- ↵⁎Reprint requests and correspondence:
Dr. Richard A. Chazal, 9800 South Healthpark Drive, Suite 320, Fort Myers, Florida 33908
The push toward cardiology integration into healthcare systems has its genesis in multiple recent developments. The implications for cardiovascular care cannot be overstated. Declining reimbursement for physician and office services, combined with increasing costs, presents for many an unsustainable situation (1). Beyond the immediacy for the individual practice, looming changes in healthcare delivery and reimbursement require re-examination and evolution of our models of delivery (2).
Throughout this process, the quality of care to our patients must continue to be the guiding principle for physicians and all healthcare providers. As pointed out by Dr. Stratienko in his editorial (3), administrators of healthcare systems in their fiduciary role see the system as a whole; physicians see individual patients, their illnesses, and their needs. As physicians, we must protect the former while respecting the latter.
As accountable healthcare organizations become more clearly defined and developed, one would hope that they will embrace a variety of providers, both independent and employed, as we all seek the best models available—and the best care (4). “One size fits all” has never suited cardiologists (witness our diversification in subspecialization).
Employed integration with healthcare systems should not—must not—mean abrogation of responsibility for the quality care of patients and the community. If applied properly, integration allows alignment of incentives and resources to improve care. Such occurs today in many of our premier academic and nonacademic centers (5,6).
The key to success in integrated systems (employed or nonemployed) is the active involvement of physicians in both care and systems management. Acceptance of employment as “the solution” will surely result in degradation of patient care, and of the caregivers. Appreciation of the challenge and opportunity available for improved care to patients—and the willingness to actively participate and lead that care—is essential. There is no better balance of authority than when hospital administrators and physician executives work together to solve conflicts in patient care.
Examples in our field abound. The care of chest pain and congestive heart failure stand out, largely because of the national (now international) toll in morbidity, mortality, and cost.
In many hospital systems, chest pain is managed by a combination of triage nurses, emergency room physicians, hospitalists, primary care physicians, and cardiologists. Although the ultimate goal of prompt, efficient, correct diagnosis and treatment is foremost in the physician's mind, individual incentives are not always fully aligned—and proper reimbursement for such care is not in place. The current system rewards delays in care and extra testing; the patient is not well served. Physician leadership in crafting and managing proper processes for best care can result in reduction in risk and cost. Integrated strategies offer the opportunity to create reimbursement models that incentivize this type of care, rather than penalize it.
Congestive heart failure looms as a growing threat to our patients' health, and to the financial health of hospitals. Even minor changes in care could substantially lessen this burden (7). Yet, our systems fragment this care into uncoordinated silos: emergency room, primary care, hospitalists, cardiologists, home health nurses, skilled nursing facilities, and hospice care. Cardiologists are paid for care of the patient, but not for coordination and organization of the care. Properly applied integration strategies offer the opportunity to improve care to the patient, save the system money, and get paid to do the right thing through proper alignment of mission/purpose and incentives. This is the type of “win-win” situation that has been often missing in the cardiology/hospital relationships of the past.
Positive change will not automatically result from “vertical integration.” Excellence in the care of patients in private (and academic) practice has never occurred in the absence of education, dedication, and participation. Passive acceptance of the hospital/system as employer/boss does not serve the best interests of patients or the community. Aggressive participation in hospital systems, service lines (e.g., invasive and noninvasive laboratories, chest pain/acute myocardial infarction, congestive heart failure units, and so on), and even management is essential. Caring physicians will demand such participation. Enlightened administrators welcome it; their less enthusiastic brethren will follow if we provide deliverables—it is in their best interest.
It is important to appreciate that traditional training in cardiovascular disease does not include management, finance, and quality improvement programs. New skill sets must be developed. Fellowship directors will need to add such training. The American College of Cardiology, through the Cardiovascular Leadership Institute, has embarked on a program of education designed to bridge the knowledge gaps for practicing and academic physicians (8).
The ultimate yardstick for the success, or failure, of our evolving systems remains the quality of the care to our patients. Maintenance of guiding principles must be paramount no matter the type of system in which we practice. As the leaders of the healthcare team, physicians have the opportunity and the obligation to lead (9).
Dr. Chazal has retirement investments with Johnson & Johnson, Novartis, McKesson, and Covidien. Dr. Valentine owns Medtronic stock (>$10,000 equity).
- Received January 31, 2011.
- Accepted February 10, 2011.
- American College of Cardiology Foundation
- Bove A.A.
- ↵Health Care Law: Patient Protection and Affordable Care Act. H.R. 3590. Accessed January 19, 2011, http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/html/PLAW-111publ148.htm. March 23, 2010.
- Stratienko A.A.
- Brindis R.G.
- Shortell S.M.
- United States Government Accountability Office
- Lee W.C.,
- Chavez Y.E.,
- Baker T.,
- Luce B.R.
- Douglas P.S.,
- Valentine C.M.
- Brindis R.G.