Let us never negotiate out of fear. But let us never fear to negotiate.
Turf battles over medical procedures among subspecialty groups are rarely resolved in a collaborative manner. Generally, one subspecialty will wield its entire arsenal to capture as much of a particular procedure as possible, regardless of whether this is in the best interest of the institution or in the best interest of patients.
Radiology, cardiology, and surgery specialties have taken up arms to treat patients with minimally invasive catheter-based surgery, spawning one of the most widespread turf battles in medical history, according to William Burke, administrative director of South Shore Hospital's cardiovascular center in South Weymouth, MA, and Frank Panzarella, a manager at Boston-based Radiology Consulting Group,
"What we're hearing on the physician side is that everybody is gearing up with the right ammunition to basically send a nuclear attack at the other side," Panzarella said in a presentation at the recent American Healthcare Radiology Administrators (AHRA) conference in Las Vegas, NV. "You go to these different (subspecialty) conferences and it's the same dialogue happening, where they're trying to lay out the reasons for each side to be the only one to do these particular procedures. The reality is that each of these sides has something to bring to the table."
The reason that passions run among radiologists, cardiologists, and vascular surgeons as to which group controls interventional procedures is simple: money. According to Burke and Panzarella, there are currently 70 million people in the U.S. with cardiovascular disease. In addition, cardiovascular disease becomes more prevalent as people grow older, and by 2020 nearly 50% of the U.S. population will be over 50 years old.
Minimally invasive imaging-guided procedures are preferred by payors, hospitals, and patients, Panzarella said. They have a lower unit-cost per procedure and per hospital stay. They also have a higher level of quality and safety and are highly effective, he said. As a result, Panzarella forecasts a 19% growth in cardiovascular therapy volumes over the next four years.
In a nutshell, the U.S. population is getting older and fatter, so the need for minimally invasive catheter-based imaging-guided surgery will continue to grow.
Payment for these imaging-guided procedures has also shown an uptick, in contrast with the proposed deep cuts faced by diagnostic imaging over the next few years. Medicare reimbursement for inpatient cardiovascular and vascular procedures has shown an average 3% increase for the current year, while outpatient procedure reimbursement soared by 10% for non-coronary angioplasty or arthrectomy and 8% for transcatheter placement of intravascular shunts.
Building a service
A radiology group seeking to create a robust interventional practice must first generate a strategic plan, according to Burke. It will need to define the group's value and position, evaluate every clinical and nonclinical aspect of its operations, perform a gap analysis and needs assessment, and write a business plan for interventional services.
The key factors for successful implementation are physician leadership, agreement, and buy-in to the interventional service strategy by the radiologists, and the support of senior administration within the practice or institution. The next step is to build a physical clinic with a dedicated staff for the interventional service, billing, evaluation and management, and admitting.
"Our interventional radiologists will see patients, admit them, and sometimes refer cases to other interventional specialties, such as cardiology," Burke said.
Communication with primary care physicians and other specialty groups is critical to building success, as is marketing the interventional services.
"On day 1, should you roll out a clinic, the biggest advantage that you have over every other practice is that you have phenomenal appointment availability," Burke noted. "In the Boston area, a procedure appointment with a vascular surgeon can sometimes be as much as four months out."
Another key differentiator is that because a radiology-based interventional practice has access to a full complement of diagnostic imaging equipment, it can offer procedure-related imaging services and interpretations in a more timely and efficient manner than other groups, Burke observed.
He advised creating promotional material for referring physicians that contains elements of patient education. In addition, he suggested brown-bag lunchtime presentations to referrers; symposia and public education initiatives; offering screening and performing community outreach; and conducting internal marketing that staff can perform.
Burke believes that an interventional practice should strive to make it easy for referrers and patients to access its services and that these services should provide a unique experience for both these groups. That is, one in which the practice actively seeks out ways to help the referring physician and his or her patients, such as through educational materials for prevention and treatment options.
Negotiating collaboration
One axiom holds that it is always better to negotiate from a position of strength. By building a robust interventional service, radiology groups are better equipped to negotiate for an equitable portion of revenue when a collaborative hand is extended to or from competing services, according to Panzarella.
This may take the form of a multidisciplinary cardiovascular center comprised of radiology, cardiology, and vascular surgery, where each specialty group contributes revenue and volume and grows the entire service-line structure, Burke said.
He believes that a radiology group can choose to compete with such an entity, which he holds as an inevitable market evolution, or it can become the driving force in its creation. Burke observed that duplication -- or even triplication -- of services, staff, supplies, and equipment for similar procedures cannot be sustained for an indefinite amount of time, particularly within an institution.
"There's a portion of revenue that's at risk," in participating in a multidisciplinary cardiovascular center he said. "The idea is that once you collaborate there are going to be more patients, and your worst problem is that you're going to need six more procedure rooms."
By Jonathan S. Batchelor
September 12, 2006
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