| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Ann Thorac Surg 2001;72:1105-1112
© 2001 The Society of Thoracic Surgeons
a Los Angeles, California, USA
Address reprint requests to Dr Matloff, 511 South Lucerne Blvd, Los Angeles, CA 90020
e-mail: jackmatloff{at}worldnet.att.net
Presented at the Thirty-seventh Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Jan 29–31, 2001.
 |
Introduction |
|---|
|
Today’s perspective |
|---|
|
On the occasion of the Joint Conference on Graduate Education in Thoracic Surgery at Oak Brook, Illinois, in 1993, I was asked to project what the practice of medicine would be like in the year 2010 as a background to deciding how and whom we should train for cardiothoracic surgery in the future [1]. Some of the issues that I thought, at the time, would be important for the future are listed in Figure 1. In reviewing these issues and in thinking about our interactions this year, it turns out that these are still the important forces affecting cardiothoracic surgeons and their patients. Contending with them is why the STS has spent this year strategically planning for the future. If there is one "take-away" message from this experience, it is that more than ever we need to support each other to achieve the Society’s mission to "HELP CARDIOTHORACIC SURGEONS SERVE PATIENTS BETTER."
|
|
Dynamics of physician reimbursement |
|---|
With regard to the calculation of PEs, in 1992 it was anticipated [2, 3] that we would have problems because of the Health Care Financing Administration’s (HCFA, now referred to as the Centers of Medicare Medicaid Services [CMS]) basic premise "that specialists, such as cardiothoracic surgeons, do virtually all of their work in hospitals, and Medicare already reimburses hospitals for overhead." The CMS has therefore resisted what they believe is double billing for overhead, including nonphysician personnel working in the hospital. Currently, the STS is attempting to ascertain with the American Hospital Association whether hospitals are in fact being reimbursed for the costs of such personnel, as we have been told by CMS is the case. What has also been a problem has been how the PE initiative has been implemented because of continuously changing and uncertain methodologies.
Nevertheless, we can claim some "successes" among our policy efforts in Washington. In 1994 and 1995, we were able to obtain a correction in the calculation error CMS had made concerning the use of arterial conduits. These corrections increased coronary artery bypass (CAB) reimbursement by approximately $60 million per year thereafter, before other legislated decreases took effect. More recently, PE advocacy efforts have countered CMS’s 1998 proposed decrease of 38%, and the actual annual PE reductions have been significantly mitigated at implementation. Total savings to cardiothoracic surgeons over 5 years could amount to $772 million dollars. This victory is important because other payors often follow Medicare policies.
We continue to vigorously pursue these issues through a variety of policy and legislative strategies that focus on our relationships with key Congressional members, including Dr Bill Frist, the consummate citizen legislator, who presented the first Thomas B. Ferguson Lecture at the 2001 STS annual meeting [4]. A key to the success of Washington-based advocacy is always how one uses consultants, in the STS’s case Capitol Health Group, and the specialty’s Political Action Committee.
We are just beginning to learn. John McDonough [5] at the Kennedy School was correct when he said, "Politics is the art of who gets what, when, and from whom."
Finally, if there has ever been a question as to how legislative enactments translate to reimbursement, the relationship is expressed perfectly in Figure 2. Reimbursement for quadruple coronary bypass using venous conduits is tracked from pre-OBRA 1989 through 2002, a 15-year experience. In constant dollars, reimbursement will have decreased by 50% in 2002. In consumer price index-adjusted dollars there will be a 77.5% decrease. Stated otherwise, reimbursement for quadruple venous coronary bypass in 2002 will purchase 22.5% of the goods it would have purchased in 1987.
|
|
Collective bargaining |
|---|
Before proceeding in this direction, I recommend reading the Society’s white paper on collective bargaining published in the STS News [6] and posted on the STS Web site (http://www.sts.org). Along with the white paper, review the critique on the Web site (http://www.ctsnet.org/doc/4745) provided by our labor consultant, Adair Dammann, who is a longtime union organizer [7]. The experience for medical professionals who have pursued unionization has been an unhappy one. What may be more appropriate is to express the existing high levels of energy, frustration, and even anger that characterize specialty practice today by developing pragmatic strategies other than collective bargaining to address our problems. This is why a Committee on Practice Management Issues was introduced at the 2001 STS annual meeting.
There is danger in the potential for our common experiences and our responses to them to result in common actions that may be perceived by others as attempts to circumvent antitrust dictates. In this regard, physicians who exit the Medicare program because of reimbursement issues may be vulnerable because any perception that cardiothoracic surgeons might do so collectively would be especially open to misinterpretation. For this reason, a position paper on Medicare participation will be published by the STS News shortly.
|
Hospitals as our primary workplaces |
|---|
What is of further concern is the fact that relations between hospitals and their cardiology and cardiothoracic surgical staff and between the professional staff themselves have been problematic. There are increasing instances of cardiologists allegedly taking over cardiac surgical practices for financial reasons, leaving patients with more limited physician choices or access to qualified and independent consultation.
To counter these trends, a STS position statement concerning such practices [8] has been endorsed by the American College of Surgeons and by the American College of Cardiology Ethics Committee. Thus, ethical concerns continue to be a problem. In response to such practice and organizational changes, cardiothoracic and vascular surgeons are beginning to develop their own catheter-based skills with which to compete. They are also increasingly developing less invasive cardiac surgical solutions to counter the promotional value being generated by invasive cardiologists offering minimally invasive services.
From the hospital’s perspective, they will be increasingly vulnerable if they are unable to develop more appropriate hospital–physician relations and physicians begin developing their own, specialty oriented, stand-alone or "carve-out" hospitals. Although this model has state regulatory statutes to contend with, it has experienced success in the United States and abroad. Some of the most successful such hospitals have been managed by physicians.
As globalization of the cardiovascular enterprise proceeds, these carve-outs will be well positioned to compete on a cost basis for patients and for clinical research opportunities. With globalization, a reversal could occur in past trends of foreign patients coming to the United States for their specialty care.
Among these changes in organizational relationships, I have not included managed care and health maintenance organizations because of the belief that their future is questionable. This uncertainty is due in large part to the weakness exposed when physicians’ financial interests are placed at risk and the traditional role of the physician as patient advocate is moved to a secondary or even tertiary position of importance. Finally, the Internet, because of its openness and the availability of information, could further hasten the demise of managed care.
|
Technology development and diffusion |
|---|
The use of technology has been, and will continue to be, a cause of and a possible solution to our cost conundrum, and to the problems created by our exponentially increasing information bases in medicine. These scientific advances hold the promise of improving outcomes, both clinical and financial, and of taking us beyond palliation, to true cures and eventually to prevention. Finally, much of technology development and evaluation occurs in hospital interactions; this is why these relationships are a key to our future.
Less invasive surgical techniques alone, as we know them now, will probably not be the answer to our long-term needs. Presently, they do make surgeons more competitive with the interventional cardiologists. The eventual effects this technology will have will be a function of our ability to demonstrate improved outcomes.
Newer molecular biologic or genetic engineering developments are techniques that are most likely to facilitate the quantum leap to avoiding atherosclerotic disease. Other basic science developments in immunology could significantly enhance our transplant capabilities. These changes would have widespread implications for cardiothoracic surgical practice in the mid- to longer-term future.
A more likely mid- to later-term, "disruptive" technologic change [9, 10] could result from imaging developments, such as with magnetic resonance imaging, being used to accomplish essentially noninvasive, diagnostic quality coronary angiography. The "disruption" would occur not from a therapeutic application of magnetic resonance imaging, but rather by virtue of its capability to separate diagnostic from therapeutic procedures. The diagnostic procedures could be carried out by radiologists, as well as other cardiovascular specialists and even technicians, with the "reading" being the critical service. The melding of the diagnostic and therapeutic services around the use of catheters is what has been the driver in treating coronary disease that has relegated us to the status of safety net providers. A change in this sequence could return cardiothoracic surgeons to their more traditional active consulting roles, with an enhanced opportunity to provide the revascularization procedure that is required in 70% to 75% of the ischemic patient populations seen currently.
If current catheter-based experience in treating acute myocardial infarction (AMI) with angioplasty or stent placement continues to evolve and is widely reproducible, invasive cardiology could further evolve, becoming totally devoted to treating AMI. Further, if the research use of stents carrying radiation doses or immune suppressing pharmacologic agents (rampadine) continues to be effective, or if human (bone marrow) stem cell use is shown to be clinically effective in achieving migration of healthy transplanted cells to damaged myocardial areas, where active proliferation and regeneration of myocytes and microvessels occur, then our longer-term role in treating cardiothoracic diseases would also be significantly curtailed. In this scenario, we would have to be prepared to transition to other practice patterns, as addressed in the STS Strategic Plan.
With the pressures created from such changes, cardiovascular surgical and cardiology invasive practices might even merge to a single specialty. It can be argued that surgery will continue to provide the more encompassing safety net. The predominant responsibility would then be surgical.
Beyond these changes, the ultimate promise of basic science developments in molecular biology and genetic engineering is to be able to screen populations for precursors of cardiovascular and thoracic diseases. By earlier therapeutic interventions in those at risk, prevention could be a reality. Before we arrive at such a capability, there will be at least one, if not two generations that will have to grapple with the medical development and with the legal, social, and ethical concomitants of such a world.
Notwithstanding the excitement generated by and the potential magnitude of change created in these scenarios, the most significant technologic changes over the next 10 years are likely to proceed from expanded applications of information technology to achieve information management of cardiovascular care. Our health care system is currently characterized, in part, by continuing increases in costs; by variability in practice patterns and in outcomes, whether expressed clinically or financially; by waste of as much as half of the premium dollars spent to purchase health insurance, in the sense that these dollars deliver no actual care to anyone; by inability to regularly comanage quality and cost; by the fact that 44 million Americans have no insurance-based access to care; and by a paucity of attention being given to the processes by which diagnostic and therapeutic activities occur, which has important implications for the occurrence of adverse, even fatal outcomes. This latter issue is being brought to focus by the Institute of Medicine’s report, To Err is Human [11], and by the activities of a large employer consortium of health care purchasers, known as the Leapfrog Group (Leapfrog Group, 1801 H Street NW, Suite 701-L, Washington, DC 20006). Leapfrog’s approach is to use outcomes to direct referrals of their combined 20 million employees based on the quality of outcomes, measured initially by the proxy of volume.
Cardiac surgeons are keenly aware of the need to address these problems with information technology solutions. The oversight that we have been subject to since performance of the first coronary bypasses 30 years ago has given us a rich tradition in the use of data that extends far beyond the issue of reimbursement. Notwithstanding the power of more than 1.5 million patients in the STS National Database, we have not appreciated the full potential of uses of these data beyond describing static outcomes at variable time periods.
In 30 years of practice, we used a database [12] to explore a wide variety of health policy-related questions: why outcomes differed after CAB, according to gender, finding that practice decisions in treating women were biased [13]; whether and how the occurrence of an AMI prior to surgical procedures had differential effects on outcomes of CAB by age, finding that those older than 65 years have increased risk of mortality [14]; and whether octogenarians and nonogenarians could be successfully operated, finding that age is a weighted determinant of operative outcome but not of longer-term survival [15, 16]. We also constructed theoretic models to be used to more appropriately reimburse physician services [17], based on the outcome benefits appreciated by patients rather than on the basis of simply providing a service.
Not surprisingly, cardiothoracic surgeons are beginning to fulfill multiple roles or positions. So, during the past 3 years, I have been working full time with a small group of consultant computer scientists, business people, and clinical cardiovascular specialists to try to define our common perspectives and the boundaries for using information technology as a segue to information management of cardiovascular diseases, including the 16 diagnostic and therapeutic domains of cardiology, cardiac surgery, and peripheral vascular surgery. Our goal has been to address the processes that characterize decision making in an attempt to reduce the variability of practices and outcomes that exist in health care today.
To date, our experience has taken us through the writing of appropriate functional specifications for the indicated software codes and the development of a limited functional prototype built to see whether chronic coronary syndromes and hypertension could be comanaged. This work indicates that it is possible to provide decision support to physicians with the hope of achieving more uniform outcomes.
The intent is to give physicians generic tools to better use demographic, clinical, and financial data to achieve more fully informed and, hopefully, more consistent or less variable decisions in real time, at the point of care. Figure 3 is a functional overview of how the system works. There are three components needed to maximize the decision-support functionality: a database that includes clinical, demographic, and financial data elements; guidelines from the evidence-based literature configured as banks of rules; and risk models.
|
At each point, relevant risk models from the literature are queried to assess whether the patient is at high risk for certain prespecified occurrences or comorbidities. The risk models allow objective assessment of risk, in terms of either a probability estimate or a numeric score. Risk models currently are based on logistic regression equations or complex formulas and are not readily used at the bedside. By making these risk models more user friendly, within the physician’s span of work, this system allows for objective assessment of risk at each patient–physician encounter. This is important because assessment of risk drives the ordering of diagnostic tests and of treatments that ultimately determine the clinical outcomes and costs.
The management of the patient’s comprehensive data with a rules-based engine allows the physician to fine tune decision making on an individual basis. The decision support is clinically and financially patient specific. It is context sensitive because it is modeled to the evidence-based literature, and it is rule specific.
At the same time that this information delivery functionality is being implemented, a parallel tracking functionality is deployed with the capability to track, report, and benchmark. These functions are used to develop the individual physician’s prior experience with similar patients contained in the database so that he or she can place personal past experience in context with the evidence-based, profile-specific recommendation that has been generated for his or her current patients. At each point, it is the physician who is in total control of the data and the decision making. He or she alone is able to assess, by benchmarking, his or her own performance in a nonpunitive way that enables continuous quality improvement.
Concern could be expressed that a computer-science based solution to our health care delivery problems will be difficult because it will require behavioral changes that are both cultural and intergenerational in character. For this system to work, the changes will require significant educational efforts, including important organizational and leadership accommodations.
|
Leadership, education, and the Kennedy School of Government |
|---|
Eight years later, appropriate leadership is emerging, albeit not yet from government. Historically, the sentinel event of this evolving experience will almost certainly be the failure of the Clintons’ Health Care Initiative in 1993. At that time, all of the appropriate governmental commitments were in place and aligned with a popular President’s agenda. However, the world of medical practice was, curiously, not systematically included in the magical committee of "509" who were given the challenge. In a way, it was fortuitous that medicine was not included in a meaningful way because our national leadership was suspect as well. The fact that the American Medical Association and other national organizations were not significantly included presented an opportunity to specialty medicine and surgery to step up to the challenge.
At about that time, the Thoracic Surgery Foundation for Research and Education was defining its strategy for funding basic science research and postgraduate education in health care policy. When the concept and need for an Executive Course in Health Care Policy for midcareer professionals was presented to Mr David Sheridan [18], Dr Ralph Alley’s longtime friend and collaborator, he immediately seized the opportunity and, through the Foundation, handsomely funded the opportunity for cardiothoracic surgeons to acquire the needed education in health care policy.
Those who have attended the executive courses at Harvard’s Kennedy School of Government know that they are developed around an understanding of the dynamics, largely economic, only slightly less so political and social, that were and still are fueling the changes that are occurring in health care today. Economics as a social science is different from the physical, chemical, and biologic sciences, but it has a scientific methodology nonetheless. Learning the language and thought process of this scientific methodology has become extremely important to understanding what is happening with our health care system. Earlier I reviewed the legislation that has determined our reimbursement over the last 12 years and spoke about managed care. It is economic theory by which health care spending is budgeted. In doing so, economic theory goes beyond its more traditional roles of describing and predicting behavior, to controlling behavior by incentives and disincentives. Inherent in this model is the concept of economic risk, which has been a difficult cultural change for physicians who have always been risk averse in how they regard their patient care obligations.
At Harvard, physicians have learned that medicine is a business, in fact a big business, but the rules of the free market do not pertain because the market within which medicine exists is complex and subtly regulated. Thus, it has become apparent that having a MD degree and 7 to 8 years of postgraduate education are no longer enough for us to practice most effectively and efficiently. Masters of Sciences in Economics, Business, Public Administration, and Public Health are becoming the order of the day! What needs to be worked out is how physicians can compete economically and still be able to maintain and even improve on traditional standards of care as measured by individual clinical and financial outcomes.
The time has come when physicians have to decide whether we will continue to be a part of the "problem" or whether we will be a part of the "solution." The lynchpin in this cultural change has to do, importantly, with the role of leadership as an inherent variable in the dynamic evolution of change, because the single most important expression of leadership is in managing change.
Cardiothoracic surgeons have indeed been fortunate to have Dr Miles Shore as our mentor in learning about change and leadership. He has also been our coconspirator in maintaining the internal integrity of the succession of the four executive courses that have proceeded from coping with the new world of health care, to understanding it, building it, and developing skills for it. He shared this experience with you in his Alley–Sheridan Lecture 2 years ago at the 1999 STS annual meeting [19].
The data indicate why cardiothoracic surgeons are as well situated as we are in terms of leadership among the specialties. The course has been presented nine times since May 1996 and more than 500 physicians, nurses, health care administrators, hospital board members, and industrial corporate officers have attended. More than 200 cardiothoracic surgeons have attended, among whom 7 have returned for a full year as Alley–Sheridan Sabbatical Scholars. This year there will be 2 more extremely well-qualified sabbatical scholars. In sum, $535,000 has been allocated by The Foundation to partially subsidize these activities.
Your contributions have been spent well when put in the context of the interactions and relationships that have been developed. These interactions have been our most successful bridge building efforts with the rest of medicine. Within the Society the esprit that exists now, especially among our younger members, is the marrow of our future.
The past attendees have included 7 STS and 3 American Association for Thoracic Surgery presidents, 12 other former or current STS officers, 4 former or current STS councilors, 15 former or current STS committee chairs, 35 former or current committee members, and 4 principal STS staff members.
If we define politics more broadly as public action taken to address public problems, then the effect of The Kennedy School experience is even broader. Two of the sabbatical scholars have become intimately involved in developing community programs to provide health care to all and shelter to those without sanctuary. Another has become a Robert Wood Johnson Fellow and is a Senior Legislative staffer in Senator Edward Kennedy’s office, assigned to the Health, Education Labor and Pension Committee.
The Society is profoundly committed to moving beyond existing modes of advocacy, thereby demonstrating our willingness to think and act outside of existing boundaries and constraints. Included are paradigms of change to address more personal responsibility for our health and considerations of populations of patients as well as of individual patients.
|
The Society of Thoracic Surgeons’ strategic plan |
|---|
Perhaps more fundamentally important than the symptom of a deficit has been the fact that the number of traditional US medical school graduate applicants to our stable number of active residency positions is down by 30%. Despite an increase in foreign medical graduate applicants, a small number of positions still are unfilled. Among the foreign medical graduates, conditions in their home countries appear to be improving so that the operational margins within which they begin practice may be better at home than in the United States. Given all that we have already talked about, these experiences create serious concern for the specialty’s future.
Therefore, the STS engaged Arista, a consulting firm, to help us address our problems. Key assumptions were that we would have a 3- to 7-year window of opportunity during which incremental change will continue, but transformational change would probably not occur. It was recognized that American physicians would increasingly be competing in a global market and that both the potential demand for surgery and the ability to recruit talented physician-surgeons would decrease.
The associated implications were that we would have to change significantly in regard to what and how we do things, including forming partnerships with others, inside and outside of medicine and the specialty. At every milestone we were and have continued to be aware of the possibility that the specialty will have to be "right-sized." Within the context of a hierarchy of value, we proceeded to explore strategic options to keep our priorities and resources in focus. Two rules evolved: (1) to make our organizational priorities at least budget neutral, if not profit generating, and (2) to focus our resources by priority criteria so they would have maximal impact.
We believe that multiple waves of change will be necessary for the STS to be repositioned (Fig 4). In changing for survival, we recognize the need to sharpen our operational focus. To change for renewal, we need to broaden our professional focus and embrace a dynamic of change to overcome complacency. To change for preemption, we recognize the need to find the next source of competitive advantage in medicine. Entrepreneurial innovation in business design is the key to executing this strategy.
|
|
In speculating on what the future of a world with better physicians and cardiothoracic surgeons with broader leadership roles and responsibilities will be like, I would say that continuous education in new technology and management tools will become as necessary as our traditional journal reading. It is virtually impossible to conceive of the future as a time when our graduate and postgraduate education and training will be adequate for more than 10 years of practice. Nor will we probably have a single lifetime job, as most of our parents did. To survive we are going to have to be successful in living with and leading change and managing new demands on us by patients, society, and our colleagues.
Within the 3- to 7-year time frame for which we are planning, the Society will be an umbrella for innovative, multiple, diverse interests and participants. Team building will be the road to the end of the journey, although we will not be able to see the end from the beginning. Our lives will be full and diverse over time, but the key to success and happiness at all milestones along the journey will be the ability for individual cardiothoracic surgeons to make a difference to society, as well as to individual patients, by living a life of service, in whatever way is necessary, to all who are in need of our knowledge and skills. In the future, cardiothoracic surgeons will have their best opportunities to fulfill themselves, personally and professionally, by becoming more involved and by helping each other to HELP CARDIOTHORACIC SURGEONS SERVE PATIENTS BETTER.
|
References |
|---|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
Top
Introduction
Today’s perspective
