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Ann Thorac Surg 2003;76:2156-2166
© 2003 The Society of Thoracic Surgeons
* Address reprint requests to Dr Bonchek, 555 N Duke St, Lancaster, PA 17603, USA.
e-mail: lbonchek{at}prodigy.net
The specialty of adult cardiac surgery faces unprecedented pressures from third-party payers, purchasing consortia, and government agencies, not only to intensify our quality improvement efforts and to conduct public audits, but also to conform to arbitrary standards for surgery volumes and outcomes. Payments have been declining steadily and steeply, and the volume of adult cardiac surgery in many institutions is threatened by advances in interventional cardiology. Hospital support for cardiac surgery programs has therefore become much less generous. It is no surprise that our specialty has lost some of its desirability as a career choice, and some residency positions have not filled in the initial match.
To begin addressing the impact of the forces that will shape our specialty over the next decade, the STS conducted a polydisciplinary, interactive conference at Heart House in Bethesda, MD from November 1 to 3, 2002. In addition to considering projected changes in clinical care, we focused on the effects of nonclinical forces, such as: the actions of those who pay for cardiac surgical services; those who influence its supply (eg, medical schools, training programs, hospitals, nursing schools); those who supply its tools and technology (equipment manufacturers, venture capitalists); and those in policy-making positions or consulting practices who are focused on health care.
To assure an interactive process, in which all attendees participated in discussions, attendance was kept under 50 participants (Appendix) by inviting only the speakers, the officers of the STS and AATS, and representatives of the industry sponsors. In selecting speakers, we were constantly mindful of the opportunity to expose nonsurgeons to viewpoints they may not have previously heard or considered, and we hoped their thinking, as well as ours, would be influenced by a forthright exchange of ideas. These hopes were justified. For example, the interaction with Kenneth Kizer, MD, President and CEO of the National Quality Forum (www.qualityforum.org), has led to an invitation to the STS to develop quality standards for cardiothoracic surgery based on the STS National Database. This constitutes real progress toward our goal of making the STS National Database the national standard for outcomes analysis, eventually replacing the arbitrary criteria and unverified risk adjustment methods used in many existing government and private models.
The conference program was organized into six topics: Quality, Delivery, Technology, Volume, Workforce, and Finance. The speakers were assigned the topics and titles for their brief, formal presentations, and were given a list of issues to address. A lengthy discussion period concluded each session. Though the conference's major task was to define challenges, not to answer every question, the conference's concluding session produced a list of "Actionable Issues," a consensus of the participants about actions we should take to respond to changes over which we have some control, or should try to take control. Many are already being addressed, under the leadership of STS President Robert A. Guyton, MD.
The summaries of the six sessions, prepared by members of the organizing committee and the STS staff, must be read thoroughly to fully appreciate the speakers' insights, but from the overlapping topics, several major themes emerged.
Quality and accountability
As a profession, we should take control of quality assurance for cardiothoracic surgery by increasing utilization of the STS National Database; by working with quality assurance organizations such as the National Quality Forum and the Leapfrog Group to define performance standards; and by actively participating in public reporting of risk-adjusted outcomes.
Collaboration
We must enhance communication and collaboration between hospitals and physicians to create cardiac-focused delivery mechanisms, for example: heart hospitals within hospitals; between the STS and industry to advance technology and to reeducate our workforce; and between payers and providers to attain mutual goals of quality focused care, cost containment, access to data, and adequate reimbursement. Adversarial relationships are counterproductive; we share many goals with those who have traditionally been "across the aisle."
Reimbursement
The mechanism of payment for our services needs restructuring if our profession is to remain attractive. Changes should be considered at multiple levels, including: removing reimbursement from the RBRVS system by introducing global pricing (to be tested by the Virginia Cardiac Surgery Initiative); working for change within the current system (consumers' rising share of the cost of health care will focus their attention on the value of services); and rewarding quality (payment for performance, risk-adjusted payments, and financial incentives for employees to select "better," not "cheaper," providers). Although massive overhaul of the entire system (eg, single payer) is still debated, most analysts predict only incremental change.
Controlling our work environment and our future
There may be disagreement about the magnitude of the impact of technological progress in cardiology on the volume of coronary artery bypass grafting (CABG), but there can be no disagreement that we must respond to these changes. Suggestions include expanding our capabilities and our role in the long term management of chronic cardiovascular disease; and enhancing the curricula of training programs to include exposure to molecular and cellular biology, so that we continue as leaders in scientific advancement. We should also reach out more effectively to medical students to continue attracting the "best and the brightest."
A Final Thought: The conference's deliberations, summarized here, and its consequences, which will occur over time, should demonstrate to STS members how much attention and effort is devoted by the Society to the issues that concern practicing cardiothoracic surgeons in their daily work.
Session on quality
Introduction
Since the Institute of Medicine report, "To Err is Human" (1999), quality is replacing cost as the major issue driving the healthcare marketplace. Payers are experimenting with selective contracting, which may favor "centers of excellence" with the highest quality, but might reward those with the lowest price. Diversion of patients from medium- to high-volume programs could unintentionally increase the number of low-volume hospitals. The speakers were asked to address such issues as increasing demands for accountability, public "report cards," employer quality initiatives, and calls by purchasing consortia and government agencies for volume criteria that could result in regionalization of specialty surgery.
Presentations
1. How Will Non-Government Quality Initiatives Affect the Practice of Cardiothoracic Surgery? Kenneth Kizer, MD, President and CEO, National Quality Forum (NQF).
2. The Future of Quality Initiatives in Cardiac Care: The Purchaser's Perspective. Bruce E. Bradley, Director of Health Plans Strategy and Public Policy for General Motors Corporation.
3. The STS National Database: A Unique Phenomenon. What Are Its Quality Implications? Fred Grover, MD, Chair, STS National Database Workforce.
4. Health Care for Seniors: The Conflict Between Expectations and Reality. Joyce Dubow, Senior Policy Analyst, AARP Public Policy Institute.
Dr Kenneth Kizer identified the NQF as a private, nonprofit organization of approximately 160 organizations from government and the private sector, that was legislated by The National Technology and Transfer Advancement Act of 1995. The voluntary process for developing standards is faster than the federal process, and the Act obligates the federal government to utilize voluntary consensus standards when they exist, unless federal standards uniquely beneficial for government have been developed.
NQF develops "voluntary consensus standards" for performance, and identifies research needs. These are transmitted to the Agency for Healthcare Research and Quality (AHRQ) and the NIH, which direct the distribution of funding. NQF has also made advances in patient safety by identifying 10 high-priority strategic areas for action, and by developing a "never events list" of 27 "serious, egregious, preventable, adverse events that should never happen in healthcare." It has identified a core set of about 30 safe practices, such as reading back verbal orders, that minimize the likelihood of errors and that should be used by all hospitals. NQF has also been asked by CMS to establish a core set of quality measures for all Medicare-participating hospitals.
Together with the American College of Cardiology, NQF is attempting to convene a national summit in 2003 on cardiovascular care quality. The goal is to create a comprehensive system for quality measurement and reporting for cardiovascular disease, by 2006.
Bruce Bradley represented the Leapfrog Group (www.leapfroggroup.org), a consortium of purchasers, many of whom also belong to the NQF. The Leapfrog Group received funding to launch when Jack Smith, Chairman of GM, calculated that, based on the statistics in the IOM report, approximately 1.3 allegedly preventable deaths per day were occurring among GM employees. About 120 major corporations are now members, plus the Department of Defense, the US Office of Personnel Management, and CMS.
The feeling of the purchasers is that "they are getting weaker and weaker in terms of their role in the marketplace," "the clinical information systems in this country are absolutely abominable", and "there isn't a business case for providers to improve care or quality." They concluded that medical errors were a major cause of morbidity and mortality, and began to focus on their main goal, which is to specify a simple set of purchasing principles designed to promote overall customer value (ie, quality and safety, not simply low price). GM incentivizes employees to enroll in higher quality health plans, and there has been a significant migration to plans with better performance.
The Leapfrog Group started with three safety "leaps": computerized physician order entry, intensive care unit staffing, and evidence-based hospital referral. Although Leapfrog's initial focus for CABG was on volume, they recognize the shortcomings of using volume as a surrogate for outcome, and would like to move to publicly reported risk-adjusted mortality criteria, of which the STS Database is preferred "far and away." They insist on better information systems, and are concerned that more money is wasted on inappropriate care or poor practices than is spent on information technology.
Finally, Bradley emphasized that the payer and provider cannot continue to behave as adversaries.
Dr Fred Grover discussed the STS National Database. The system is now open to multiple software vendors that meet certain criteria, and warehouse storage and analysis are at the Duke Clinical Research Institute. Site-specific reports are provided to members every 6 months (formerly once a year). The Database also facilitates statewide and regional collaborative efforts to improve outcomes, with round-robin visits and discussions about processes of care and methods. There is now an AHRQ-funded research project to see if such efforts lead to measurable improvements in outcomes.
The Database provides the crucial substrate for collaboration with employers, insurers, and large quality assurance programs. The system is already operational and validated, and is trusted by the doctors and hospitals that provide the data and pay for the system.
Joyce Dubow emphasized that though future consumers will bear increasing responsibility for both the cost of healthcare and its quality, the system is enormously complex and difficult to navigate, particularly for older people. The U.S. has a serious healthcare quality problem, but consumers do not seem to be aware of the extent or seriousness of the issues. Of surveyed people who had information available to them about the performance of health plans, hospitals, and providers, roughly 25% had seen the information and less than 1% had used it. This demonstrates that consumers are primarily cost conscious, and are not making decisions on the basis of quality.
Thus, providers and insurers do not get rewarded in the marketplace for better quality. Consumers have little confidence in data they get from health plans or providers, and want data from other, presumably more trustworthy, sources. Our challenge is to reach consumers with standardized information that is easy to process. Finally, the cost of collecting and reporting information is a cost of doing business, and payers (including Medicare) need to acknowledge these costs in their reimbursements.
Session on delivery
Introduction
Consumer demand for healthcare is rising, fueled by Baby Boomers, aging, the Internet, and direct-to-consumer marketing. Many hospitals are experiencing capacity shortages in critical care units, operating rooms, and emergency departments. Academic centers face competition from well-funded nonprofit and for-profit hospitals. Rising healthcare expenditures are attracting new capital into the health sector.
The speakers were asked to address such issues as: the influence of private and government payers on the way health care is delivered; the high cost to hospitals of the information technology revolution; the impact on academic medical centers of a decline in revenue from cardiac surgical care; the proliferation of nonsurgical therapies; and the impact of Wall Street capital.
In the end, the speakers shared a concern that the present system of health care delivery in the United States is unstable. Potential shortages of financing and trained professionals raise major concerns about the future quality and availability of health care. There was no consensus on a single solution for these problems, only a belief that all parties must work for both incremental improvements and, in the longer term, for major change.
Presentations
1. The Wall St. Perspective on the Future of Cardiac Surgery. Kenneth Abramovitz, Senior Health Care Analyst, The Carlyle Group.
2. Health System Change and The Impact on Care for Patients With Heart Disease. Marilyn Moon, PhD, The Urban Institute.
3. How Will Academic Medical Centers Survive the Next Decade? T. Michael Bolger, JD, President and CEO, the Medical College of Wisconsin.
4. The Nursing Crisis: How Did We Get Here, and Where Should We Be Going? Mary Grace Simcox, RN, EdD, Dean, Lancaster General College of Nursing and Allied Health Sciences
Kenneth Abramowitz at the Carlyle Group, a major venture capital fund, said that rising health care costs threaten the economic stability of many major employers. He expects employers to change from the current "defined benefit" programs to "defined contribution" programs in which emplyees choose how to spend their health care contribution. To accomplish this, employees must be taught how to make these choices. By 2007, he forecast that 25% of employees would be in "defined contribution" programs. Participation in current "high-option" programs, where the employee shares 20% or less of the cost, will drop from 75% to 35%, whereas employees who share more than 20% of costs will rise from 10% to 30% of the total. He expects health care administrators to selectively recommend approved plans with differing structures of care to employees, rather than simply offering a "voucher" to spend anywhere.
Marilyn Moon, a well-known health care economist, disagreed that forcing patients to make more choices about health care was a desirable option. Echoing Joyce Dubow, she emphasized that consumers have limited ability to make judgments about health care. HMOs/PPOs are not providing a range of choices; employers are not paying HMOs enough to assure quality care; managed care plans are not providing sufficient information about providers to enable choices (they do not even answer their consumer call lines); and most employers do not even know what doctors or hospitals are in their systems. Internet sites accessible to consumers are not yet sufficiently helpful. This makes the family physician important as the patient's adviser in making choices.
Medicare managed care plans initially attracted enrollees by providing added benefits, not by promoting quality, and when they stop providing the added benefits, beneficiaries often leave the plans. Under "defined contribution" plans, additional "tiers" of patient care will develop, either because the contributions will be inadequate, or because employees will choose unwisely and, in the end, receive lower-quality care.
As did Bruce Bradley, she urged employers, health care providers, and insurance carriers to reduce the adversarial relationships that currently prevail.
T. Michael Bolger, JD, warned that academic medical centers face problems due to managed care, market consolidations, workforce shortages, and shrinking operating margins. Because academic medical centers are less efficient and thus costlier than nonteaching hospitals, managed care, to reduce costs, is directing patients elsewhere. Although most employers pay lip service to quality care for their employees, to most purchasers, "it's about the money." The ability of academic centers to finance expansion or the acquisition of new technology is jeopardized, because they cannot issue A-rated bonds unless they maintain net operating margins of 3% to 5%.
The health care system itself drives up costs at academic centers, as the uninsured postpone care and then become more expensive to treat. Other cost drivers include the efforts of employers to shift risk to providers; the excessive number of claims payers, which is inefficient; the tort system, which he believes adds 10% (including defensive medicine) to cost; and the rising cost of prescription drugs.
He suggests that we must develop some "new paradigm" for health care that addresses these issues, rather than just fighting against the negative forces. For their part, academic centers must attack expenses ruthlessly, while developing advanced information systems. These are essential to cost control, because "you can't manage what you can't measure."
Mary Grace Simcox, RN, EdD, agreed that nursing shortages are becoming critical. The causes are the aging of the "baby boomers," the concurrent aging of the nursing population, and the lack of replacement nurses for those who retire. This lack is due in turn to the economic pressures of managed care; reductions in payments to hospitals under the Balanced Budget Act of 1997; the costs and complexity of high-technology care; and the unfilled positions (students and faculty) that has caused some nursing schools to close, and has prevented others from expanding.
In summary, Simcox said, "the nursing profession needs reconstructive surgery:"
1) High school educators should communicate that there will be satisfying positions in nursing.
2) Hospital and nursing administrators must develop an organizational commitment to providing a satisfying work environment with the technology that will assist nurses and decrease their burden.
3) Physicians and administrators must develop and enhance a collegial work environment, with good interpersonal relationships.
4) Hospital and nursing administrators must provide continuing training, both on-site and through tuition assistance.
5) Legislators must expand nursing programs, improve incentives, and regulate reductions in overtime and patient ratios.
Presentation on information technology
The Influence of Emerging Information Technologies on the Practice of Cardiothoracic Surgery. Peter Greene, MD, Executive Editor, CTSNet.
Dr Peter Greene provided a technical perspective to the conference, during a luncheon address. His general theme was that technology is a tool, not an end in itself, and will thus affect broader issues:
1) Delivery: technology can enable better care by improving communication and coordination, especially across geographic and organizational boundaries.
2) Workforce: technology can enhance delivery of training and learning materials.
3) Quality: technology can improve the exchange of information and enable real-time learning.
Existing STS initiatives illustrate these benefits. The STS Database will play an increasingly important role in improving the quality of cardiothoracic surgery. The MedBiquitous online community is already promoting collaboration, innovation, and learning, both within professional associations such as the STS, and between physicians and manufacturers.
New initiatives will allow technology to play an even more important role in the future. The XML protocol enables data to be shared far more easily than before, much as the World Wide Web protocol enabled documents to be shared. XML will be a strong force for collaboration in health care, even though at present its impact is diminished somewhat by restrictions on patient information imposed by HIPAA (Health Insurance Portability and Accountability Act). In a related initiative, uniform standards for packaging of learning materials will lower the cost of producing and distributing materials over the Internet.
Session on volume
Introduction
Coronary artery bypass grafting has been the major operation that supports cardiac surgery programs, but new drugs, devices, and genomic discoveries will emerge as alternatives to surgery. The speakers were asked to address the implications of a potential decline in CABG volume, as well as the potential for compensating developments, such as new cardiac procedures. Another potential influence is increased pressure to reduce surgery by health plans, third-party intermediaries, and government payers.
Overall, the speakers presented reasons for both optimism and pessimism. Although stents are growing in popularity and effectiveness, it is unlikely they will eliminate CABGs as a necessary therapy for coronary artery disease. The surgical treatment of congestive heart failure will increase dramatically, and may surpass CABG as a source of revenue. Surgeons should become more involved in the long-term management of cardiovascular disease, and possibly peripheral vascular disease as well, because the latter does not capture the interest of cardiologists. It is crucial for cardiothoracic surgeons to engage in fundamental research that will lead to surgically applicable advances.
Presentations
1. Environmental Challenges to Cardiothoracic Surgery. Philip L. Ronning, Vice-President, The Tiber Group, Chicago.
2. The Future Impact of Surgery for Congestive Heart Failure. Eric Rose, MD, Professor of Cardiac Surgery, Columbia-Presbyterian Medical Center, NY.
3. The Future of Cardiothoracic Surgery: The Corporate Perspective. Earl M. ("Duke") Collier, President, Genzyme Biosurgery.
4. Cardiologists and Cardiovascular Surgeons: Collaborators or Competitors? Bruce Fye, MD, President, the American College of Cardiology.
Phillip L. Ronning, a business consultant, reviewed five different predictions of CABG volume over the next 3 years. These ranged from the Tiber Group's low prediction of no basic change, to Sun Trust Capital Markets' high prediction of a 50% reduction. Between these extremes, Medical Communications Media forecast a 10% reduction, the TCT conference a 22% reduction, and the Advisory Board a 29% reduction. Population growth alone is unlikely to compensate for a decline in volume of 10% per annum, and some centers are apparently experiencing greater decreases.
Despite evidence that Medicare reimbursement for coronary stents is inadequate now, CMS has been proactive in raising payments for stents, and payments may be increased when manufacturers present cost effectiveness studies. Cardiologists, not third-party payers, will have the most direct impact on the volume of stent procedures. Ten variables will affect the volume of stents used: (1) aggressiveness of cardiologists; (2) reimbursement; (3) liability; (4) early results; (5) necessity of surgical backup; (6) integrated C.V. groups; (7) cardiac institutes and single service line hospitals; (8) health systems; (9) managed care responses; (1) local demographics.
To predict the impact of PCI on CABG volume, these variables all need to be tracked and analyzed carefully, which is no simple task. In addition, cardiothoracic surgery must maintain a dialogue with cardiology, and with the institutions that support invasive and minimally invasive cardio-vascular interventions.
Dr Eric Rose, Principal Investigator of the REMATCH trial of LVADs, brought a fresh and encouraging perspective, by emphasizing that left ventricular assist devices (LVADs) provide an opportunity for expansion in an area that has previously had only limited utilization. Columbia Presbyterian has recently reached an economic inflection point between CABGs and the surgical treatment of CHF using LVADs. Last year, 750 CABGs produced an income of $20 million dollars, whereas 150 LVADs generated comparable income. Although not mentioned by the speaker, this shift would ultimately result in the need for a smaller cardiothoracic surgical workforce.
Heart transplantation using human donors appears to have already peaked, and the total artificial heart has not yet been successful. However, LVADs have improved in the last several years, and have allowed extended outpatient periods, finite morbidity, a "reasonable" quality of life, and approaches to device failure that have not always required reoperation. The REMATCH Trial documented the clinical and cost effectiveness of LVADs, when compared with medical management of severe CHF. The future of LVADs lies in smaller, more effective pumps that can help resuscitate acutely decompensated hearts, and can thus serve as a bridge to eventual revascularization with angiogenesis, gene and cell therapies, and bone marrow–derived stem cell transplantations.
Earl "Duke" Collier, Jr, opened with an admonition that cardiothoracic surgeons "must participate in the management of chronic disease to avoid being relegated to the worst position on the food chain." He divided the current cardiovascular disease marketplace into three categories: (1) ischemia, (2) heart failure, and (3) arrhythmias. In the marketplace of 2002, the treatment of these entities favors cardiologists. Stents have achieved rapid acceptance, whereas the acceptance of LVADs has been slower. However, there are currently phase 2 trials using autologous skeletal muscle, and preclinical work with adult stem cells. It is still unclear what type of delivery system will be used for these entities, and this is an area ripe for surgical research. Although he believes there will be a cardiology-based preference, there will still be a need for surgery, although he did not say how much and what kind.
In closing, he warned cardiothoracic surgeons not to be "button salesmen in an age of zippers." It is important that this specialty be centrally involved in the basic sciences as they relate to cardiovascular disease, that we be participants not bystanders in the management of progressive heart disease, and that we understand that any changes will have to be made at the research level.
Dr Bruce Fye, an accomplished historian, pointed out that thoracic surgeons had successfully reinvented their identity in the past when surgery for tuberculosis disappeared, and they might have to do so again. Rather than succumbing to the notion that the future of cardiac surgery is in the hands of the cardiologists, surgeons should recognize the uniquely physiologic aspect of cardiac surgery, and consider that the future of cardiac surgery may actually be in the hands of the molecular biologists and pharmacologists.
But despite the traditional collaboration between cardiologists and cardiac surgeons, Fye acknowledged that cardiologists would not share catheter therapy for coronary disease with surgeons. However, peripheral vascular disease was unlikely to be a major focus of cardiologists, because they are already in short supply, and have enough cardiac work to keep busy. He therefore saw that as a fertile area for cardiac surgeons to compete with vascular surgeons. He emphasized the importance of vision, and he tied this to a recommendation that cardiac surgery research needed more funding and more activity, because research would be the source of new opportunities in surgery.
Session on workforce
Introduction
The current "physician surplus" may turn to a physician shortage by 2010, with fewer applicants to residencies. Issues that speakers were asked to address included the high cost of medical education and the impact of inadequate numbers of graduates on recruiting the "best and brightest" to cardiothoracic surgery; the impact of declining CABG volumes on low-volume training programs; the role of female CT surgeons; the new career roles CT surgeons may be forced to consider if CABG volume declines further; and the effect of physicians' changing lifestyle preferences.
Although the speakers in the session expressed differing opinions about whether there would be too many or too few cardiothoracic surgeons over the next 5 to 10 years, all agreed on the necessity and inevitability of a changing role for the cardiac surgeon.
Presentations
1. Physician Workforce Trends; Glut or Shortage? Richard Cooper, MD, Director, Health Policy Institute, The Medical College of Wisconsin
2. How Will We Meet Society's Needs for Cardiothoracic Surgeons? Edward Verrier, MD, President, The Thoracic Surgery Directors Association
3. Why Would Anyone Want to Be a Cardiothoracic Surgeon? Paul Uhlig, MD, Dartmouth Medical School
4. The Changing Role of the Surgeon in an Era of Technological Change. Bruce Lytle, MD, The Cleveland Clinic
Dr Richard Cooper, an expert on workforce trends in medicine, pointed out that health care spending grows an average of 3% annually, and almost exactly parallels trends in GDP, with a 4- to 5-year lag. The need for physicians will grow proportionately, but at a lower rate, and with a longer lag time (10 yrs.) Thus, though the rate of growth in both health care spending and demand for physicians depends on economic considerations, both will inexorably increase. Nonphysician clinicians will contribute significantly to the provision of medical services. The shortage of MDs is enhanced by the increased percentage of MDs who are women, because they choose to work 15% to 20% fewer hours in a lifetime than do men. In today's society, such life-style choices even affect men.
The system of medical education has limited ability to adapt to the increasing need for physicians, and by 2015, there will be a shortage of 80,000 to 100,000 physicians. Even if the capacity of existing medical schools increases, and new ones are built, the most optimistic estimate predicts an additional 4,000 new doctors per year in 2030.
Looking ahead, the applicant pool for medical school will be stable for the current number of openings, but with more women and few minorities. Male and female applicants to medical school will be equal, and will represent approximately 2% of graduating college seniors. (The applicant/acceptance ratio is now 1.55. There are data to show that at >1.4, the quality of the student body declines.) Even though there will be more Hispanics in the age group of 20 to 25 years, from which applicants come, Hispanics are not increasing their rate of college education.
The annual number of International Medical Graduates (IMGs) who receive ECFMG certificates is approximately 4,000, but even double that number would only be a fraction of the physician shortage, and there would be no PGY1 positions for them, as domestic graduates fill all but about 4,000 of the 20,000+ PGY1 positions. Moreover, it is hard to predict global forces that could impact the number of IMGs that would want to come here. We must also consider the impact on their native countries of our taking more IMGs. Is the resulting brain drain consistent with our being responsible global citizens?
Thus, there will be an increasing demand for MDs, which is unlikely to be met. The shortage will certainly affect specialty distribution and relationships between the specialty professional organizations, which will be competing for candidates to enter their specialty.
Dr Edward Verrier asserted that the quality of medical school applicants (by GPA and MCAT scores unadjusted for grade inflation) has not yet fallen, though it seems clear that it must do so soon. There are also a number of negative changes in graduate medical education. Residents completing training are older and are past their most creative years. The debt load of medical school graduates is higher than ever, and it increases further during residency. Residents are under pressure to start earning money, and are thus discouraged from seeking a research career. For current residents, there are few academic positions, and private positions come with buy-ins that are long, expensive, and uncertain. Many private practitioners who were planning to retire can no longer afford to do so, and remain working. General surgery "feeder" programs have declining numbers of applicants. Twenty percent of beginning residency positions now go unmatched, though they fill eventually, presumably with applicants who did not match with their preferred choices in the first round. Osteopaths, FMGs, and offshore grads also fill many positions.
Though fewer cardiothoracic surgeons may be needed if predictions of declining CABG volume are correct, an increased number of residents will be required if new regulations that restrict resident work hours are widely adopted. The resulting manpower shortage in teaching hospitals could force academic faculty to take over many responsibilities now fulfilled by residents, and the professional profile of the specialty would change radically over time.
Pertinent to attracting the "best and brightest" are reports by Ezrum (Surgery 2000;128:253-256) and Woodward (Am J Surg 2000;180:570), who studied factors associated with the selection of surgery as a career. Because we ca not affect medical school demographics, we must deal with surgical mentorship and lifestyle issues. The following measures could improve the CT Surgery workforce.
1) Early exposure of medical students to surgery.
2) Shortening of training; revision of CT surgery's relationship with general surgery; encouragement of increased flexibility by the ABTS; development of alternative pathways for training (eg. lengthening it for women who want to work less than full time; allowing two female residents who wish to meld family with career to share a position).
3) Use of the Internet for teaching.
4) Development of training tracks for academic preparation (eg, Canada's academic scholar's track).
5) Inclusion of research at the molecular/cellular level in training programs.
Dr Paul Uhlig pointed out that new approaches to treatment are changing the role of the surgeon, and we are challenged to reassess our self-image and, ultimately, to reshape ourselves as practitioners and as a specialty.
In the early years of heart surgery, our paradigm was exemplified by test pilot Chuck Yeager and his contemporaries: pioneers drawn to the edges of the envelope: bright, focused, innovative, in control, unflappable, with a desire to be "the best." But the "Right Stuff" was not the same in the later era of the astronauts, when more collaborative team players with a knowledge of systems were needed. Similarly, heart surgery has changed from the early years in many ways. Operations are no longer considered uniformly hazardous, and standard operations are expected to go smoothly. Advances in technology across specialty lines are occurring rapidly and regularly.
Thus, we CT surgeons need to reconsider both our practice model, and the type of people who will want to do what we do. Bright, focused, capable, unflappab, yes, but increasingly with a thorough knowledge of systems, and a capacity for collaborative leadership. Though until recently our students may have still envisioned the original role model, our future success in attracting outstanding residents to our specialty will depend upon our willingness to move to the new frontiers of health care. Navigating those frontiers successfully requires a slightly different version of the "right stuff." Our ability to make this transition will determine our future.
Dr Bruce Lytle noted that the operations we do, and the way we do them, are being eroded. Though they will not become obsolete immediately, the importance of what we do for coronary disease will certainly diminish. Moreover, the phenomenon of CABG will not happen again: a well-compensated, yet safe and effective procedure, for a common disease.
To avoid obsolescence, we must reconsider what a cardiac surgeon is, and to maintain a central role in the management of patients with cardiovascular disease, we must acknowledge that these serious threats to our specialty will not disappear. We should:
(1) Adopt a long-term view of cardiovascular disease. We cannot merely see a patient in relation to their surgery, and ignore them after this single event.
(2) Develop a skill set and management strategy to treat valve and great vessel disease percutaneously, including the imaging that is needed.
(3) Continue the development of endoscopic strategies.
Session on finance
Introduction
Coronary artery bypass grafting is one of the highest-margin service lines in many hospitals, and a decline in volume would threaten many other hospital programs and services that CABG subsidizes, including uncompensated care for the medically uninsured. Other threats to hospital finances include inadequate reimbursement for costly new technologies, declining Medicare and other third-party payments, and increasing malpractice premiums. Speakers were asked to address the impact of the above factors on heart surgeons' incomes, on recruitment of future CT surgeons, on the financial viability of heart centers of excellence, and on health industry manufacturers and suppliers. Increasing reliance on corporate support for educational programs and research could alter the relationship between the profession and industry.
The common theme throughout this session was the linkage between cost and quality. If quality is overlooked, costs will actually rise. Quality should be addressed at multiple levels, including providers, payers (with particular attention to their understanding of quality and the utilization of data), and our Society. Such a commitment will also improve our image and attract "the best and brightest" to our specialty.
Presentations
1. Options for Medicare Financing and Reform. Michael D. Bromberg, Chairman, Capitol Health Group (Healthcare Consultants).
2. How Will Community Hospitals Finance Cardiac Care Over the Next Decade? Michael A. Young, President and CEO, Lancaster General Hospital
3. The Future of Health Plans. Karen Ignagni, President and CEO, American Association of Health Plans
4. Financing the Future of Cardiac Care and Education: The Corporate Perspective. Michael A. Mussallem, Chairman and CEO, Edwards Lifesciences
5. Financing the Future of Cardiac Care: Political Realities. Paul Harrington, Executive VP, Vermont Medical Society; formerly Health Policy Advisor to Senator James Jeffords.
Michael Bromberg, one of the Society's regular consultants, gave an overview of the current environment in Washington. Health care policy gridlock persists at the Congressional level, and in the absence of new legislation, 2002 was the "year of regulations." More than 1,600 Medicaid plan amendments were approved, as well as multiple demonstration projects. In the foreseeable future, no major change (eg, Medicare "vouchers" or a "single payer") is likely. The immediate focus at CMS and HHS is on quality report cards, which both CMS Director Scully and HHS Secretary Thompson would like to make the legacy of their administration. Scully would like to go further, by paying more for higher quality (tier pricing). Though Congress will debate the Patient's Bill of Rights, Medicare drug benefits, Medicare reform, and the uninsured, the primary issue will be healthcare costs, which are up 10% to 13%, while CPI is up 3%. The sleeper issue is the uninsured, including those who have insurance but fear losing it.
The proposed reduction in the Medicare conversion factor is perceived as a mistake that will restrict access, and it will likely be reversed. Looking specifically at cardiothoracic surgery, the STS should declare there is a crisis, and call for change. The STS should embark on a multiyear campaign (2 to 5 years) that adopts four strategies:
(1) Encourage an independent study (university based) that highlights the crisis in cardiac surgery reimbursements, and that leads to reform in the RBRVS system by detailing how access and/or quality are in jeopardy because of low payment rates, lack of trainees, and a shrinking work force. This must be done within a year, so the results will be known when Congressional debate arises. Some key legislators, like Congresswoman Nancy Johnson, understand and agree with the issue and might be willing to legislate it.
(2) Embrace quality report cards, take advantage of this administration's willingness to consider paying for quality, and help develop such a payment system.
(3) Be willing to "fight" our own fellow physicians for what we need, such as changes in Medicare practice expenses so that assistants at surgery are reimbursed. (Congress will not want to join in this "food fight".)
(4) Consider new initiatives (eg, the Virginia Cardiac Surgery Initiative), which focus on quality as a cost containment measure, and use global payments to remove cardiac surgery from the RBRVS system.
Michael A. Young affirmed that cost pressures on voluntary hospitals continue. Strong hospitals (those with profit margins of 10% and good credit ratings) continue to do well, but the weaker hospitals are in jeopardy. Hospitals are facing huge demands for capital, particularly with losses in psychiatry, obstetrics, drug and alcohol abuse, and more recently, implantable defibrillators. Other causes of hospitals' chronic lack of profitability are rising drug and labor costs, and skyrocketing malpractice premiums. Labor consumes 40% of the budget, of which, half goes to nurses. In cardiology, the introduction of electrophysiology labs, drug eluting stents, and other high-tech devices, is contributing to rising utilization costs. Cardiac surgeons must become the administration's partner in trying to control costs.
Proliferation of cardiac surgical programs in small community hospitals is declining because capital markets are unwilling to invest in these hospitals with shrinking profit margins. Also, these hospitals are unable to find staff (anesthesia, perfusion, nurses, and even surgeons) to provide the service.
His recommendations:
(1) Differentiate premier cardiac programs as geographically freestanding service lines within hospitals. In addition to discouraging competition from for-profit "heart hospitals," this differentiation will allow focused resources and efficiencies of care delivery. In addition, it will encourage defined initiatives for patient safety, enable providers to benchmark outcomes, and provide heightened customer services.
(2) Hospitals should not compromise quality. Staffing cuts intended to save money only lead to decreased quality of care. We should not accept mediocrity in any aspect of healthcare delivery.
Karen Ignagni reinforced Bromberg's assertion that health care policy will change in small increments, and that Washington has no strategic plan for health care policy. Five major committees deal with health policy, and they often seem not to communicate, but surgeons' interaction with these committees must continue to focus on quality to reduce costs. Payers are worried about quality, particularly on the heels of the Wennberg Report, which described the wide variability in practice patterns. Considerable attention is being given to evidence-based care with external review. The private sector will pay for performance, but a reasonable reporting methodology must first be created, which will require collaboration among payers, providers, and policy makers. Finally, there may also be a push toward payment for disease management
Some of the cost drivers within the healthcare delivery system are unfunded mandates, litigation, fraud and abuse, and overutilization. The current upward trend in utilization can be partially explained by an aging and sicker population, but increased supply utilization, increasing lengths of stay, and increasing emergency room visits also add to costs. Patient safety remains a major issue. Though it is generally felt that better disclosure is needed, there must be protection for those who are disclosing, which highlights the need for tort reform. We should continue to press for it, with quick adoption of external review before a case comes to court. The issue of who gets the data and who discloses it are currently unsolved. The salient point is that disclosure of information is going to be important, and the major stakeholders (physicians, hospitals, payers, and the Society) should take leadership roles in promoting disclosure.
In the marketplace for health plans, there are five major areas of focus: HMOs, PPOs, point of service plans, flexible benefit plans, and defined contribution plans. Unlike Abramovitz, she considered it doubtful that employers will move to defined contribution plans quickly, but once patients are responsible for expenditures and payments, more attention will be focused on these plans. There will be a strong drive for "consumer reports," which will be done by self-appointed agencies with little experience.
Many of the uninsured have no coverage because they can not afford it, not because it is not offered to them. Labor has not been willing to see their premiums rise to cover the uninsured. The insurance industry and doctors are natural allies in working for basic care for these people, and this is a good opportunity for private sector/public sector collaboration. (A later speaker, Paul Harrington, noted that before we engage in organized advocacy, we must first define our values, which should be quality, adequacy of reimbursement, and children's protection.)
Mike Mussallem pointed out that the STS must reach a balance between merely refining what we already do ("sharpening the saw"), and transformation, which will help us attract the best applicants. The ability to attract investment, particularly from industry, will also be crucial. In a uniquely symbiotic relationship, research and education generate technology development, which drives industry growth, which sponsors research and education. The challenge for manufacturers is to generate revenue to invest in the future. Spending on research and development in health care is primarily by drug companies, with estimated annual expenditures of $10 billion, followed by device companies with $2 billion, followed by the NIH with $795 million. Because most of the money in cardiac surgery comes from device companies, low profitability would cause the major players to leave the field, with serious consequences for the specialty. Industry and cardiac surgeons should collaborate to apply new technology to fulfill unmet clinical needs. Conflicts of interest should be managed forthrightly, not ignored.
Cardiac surgeons should continue to emphasize the durability of surgical benefits, but must realize that payers have a short-term horizon, because consumers move often from one health plan to another. There is an increasing likelihood of disruptive technology that will influence patient choices, because patients will choose procedures that are easiest on them, even if it means return trips to the catheterization lab. The future cardiac surgeon may have a combined invasive and percutaneous repertoire. An example is low-grade aortic stenosis, with percutaneous aortic valve replacement by surgeons, but such opportunities will require extensive reeducation. There is a strong role for industry to assist in this process.
Before the meeting, Mr. Mussallem conducted a survey of the participants to assess their attitude toward industry-funded education. Ninety percent of the respondents felt it was valuable and synergistic, with 70% expecting it to grow further. The benefit cited most often was enhanced awareness of new technology. Only 30% felt that information presented by manufacturers in this manner is biased, and 90% felt that if professional societies play a role in the direction of that education, bias might be substantially reduced.
In summary, because change is inevitable, the Society should welcome partnerships with industry and government, and cardiac surgeons should act as innovators and champions of technology. Although government may increase support for residency training programs, industry can be valuable in re-educating our current workforce. Our major focus should remain on patients' needs and preferences, because they will drive the market. Because future investments in cardiac surgery technology and research will depend on market growth, a profitable industry, with the capacity for continued investment in the future, is mutually beneficial.
Paul Harrington made four central points about healthcare policy:
(1) Politicians and policymakers are typically less dynamic than heart surgeons. Harrington has a degree in geology, with particular emphasis on glaciers, which was a perfect background for Washington policymaking, because like a glacier, "Washington moves slowly but eventually grinds fine."
(2) The political process is inherently risk-averse. It far safer to have done nothing than to have done something wrong.
(3) No one does anything by themselves. It is crucial to identify allies. Everyone should get to know their legislators and their staff. Many staffers are very talented and very important, because legislators depend upon their advice. We should also consider joining an existing effort that may have objectives similar to ours, and we should study examples of how things were accomplished in the past.
(4) Change is possible. Health care policy gridlock will end at the 2004 Presidential campaign, when cost and access will be primary health care issues, as will the prescription drug benefit. In 2005 and 2006, the promises of the next presidential campaign will begin to be fulfilled, and until then, the STS should be creating alliances and advancing its agenda. The typical time frame in Washington for a political issue is 5 years, and tenacity is important. The current 3-year fix for physician reimbursements might be dangerous, because at the end of that 3-year period, we may encounter a sudden large drop in reimbursement.
With respect to quality report cards, the federal agencies favor voluntary reporting, but some states are moving toward mandatory reporting (eg, Massachusetts). There are still tort issues associated with public reporting, which creates a conflict when providers wish to report but fear lawsuits. Tort reform should be linked to quality reporting and to quality improvement, and the STS should attempt to advance both.
With respect to payment methodologies, it is likely that the federal government will strongly support defined contributions, and there will be multiple methods of paying for physicians' services. Medicare and Medicaid as we know them will continue. The STS should vigorously pursue tests of alternate payment systems, such as the Virginia Cardiac Surgery Initiative, which links physicians' payments to hospital profitability, while maintaining a focus on quality. Thus, when Medicare reform comes up in the future, there will already have been experience with some of the payment methodologies being debated. (Legislators have a strong desire to build on existing programs.) Finally, the STS should look closely at the most recent IOM report, "Leadership by Example," and should attempt to collaborate with the IOM to try to set the agenda, or at least to draw attention to the issues that are important to us.
The discussion period emphasized the importance of performance measures to differentiate high-quality providers, and to prevent us from becoming a commodity. We should define quality before others do it for us. We should take control of the disclosure issue, because the health plans do not want to do it for us, but rather with us. We should work with our major stakeholders to define the core issues in the delivery of cardiac surgery care: patient choice, adequacy of reimbursement, and quality.
Concluding session on actionable issues
From each of the previous sessions and their discussions, a number of trends and critical forces were identified. A consensus of the participants was developed about actions we should take to respond to changes over which we have some control, or should try to take control.
Quality assessment/acquisition of performance data
a) Publicly release our risk-adjusted data in preference to payer/government data.
b) Engage Leapfrog and NQF; try to change Leapfrog to the STS risk adjustment model.
c) Measure long-term outcomes (value of operations, not just mortality).
d) Take ownership of the process of evaluation and control of cost.
e) Build the initiative around a patient focus; they deserve quality information, etc.
Improvement in workforce development
a) Modify residency training: curriculum development should put more emphasis on innovation/new techniques and technology, as well as cellular and molecular biology. ABTS and TSDA must be on board.
b) Reverse decline in CT surgery applicants by active recruitment; get our message to medical students early.
c) Protect R&D time for young faculty.
New paradigms for relationship with industry
a) Appreciate manufacturers as partners with special expertise in technology:
i. innovation, not just as salesmen.
b) Work with industry to fulfill unmet needs; utilize their expertise at:
i. problem solving/innovation/conduct of clinical research.
c) Recognize industry as a resource for our transformation, and as lobbyists with considerable influence.
d) Maximize the value of their support of educational programs.
e) Be aware of technological innovations at their inception, so we do not lose ownership.
Change in reimbursement models (away from surgery piecework pay)
a) Explore global fees (Virginia Cardiac Surgery Initiative).
b) Support universal coverage for heart care.
c) Support coverage for the uninsured.
d) Energize the PAC (Can industry's influence as lobbyists be useful?).
e) Explore reimbursable areas of cognitive care (critical care).
f) Publicize our reduced mortality/morbidity.
g) Make payers more aware of our efficiency (declining cost, LOS, etc.).
Education of existing surgical workforce
a) Develop a system for rapid testing and dissemination of innovation.
b) Embrace less invasive approaches.
c) Learn how to initiate and conduct clinical trials.
Innovation in delivery/practice organization
a) Control our definition of who we are and what is our domain.
b) Provide comprehensive cardiovascular disease management; start with management of CHF (Incorporate vascular surgery?).
c) Consider organizational transformation at the local level: regionalization (virtual networks; new practice arrangements) cardiology/cardiac surgery group.
Future planning
a) Develop a process of proactive strategic planning for potential crises (scenario planning).
Concluding comments
We hope this report has made it clear that although this conference addressed a broad array of questions about the future of cardiac surgery, many could not be answered now, either because the information is changing rapidly, or is essentially unpredictable. One of our major tasks, as stated in the Introduction, was to define the challenges, not necessarily to answer all the questions, and to outline plans for dealing with the important challenges we can identify. Another objective was to expose nonsurgeons to our viewpoints, and to influence their thinking, as well as ours, by a forthright exchange of ideas. This objective was clearly achieved, as evidenced by the enthusiastic participation of so many prominent speakers, and by continuing dialogues with them after the conference.
We hope it is apparent to the members that the STS is engaged in long-term strategic planning to address the issues that concern practicing cardiothoracic surgeons in their daily work.
Acknowledgments
Sponsored by unrestricted educational grants from Edwards LifeSciences, Ethicon/Cardiovations, Genzyme Biosurgery, Guidant Corp, and Medtronic, Inc. Special thanks to the STS leadership and staff who made this conference not only possible, but successful: Past President, William A. Baumgartner, MD, and Current President, Robert A. Guyton, MD. STS Washington, DC Government Affairs Office: Robert Wilbur, Director; Ryan Erenhouse, Assistant Director; David Boyd, Administrative Asst. STS Chicago Office: Robert A. Wynbrandt, STS Executive Director and General Counsel; Joyce Gambino, Director of Meetings and Conventions. Finally, profound thanks to the far-sighted sponsoring corporations and their leaders, who not only provided financial support for the conference, but participated insightfully in the discussions. In addition, Earl M. ("Duke") Collier, Jr, President of Genzyme Biosurgery, and Mike Mussallem, Chairman and CEO of Edwards LifeSciences, made provocative formal presentations.
Footnotes
The STS Future Planning Conference for Adult Cardiac Surgery took place on November 1–3, 2002, Heart House, Bethesda, MD.
The STS Future Planning Conference Organizing Committee consisted of: Lawrence I. Bonchek, MD, and Daniel P. Harley, MD, Co-Chairs; John Mayer, MD, Chair, Council on Health Policy, Reform, and Advocacy; Jeff Rich, MD; Paul Uhlig, MD; Cliff Van Meter, MD; and Kevin Accola, MD, Chair, Workforce on Health Policy. Consultants to the Committee were: Mark S. Bonchek, PhD, Managing Director, Tapestry Networks, and Russell C. Coile, Jr, Editor, Future Health Trends.
Appendix
Participants (in addition to invited speakers)
Kevin A. Accola, MD Chairman, STS Workforce on Health Policy, Reform, and Advocacy William A. Baumgartner, MD President, STS Anita B. Bessler Corporate Vice President, Global Franchise Management Edwards Lifesciences Corporation Lawrence I. Bonchek, MD Co-Chairman, Organizing Committee Mark S. Bonchek, PhD Managing Director, Tapestry Networks; Special Consultant to the Organizing Committee Sean Coughlin Capitol Health Group Fred A. Crawford, Jr, MD President, AATS Robert Guezuraga Senior VP and President,Cardiac Surgery, Medtronic, Inc. Robert A. Guyton, MD First Vice-President, STS Ron Guido Vice President and General Manger Ethicon/Cardiovations Daniel P. Harley, MD Co-Chairman, Organizing Committee Randy Kesten Vice President, Operations, Cardiac Surgery Group, Guidant Corporation Nicholas T. Kouchoukos, MD Chairman, Council on Education and Member Services Douglas J. Mathisen, MD Treasurer, STS Jack M. Matloff, MD Past President, STS John E. Mayer, Jr, MD Chairman, Council on Health Policyand Relationships Carin Mehan Director of Physician Relations,Medtronic Cardiac Surgery Gordon F. Murray, MD Secretary, STS Jeffrey B. Rich, MD Member, Organizing Committe
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