Cost-cutting Strategies that Deliver: Three Solutions for the Cath Lab
In a real-world setting, many administrators struggle to balance pinching pennies and delivering care. As hospital reimbursement dwindles and innovation blossoms, hospital staff must find creative ways to save a buck without skimping on care. Staff members from three hospitals share solutions ranging from data dissemination to innovation to physician engagement.

More data, please

With more than 90 clinics and 11 hospitals, Allina Health acts as a healthcare delivery workhorse throughout Minnesota and Eastern Wisconsin. With 105,057 inpatient hospital admissions in 2011 alone and a $3.1 billion operating budget, the health system has sought to simultaneously reform care and cut waste.

While most hospitals have realigned their focus to cost savings, Allina has set the bar high with a goal of cutting $100 million in 18 months. “By our standards, we believe that up to 40 percent of healthcare is not value-added and can be improved upon,” says Christine Bent, senior vice president of clinical service lines at Allina.

To eliminate waste, Allina employs a triple aim and growth strategy that seeks to improve patient experience, patient outcomes and make care more affordable. A major aspect of this approach is improving performance measures and making data more transparent, says Bent.

Adding service line structures (eight to be exact) across the system has helped to coordinate care. Understanding where waste exists by driving down variation has been just one tactic to help slash high price tags.

At Allina, financial, EMR and other data from national cardiovascular registries, such as the Society of Thoracic Surgeons (STS) and the National Cardiovascular Data Registry (NCDR), are aggregated into a robust data warehouse to help track variation throughout the system. Based on the data, physicians receive feedback on a monthly basis that illuminates trends and highlights opportunities for improvement in outcomes.

At the Minneapolis Heart Institute, one of Allina’s cardiac centers, cardiologist Craig Strauss, MD, and colleagues developed a real-time clinical decision support tool to assess and improve PCI quality and outcomes. Data on the assessment tool, which used a pre-PCI bleeding risk score, were presented at ACC.12. They enrolled 8,309 PCI patients treated at three high-volume hospitals within the Allina cardiovascular service line between January 2009 and September 2011 and grouped patients by low risk (0-7), intermediate risk (8-17) and high risk (18+). Of the total cohort, 15 percent were classified as high risk, 48 percent as intermediate risk and 37 percent as low risk. Complication rates were 24.5 percent, 7.5 percent and 2.4 percent, respectively. Total costs were $22,821 for high-risk patients, $14,500 for intermediate-risk patients and $11,539 for low-risk patients.

“Depending on what category a patient falls into, they received a different care process,” Bent offers.

By providing real-time feedback, protocols have become better aligned. For example, Bent says that increasing bivalirudin (Angiomax, The Medicines Company) use from 25 to 50 percent in high-risk patients has the potential to save nearly $250,000 per year. “This is really all about standardizing care processes,” she adds. Another protocol that Allina is looking to master is attempting to discharge low-risk patients from the hospital earlier. By discharging these patients appropriately, the system could save nearly $600,000 annually, thanks to earlier transfer out of the intensive care unit.

In addition to cost-savings benefits, a focus on protocols such as increased bivalirudin also may result in fewer complications. “Upping our bivalirudin use has the potential for there to be 13 fewer complications per year,” she adds.

These strategies aim to evaluate initiatives designed to reduce variation in care and create value. And the key to finding potential value-based initiatives is transparency, Bent says. She adds that making these data available through the organization to physicians and other staff has helped generate ideas to transform care, cut costs and enhance patient care.

Innovation & cutting cost

A 5 percent drop in volume each year over the last five years and a decrease in reimbursement have made administrators and physicians at Brigham and Women’s Hospital (BWH) in Boston a little smarter and a little more apprehensive about spending.

“It is sad how much we get reimbursed for a right heart catheterization now,” says Ana A. Mercurio-Pinto, director of cardiovascular medicine at BWH. So how do physicians and administrators become more judicious while still keeping up with the competition? The key is continuous innovation, she says.

While dwindling reimbursement and revenues make newer, more expensive procedures hard to justify due to their often lofty costs, providing those resources helps the large academic medical center stay afloat, especially among its competition. “We are constantly figuring out ways to differentiate ourselves from the others and embrace change,” she adds.

At BWH, Mercurio-Pinto says staff banks on the fact that the facility can offer alternate, innovative healthcare that some other facilities cannot. “We’re remaining open to innovation. While we realize this will cost us money, we also are hopeful these types of innovations, like transcatheter aortic valve replacement [TAVR] programs, will bring us [more patient] volume, educate our fellows and create job security for cardiovascular medicine.”

Surgeons at BWH performed its first TAVR procedure in April 2009. The procedure may be over the tipping-point of cost to revenue generation, but the transformation it offers to practices and patients seems to add value. In fact, the PARTNER trial provided insight into the ground-breaking procedure when it found that TAVR could reduce the rates of death, repeat hospitalizations and incidence of stroke in severe aortic stenosis patients not suitable for surgery (N Engl J Med 2010;363:1597-1607).

Other research found that TAVR patients had an incremental cost-effectiveness ratio of approximately $50,200 for each additional life year gained, or about $62,000 for each quality-adjusted life year gained, based on the cost-effectiveness analysis of cohort B of PARTNER (Circ online Feb. 3, 2012). TAVR may not be cost-effective for the hospitals themselves, but the stature it gives hospitals and the benefits seen by patients make it worthwhile.

Besides an emphasis on innovation and staying ahead of the competition, Mercurio-Pinto says internally employees focus on looking at performance data and places within the healthcare system as a whole where money can be saved.

“We, as a staff, must be cautious and cost-conscious,” she says. At Brigham, administrators have had to clamp down on overtime, hiring and fixed costs. “At the end of the day, the cost of the stent is not going to change a whole lot,” she says. “Now we are focusing on fixed costs, rather than these variable costs.”

Now more than ever it is important to assess patient care and costs from a global perspective. “How a patient contributes to the entire institution from admission to post-discharge, from imaging to the ambulatory practice, is what we have to focus on. We are trying to gain a better snapshot of the patient,” she adds.

While some may feel that physicians and administrators hit heads in terms of who’s in charge, especially as the notion of reimbursement cuts and the changing landscape continues, Mercurio-Pinto says that physicians, at least at Brigham, still hold most of the clout. “At the end of the day, we are still very dependent on our physicians,” she adds. It is the physician’s call as to what technology, procedure or next step will be best for the patient. At BWH, Mercurio-Pinto and other administrators make robust data avail- able to the physicians in the cath lab and other departments, so they can compare the revenue with the expenses.

Additionally, she says that outside forces, such as increasing reimbursement cuts, have forced BWH staff to consider same-day elective procedures when appropriate. In 2007, BWH’s Frederic S. Resnic, MD, MSc, estimated the approximate cost savings and revenue impacts of same-day discharge for eligible PCI patients. Of the 800,000 PCIs performed annually, Resnic estimated that nearly 250,000 would be eligible for same-day discharge (Circ 2007;115:2248-2250). With this in mind, Resnic calculated that the adoption of the same-day discharge program across the U.S. could lead to a direct cost savings of more than $600 million to hospitals, which would free up inpatient capacity by 250,000 patient bed days per year.

“We have had to redo our care models, re-evaluate process flows and make sure that we have the proper IT and nursing support staff to perform these quicker turnovers,” she says.  

To do so, Mercurio-Pinto meets with the cath lab director to review the numbers for every faculty member. Data include relative value unit (RVU) productivity, revenue and outliers. “We basically are just seeing what we can trim,” she says. “We are looking to get the most out of every dollar.”

The key to the future of care will be focusing on the global perspective of care rather than episodes of care. “We will need to figure out how to work more collaboratively within the institution and eliminate the boundaries between each specialty,” she says.

Tips to Success The following areas could help others focus on care while simultaneously cutting costs:

Build up a data warehouse: Implementing the EMR can help with care management. Building a data repository can make the data transparent and help identify future opportunities to improve care and cut costs, says Christine Bent, senior vice president of clinical service lines at Allina Health, headquartered in Minneapolis.

Shore up the primary care base: “Primary care physicians [PCPs] are really our über service line and you’ll want to partner with them,” says Bent. It is very important to give PCPs the tools to be successful.

Stop siloing care: “Start making investments in care coordination,” says Bent. “Seamless hand-offs will be a very important aspect of the future of care.” Having various departments work together will lead to success. For example, have nurses, support staff, care guides and pharmacy staff, among others, working together to say: What is it we need to do to care best for the patient?

Get physicians collaborating with administrators: Share quality data and start with a quality agenda, Bent offers, and look for opportunities using available cardiovascular data.

Getting physicians on board

After integrating two practices, staff at Lourdes Cardiology Services, part of Lourdes Health System in Camden, N.J., decided to embrace the mantra of change and form a cardiovascular service line finance committee in hopes of aligning physicians and administration to improve hospital incentives.

To do so, the system created a master dashboard to define hospital metrics and measure each area of the service line to create transparent data for improved quality. “Our initial goals were to focus on eliminating unexplained clinical variation,” says Darius P. Sholevar, MD, an electrophysiologist at Lourdes Cardiology. While this was a tactic to enhance quality, it also became a mission to target waste.

“We looked at the bare-bone metrics, including the number of ablations, number of catheterizations, procedural volume, the costs per case and length of stay,” Sholevar adds.

While the staff had lofty goals, making these data available and changing the mindsets of the physicians would present a challenge. “For years, physicians and hospital administration have been operating within two completely separate worlds,” says Audrey H. Sernyak, MD, an interventional cardiologist at Lourdes Cardiology.

“For years, there has been no physician ownership in hospital costs. We have been shopping on the corporate credit card and somebody else has been paying the bills,” she says. “Now, we have to care.”

But how to change this mindset? Because physicians are so data-driven, Sernyak says the first place to start is the costs of a cath lab case. “It will be simple to find the low-hanging fruit,” she says. “We needed to find out what we are spending money on.”

Administration at Lourdes presented dashboard data completely unblinded to their physicians. Because physicians are so competitive, Sernyak says, it seemed to make them think twice about their performance and what they were costing the system. “Your physicians need to ask themselves, ‘Did that $60 balloon make a difference to the case clinically, or could I have saved $60 and used something clinically equivalent?’” she adds.

“We had to ask ourselves what things demonstrate no clinical efficacy that we are spending money on,” says Sernyak. At Lourdes, the first focus was on variable costs. And the biggest variables were in the use of anticoagulants, closure devices and the number of stents.

Lourdes reduced closure device use after staff determined that   the devices did not improve patient satisfaction and were only costing the practice money. To curb usage, physicians sat down to create guidelines on what patient cases a closure device would be warranted, such as patients who will discharge earlier or patients who can successfully ambulate.

By providing transparent data to physicians, Lourdes saw reduced costs, such as:
  • $800 per PCI cost savings in the first year and a $50 reduction per diagnostic cath case;
  • In groin closure devices, a savings of $185 per unit;
  • In same-day discharge after PCI, a savings of $250 per case; and
  • Decrease of 0.1 stent per case dropped cost by $140 per case.
It is imperative to get the financial staff and physicians together at one setting and present every piece of data. “This is where you will get action,” Sholevar says. “If you can show doctors that 10 percent of the sheaths that are opened in the cath lab are thrown out because they were inappropriate, that will really strike a nerve. After all, everyone wants to eliminate waste.”

Whatever the tactic, the message is clear—cardiovascular care needs to become more cost-effective. Strengthening physician and administrator relationships, making key cost data transparent and weeding out unnecessary costs provide a good start for gleaning savings while still enhancing care.