Crucial Component for Change: A Strong Physician Champion
Felix Lee, M.D., discusses the importance of physician engagement in establishing best practices, the role of physician advisors in HealthTrust’s clinical contracting strategy, and his goals for educating and enlisting physician champions on a local level.
What are some of the reasons you chose to specialize in interventional cardiology?
I originally majored in the neurosciences during college, but my interests turned to interventional cardiology during medical school after I witnessed the devastating, near-permanent effects of stroke. In contrast, during my cardiology rotation I realized what a profound effect something like timely primary balloon angioplasty and stenting could have in mere minutes, bringing patients suffering a massive heart attack back to full health.
As someone with a penchant to micromanage, I also realized no other specialty gives you the ability to pharmacologically control and manage so many aspects of the circulatory system. And that’s even before bringing in our armory of devices such as balloons, stents, pumps, oxygenators, pacemakers and defibrillators into the picture.
What kind of changes have you seen in the field of interventional cardiology since you first started your practice?
For the longest time, interventional cardiology was stuck at a plateau in terms of interventional device technology. We were only making incremental improvements with different stent designs and stent metals. But now, we have restenosis-defying drug-eluting stents, heart-supporting catheter-based left ventricle assist devices and blood-oxygenating ECMO devices. And advanced procedures using these devices are no longer restricted to major tertiary care centers with heart transplant programs; they’re also being done at our local community hospitals.
We have also seen many advances in how we treat structural heart disease over the past decade, including the ability to replace heart valves with minimally invasive, catheter-based valves. What used to require median sternotomy and full circulatory arrest can now be done with a catheter-based approach on a moderately sedated patient in a fraction of the time. A procedure that used to take five or six hours can now be performed in less than 90 minutes.
Technology advances have also allowed us to perform many procedures in a timelier fashion. That is the case with many of our STEMI (ST-segment elevation myocardial infarction) programs in which we treat all heart attacks as rapidly as possible. When patients come in with an acutely closed artery, our goal is to get them on a table, access their radial artery, perform coronary angiography, extract intra-arterial clot and deploy a stent—all within 60 minutes, as opposed to the national goal of 90 minutes. Even before the procedure is done, many of our patients feel better immediately. Some even want to hop right off the table, with their wristband in place, and return to work that afternoon.
Miniaturization has also allowed us to develop devices such as cardiac defibrillators that can be implanted underneath the skin to treat patients at high risk for sudden death with either severe heart failure or ventricular arrhythmias. Because defibrillators are recording and monitoring the heart rhythm 24/7, and have the ability to shock people out of a lethal arrhythmia even before they lose consciousness, they’re the best possible insurance policy.
As equipment and devices continue to get smaller, they are helping to decrease bleeding complications and mortality. Patients having a sudden cardiac event historically had a mortality rate of 80 to 85 percent, but today survive 50 to 60 percent of the time, getting through their acute illness and on to an improved quality of life.
What are your responsibilities as Good Samaritan Hospital’s medical director of cardiovascular services?
My duties include introducing new programs, ensuring the quality of current programs and improving practice management. Good Samaritan, like many other hospitals, is experiencing the growing pains of integrating electronic medical records (EMRs) with computerized physician order entry. As such, I’ve been involved in the design and implementation of our EMR order sets to make the physician experience easier and with as few clicks as possible.
One of my biggest responsibilities is in the area of continuing education. I enjoy getting physicians together in a public forum for a healthy debate so everyone can see the level of evidence behind each opinion. We have championed our own unique style of “edu-tainment” where we combine medical evidence-based education in a lively, entertaining debate format. This keeps our audience interested and, ultimately, helps us adopt best practices.
What’s an example of how this format has helped you adopt a best practice?
We’ve been extremely successful at redirecting many of our interventional cardiologists from a transfemoral approach for percutaneous coronary interventional procedures to a transradial one.
The majority of interventional cardiologists at our hospital are 50 years or older. Most of our training and practice have been with the traditional femoral approach, allowing us to take a fairly straightforward direct route to the heart, using large catheters through which wires, balloons and stents can rather easily pass for successful interventions. However, about 20 years ago, a number of pioneering physicians started to champion the radial access approach. Although the radial artery in the wrist is considerably smaller than the femoral artery in the groin, radial access bleeding after an intervention is easier to manage, monitor and control. Multiple large studies have since confirmed that a radial approach is much safer for patients than the femoral approach and better tolerated, which ultimately translates into fewer complications and lower mortality.
It became obvious to a number of us at Good Samaritan Hospital that moving to this approach would ultimately be the best practice. We knew we had the tools and the capabilities; now we just needed physician engagement. The difficulty in moving to the new technique was changing ingrained ways of doing things and the steep learning curve.
Given how busy we all were in our daily practices, we realized we had to make this change slowly and in a physician-friendly manner. Several of us started to adopt the radial approach until we reached 10 percent of our cases. We then held conferences and presented cases to highlight the benefits. We did not dictate anything to anyone, but physicians are competitive by nature and most did not want to be left behind the curve.
The result? In two years, we moved the needle for radial access from 5 to 6 percent to 75 percent adoption (65 percent of our interventions). Not only has it been a best practice for treating patients, it has helped the hospital’s bottom line. And that is how we achieved the ultimate value formula: interventional care with better quality and increased cost savings.
What role do physician advisors play in HealthTrust’s clinical contracting process?
The Physician Advisors Program was the brainchild of CMO Michael Schlosser, M.D., to engage practicing physicians and solicit their input on products’ strengths and failings. The idea is to bring professionals from all different kinds of hospital practice settings together to discuss what the clinical evidence has to say. We determine if a new product is better than one already on contract or if it presents an advantage that we could translate into better care and cost savings. A device that’s premium-priced without premium data backing it up generally won’t fly with our advisors. Is a $3,000 stent really better than a $300 stent? Our decision to recommend the adoption of a new product has everything to do with whether or not it will bring value to patients.
We hold teleconferences and quarterly on-site meetings in Nashville to discuss new devices, clinical trials, product recalls and how physician practices are being affected. The HealthTrust physician services team does a great job of reviewing hundreds of studies and summarizing the information in ways that are meaningful to physicians. HealthTrust ultimately uses our evidence-based findings to make better contracting decisions.
Ten years ago, physicians never participated in these discussions, as our professional fees weren’t tied to product costs. Our preference was for whatever was newest regardless of the cost. But with reimbursement amounts decreasing and the advent of episode-based bundled payments, many physicians now realize they have skin in the game and need to be a part of the conversation about product selection and utilization with an eye on costs. If physicians are wasteful, nothing will be left in the bucket for physician payments.
As cardiovascular service line medical director for HealthTrust, what are your goals for educating physicians to be leaders in the clinical contracting process?
My job is to help manage change in a collaborative manner. Disruptive changes bring efficiencies and clinical benefits in the long run, but we’re still working to get past the upfront hurdles. I want to help our regional physician advisors learn how to become champions of value-based care in their community.
Physician are more likely to trust and listen to other physicians; we have credibility with one another because we work in the same clinical trenches.
When we find a particular product or approach that is significantly better than what we presently have, we need to evangelize its use. I want physician advisors to be the ones to get the word out. These trusted local relationships are what will drive best practice consensus and accelerate adoption of technology that is truly the best on the market.