Enhancing the Cardiovascular Service Line for Value-Based Success

Many issues are impacting today’s clinical service lines, especially cardiovascular services. Health systems, hospitals, and physician groups are focusing on growing their cardiovascular service lines to address shifts in site-of-service, improve patient access, and position themselves for enhanced financial performance under value-based contracts. 

In this episode of Value-Based Care Insights, Daniel J. Marino talks with Dr. Hani Salti, a clinical cardiologist and Clinical Assistant Professor at a large academic-based health system.  Dr. Salti shares his insights on the growth of cardiovascular service lines, the need to develop strong physician leadership, and the growing impact of cardiovascular services on population health.  

KEY TAKEAWAYS: 

• The cardiovascular service line drives tremendous clinical value by creating a comprehensive longitudinal care model that includes general cardiology, invasive, and non-invasive services.
• New financial models will align incentives and modify behaviors of cardiovascular physicians, providers, and payers.
• Value-based performance will have a sizable impact on cardiovascular services creating financial opportunities.

LISTEN TO THE EPISODE:

 

 Transcript:

Daniel J. Marino: 

Welcome to Value-Based Care Insights. I'm your host, Daniel Marino. In today's episode, we're going to spend some time talking about cardiovascular service lines. As I've mentioned in previous episodes, hospitals have focused a lot of attention, on expanding their capabilities in different service lines. 

Some hospitals and health systems and even some physician groups have spent a lot of time expanding primary care, service line, orthopedic service line. But cardiovascular service line is interesting in the fact that it touches a lot of different subspecialties and incorporates a lot of different areas of needs within the patient populations, if you will. 

And there's been a couple of real drivers for that. I think one is that as our population starts to age, cardiovascular services is an important element that patients are looking for to continue to, allow for a healthy lifestyle. What we're also starting to see is that, as we start to advance into population health and we track our outcomes and we look at social determinant factors, cardiovascular care is a natural progression that patients are looking to really begin to manage around. 

Payers are looking for it in terms of being able to track a lot of our outcomes, and it does provide a pretty strong economic opportunity. Four hospitals, four health systems, and frankly, for physician groups. Well, to continue the discussion today, I am really pleased. To have a great guest joining me today, Dr. Hani Salti, he is a physician with a very prominent cardiovascular group, has worked in obviously cardiovascular services in in all of his career, but he brings a very interesting perspective to our conversation today. Not only is he involved. In the growth and the direction of cardiovascular services of his group. 

But he's also very involved in a lot of the population health and value-based components related to cardiovascular care as well. Dr. Salti, welcome to the program.  

Dr. Salti:

Thank you for having me. Please to be here. 

Daniel J. Marino:

So, Dr. Salti, when you think about where cardiology, where cardiovascular care has gone, boy, it's made tremendous amount of leaps over the years. Reflecting back, what do you see are some of the biggest changes that has affected you, your colleagues? I guess the specialty in total.

Dr. Salti:

There have been a lot of changes over the years and it, this is an ever-changing, service line and product. 

And I look back to even my medical school and my early training years. I was in Michigan Medical School in University of Michigan and, Northwestern for training. And if you think about those times, these were hubs, tertiary care hubs where patients would come to from all over the state and sometimes from all over the country to see a particular specialist, whether it's in cardiovascular care or any other specialty. 

And they come, they get their service there. They may stay for a period of time, even in the local geography, and then they go back to their locales. And over the years, some of the earliest changes is where institutions are bringing the care more to where patients are and so the geography has become different in terms of where the care is offered what the patients have to do to access that care. 

And that's just to begin with.

Daniel J. Marino:

right. I agree with you. You know, I've had the opportunity early in my career, I've worked with a pretty large integrated cardiovascular group and it's always been a specialty that's been near and dear to my heart. I provided a lot of practice administration for the group, and you are right, we set ourselves up for a destination center. 

And now it seems like. Through a lot of the advancements of technologies, through a lot of the advancements of therapies and so forth, care has become a lot more localized. But what I'm also seeing, and I would be interested in hearing your thoughts on this, it used to be that cardiovascular services, the interventional side was very transactional based, right? 

So a patient became a candidate for surgery, we immediately put them in surgery, and then they transitioned out. Now within cardio with cardiovascular care, it's very integrated, it's managed, it's focused, so as a patient becomes a candidate for cardiovascular care. They're monitored. There's a lot of therapies. 

The interventional side almost becomes, I don't want to say a last resort, but it's certainly not the first resort of treatment as we begin to think about that. And, and so it's really expanded the whole dynamics of what cardiovascular services really is. How has your group really responded to that? 

Dr. Salti:

It’s absolutely a reality and a challenge that every group has to deal with and it's actually every group has to embrace and this actually speaks to the comprehensive care of the patient. The patient does not come and see you just to get a procedure and to go through the procedure well. The patient wants to be healthy, to have good outcomes to live life the way, the way they desire. And so this is not simply taking care of them, it is not simply about performing a procedure and having a good outcome of the procedure.  

So even our outcomes are not measured based on procedure complication rates or success or failure, our outcomes based on how are patients doing overall. Are they even satisfied with the care just in terms of patient satisfaction and so it's a com and then the services we have to offer them are not have to be comprehensive. They cannot be a successful service line, you need to be able to offer the patient the full scope of what needs to be offered to them in various situations, whether it's procedures, including surgeries, whether it's cardiac, rehab, preventative care, devices for electrophysiology colleagues. And so you have to take them and be able to take them through the entire journey as they seek care from you and you deliver it.

Daniel J. Marino:

That is such an important point, and I would even go so far as to say that is a really a primary critical success factor of building a successful cardiovascular service line. You need to have all of the subspecialties integrated, right? So, they're working together and managing the patient where they are as the patient's risk, condition and complexity needs change. 

And, you know, when you think about it from a value-based care population health perspective. You're measuring really the outcomes over that of that patient over time. But if you do this well and you have clinical pathways and protocols that you're able to measure, you will significantly impact the overall cost of care, and at the same time provide an incredible experience to the patient.

Dr. Salti:

That's very true. And for somebody delivering the care you need to understand the patient as they come to you. What is their risk? What are their comorbidities? What other diseases interact with each other? So, population health, tremendously valuable. To be able to understand it, utilize it in, in all your decisions, so that you understand the person the patient as they come to you in their entirety. 

And of course, that's tied to outcomes, payments, reimbursement, which in turn feeds back to your, to your experience as a provider delivering that care. Yeah I absolutely agree. You know, one of the challenges that I often see as I work with A number of different service lines not just cardiovascular services, but access is an issue. 

Access is an issue all over healthcare, whether it's primary care, it's, you know, cardiology, cardiovascular services, whether it's orthopedics, it seems like, you know, there continues to, to not be enough physicians, not enough providers, and yet the needs are certainly there in delivering that care to the patients. 

How your group responded to some of the access changes and really the needs of the patients? One response is what I was touching upon earlier, which is you have to expand your geography. You have to meet patients where they're at geographically. You, you should not expect them anymore to come to you. 

And this is not just in cardiology, I mean patients. Patients press a button and expect a car to come pick them up, right? Or, or press a button and expect the food to come to them. And it should be no different in healthcare. They, they want the healthcare to be where they're at and to meet them where they're at. 

And so, to make yourself available where the patients are available is very important and then you have to make, you have to understand your referral patterns. Some of them are their traditional, you mee the primary care doctors. You have to build relationships with them or other specialties. 

But also sometimes, we we're seeing more and more self-referrals, right? Study the various entities that are supplying care in their area. And they're choosy. They may choose a primary care doctor in one institution and see a specialist in another institution simply because of either reputation or what they offer or where they're at. 

Daniel J. Marino:

Right. Or convenience for that matter.

Dr. Salti:

Convenience. And you have to remember, a lot of patients are not even seeing the traditional primary care. They’re getting their services in alternate locales, whether it's at the pharmacy even. So how they come to you is different and you need to meet them where they're at. You should not expect them to adapt to what you want, how you want them to behave. You need to, you know, be available for them.

Daniel J. Marino:

That is such an interesting point. You know, an important point too, the paradigm shift I think is we are, we all are, are going through right now to provide more convenience based healthcare services is something that is, is critical and patients are asking for that, you know, and, and some of the subspecialties, I think we tend to focus more on that traditional way of delivering care where we want the patient to actually make the appointment and come to see the physician. 

But you are spot on. You need to have a lot of different types of opportunities to connect with the patient, whether it's through telehealth or it's through other types of conversations, or be open to the fact that, you know, patients may be self-referring and, and so that relationship with the patient versus the relationship with their PCP.  

Frankly, maybe a little bit different  

If you're just tuning in. I'm Daniel Marino and you're listening to Value-Based Care Insights. I am here talking to Dr. Hani Salti. We're discussing the advancement of cardiovascular service lines and Dr. Salti's perspective on what makes for a successful service line. 

Great discussion. Dr. Salti, as I think about the value-based care component of this an area that I think is always a little bit of a challenge is as we start to think about really aligning the patient with their primary care. Many patients that are within cardiovascular services see their cardiologist as their primary care physician. Right. And cardiologists are internal medicine trained and many of them do a fantastic job of providing primary care services. How do you manage that within your group? Do you assume some of that primary care responsibilities for the patient helping you to kind of manage the total complexity and needs of that patient? Or is your preference to send them back to the primary care physician and maybe have that collaborative working relationship with the pcp? 

Dr. Salti:

I think as a group, our preference is to have a collaborative relationship. Having said that, we have seen all the whole breadth of how patients perceive cardiology.

Daniel J. Marino:

Yeah, I can imagine. Sure. 

Dr. Salti:

Yeah. And, and some of our maybe older cardiologists who have been in practice decades and still may function like that in certain situations. But then generally, and I think that's true for most is we try to encourage them to have a relationship with to keep the relationship with their primary care doctors. 

And if they don't have it because they saw you primarily without a referral, we definitely encourage them to establish the relationship with the primary care doctor. 

Daniel J. Marino:

Yeah. And I do think that's probably the preferred approach, right. You know, to really create that alignment and, and from a value-based contracting standpoint, you know we're constantly looking at who the patient is attributed to and really putting together a very collaborative, very comprehensive approach to managing that care, not just for cardiovascular services, but if the patient has say, you know, a GI issue or orthopedic issue or whatever the case may be, it's, it's coordinated through the primary care. So that makes a lot of sense. 

Dr. Salti:

Yeah, absolutely. And, and, you know, population health is not an individual effort. You can expect Exactly A particular specialist to capture the entire popul risk of your patient and let alone the whole population. So, it is a team collaborative effort with multiple, of course, primary care, but all the specialists have to participate in capturing their respective, you know, conditions of the patients and documenting on it. 

And so, it has to be a collaborative effort for it to be successful.

Daniel J. Marino:

Yeah, great point, great point. I absolutely agree. You know, when you, when you look at cardiovascular care over the last couple of years we're seeing a lot of pressures to shift a lot of the care that's being delivered. Mostly the interventionalists or procedural type care. 

You know, a couple years ago, a vast majority of it was done in the hospital, on an acute basis. More and more now is being shifted to the ambulatory setting or the outpatient setting. How has your group dealt with that? How have you managed that transitions that that undoubtedly have occurred?

Dr. Salti:

So, it's a challenge. It's a and again, challenges have to be embraced. Absolutely. But it's, it's a challenge and so it's about number one access. So again, you have to shift some of the services to ambulator, which enhances access to the patient, but also you need to be able to deliver the same quality of care in all these settings that you're, that you're at. 

So, and that's true. Not just on the provider side, but even. A patient may come and have an, have an echocardiogram performed in an offsite versus in the hospital, the quality of that echocardiogram needs to be the same, right? And, so you need to train your sonographers, you need to train the, the support staff to, to be able to deliver the same quality and the same experience with the patient wherever they meet you.  

Right. And that is a challenge. You know, we talk about practice variability among providers and physicians, but there could be practice variability in how even our support staff is able to support that care.  

Daniel J. Marino:

Oh, absolutely. And I think that level of training, at least initially, is different, right? 

I mean, there is some training that has to occur more on the outpatient arena. And just making sure that the investments in the equipment are there and you know, just the overall focus and attention is really given to the ambulatory arena. I think it's easier to accommodate that in the hospital because it's more just the philosophy, the mentality is

Dr. Salti:

Yes. And, and even administrative staff are present. Yeah, mostly in the hospitals. They see what's happening. They can see what's on the ground, what's needed, but to have a fully functioning Offsite that's able to deliver the same quality and you know that that site needs to be function independently and  

Daniel J. Marino:

No, I agree with you. So, if you, you know, given where your group has gone and some of the, the upcoming challenges or changes that are undoubtedly occur, we talked about many of them here today. 

You know, the, um, Let's say the impacts of population health and value-based care shifts in the site of care from acute to ambulatory. Um, you know, managing, working with the different providers and managing the care more, you know, collaboratively. So forth. Where do you see the big growth opportunities occurring for cardiovascular services as you sort of, you know, look at your crystal ball and think about where things might go in the next couple of years?

Dr. Salti:

So, first of all, the opportunities are always there. The patients are living longer.  the cardiovascular disease still remains, you know, the number one prevalence. And so the population, the opportunity for growth is there. You need to be able to meet it with access, comprehensive care, quality care. 

The scope of care that you deliver and you need to be able to build all those elements that can support, your care. Whether it’s, the interventional side, the structural side, the heart failure side, the EP side, preventative, weight management, cardiac rehab. And so the growth will be there as you support those services, but you need to be able to invest, in those services and ensure that you deliver that you have access. The patients have access to them and you deliver it with good quality.

Daniel J. Marino:

Yeah. And all those elements tied together, like you said, taking advantage of. Where the, you know, the environment is going and the reimbursement elements and so forth. You know, as you're thinking, as you were kind of describing that we've had an opportunity to work with a number of different service lines at cardiovascular service lines, has been one that we've worked with quite a bit, and we've done a lot of strategic development, a lot of areas where we've developed strategic plans and so forth. 

And you really do have to think about cardiovascular services and the service line as its own separate business, right? Where are we going to grow? How are we going to be able to take the care out to the community? And even how we're going to market ourselves, right? Creating ourselves, branding ourselves around high performing cardiovascular services. That recognition and connection with the patient becomes really powerful. And as you kind of think through all the elements that you just talked about, building that into a strategy that really allows you to gain a lot of momentum and really see a lot of opportunity for growth.

Dr. Salti:

And once you acquire a patient and allow them access into your system, there's a big trickledown effect into multiple divisions within your organization. Be, you know, a cardiac patient will touch multiple, aspects of your division, whether it's radiology. Cardiovascular surgery and vascular are of course almost automatic, but renal, endocrine and diabetes,  support, whether it's oncology and hematology and coagulation issues, vascular medicine, pulmonary and critical care. 

So, you are supporting the services then offered by all these other specialties and so a successful cardiology service line is, In instrumental in the success of an entire organization.

Daniel J. Marino:

Yeah. Boy, that is an absolute great point. So, any of our listeners today, you know, that are tuning in, that are interested in expanding their cardiovascular service line maybe kind of reaching out and connecting with some of their community providers. Is there a couple piece of advice that you may offer some of our listeners today in terms of where they are and maybe where they need to go?

Dr. Salti:

You know, I think it boils down to the basic access quality, scope of care delivered, be able to be, be available, do-good work, and be able to, to provide what the patient needs. 

And once you work with these three elements, You can scale them up to your capability and time allow, but that's where, yeah, any, anybody can start.

Daniel J. Marino:

Well, I agree with you and the, you know, one of the things that's always fascinated me about cardiovascular services is, you know, it touches so many different areas of the healthcare continuum, right? Not just in terms of what happens in the hospital and the ambulatory, but certainly expanding to post-acute and care in the home, which there's a lot of focus on, but it also integrates a lot of the providers and the providers’ support. So, I think reflecting back on those three elements, access, quality, the scope of care. 

For an organization that really focuses a lot of attention on this, there is a, there, there's a tremendous opportunity for you to expand the amount of services, expand your breadth of reach to the community, as well as then be able to contract around it. 

Dr. Salti:

Correct? Correct. And, and, and you'll be able to lift up other aspects of your, of the organization you're working with as you do it successfully. 

Yeah, absolutely. Well, Dr. Salti, I want to thank you for coming on the program today. You know, it's been a great discussion as I mentioned, cardiovascular services. I'm doing a lot of work in this area right now. It's always an area that has been near and dear to my heart, and sounds like you've done fantastic in your group. 

So I'm very excited for your direction and I'm particularly excited about how you're taking a population health. Value-based care approach to it because again, as you know, on value-based care insights, that's an important element that we try to share with the group. So, I commend you for, for really thinking through that a lot. You're doing a nice job.

Thank you very much. Pleasure to be here. And yes those are all things we cannot forget about and more to come. This is the beginning of our journey. Not the end yet.  

Daniel J. Marino:

Yeah, absolutely. Well, for our listeners today, I want to thank everyone for tuning in. Great discussion on cardiovascular services. And as Dr. Salti mentioned, you know, it really comes down to thinking through what the strategy is. Thinking through what the approach is, dealing with access, dealing with your collaboration with your physicians, so on and so forth. I want to thank all of our listeners again for tuning in until the next insight. 

I am Daniel Marino, bringing you 30 minutes of value to your day. Take care.

About Value-Based Care Insights Podcast

Value-Based Care Insights is a podcast that explores how to optimize the performance of programs to meet the demands of an increasingly value-based care payment environment. Hosted by Daniel J. Marino, the VBCI podcast highlights recognized experts in the field and within Lumina Health Partners