Reimagining Cardiovascular Service Lines to Drive Growth and Value

Daniel Marino:  

Welcome to Value-Based Care Insights. I am your host, Daniel Marino. As I mentioned on previous episodes, we are spending time talking about different service lines that are impacting physicians, hospitals, health systems across the country. And in today's episode, we're going to take a deep dive into cardiovascular services. Cardiovascular services is one of the areas that I've been very familiar with over the course of my career. I had the opportunity early on in my career to manage an internal medicine group, of which we had about a half-dozen cardiology and cardiovascular surgeons that were part of the group. So, I've really spent a lot of time over the course of my career, both helping medical groups, hospitals, and health systems with cardiovascular services. But really watching the change that has impacted the service line, and for the most part, really impacted physicians and patients as we see that evolution occur, particularly around where care is being delivered, inpatient versus outpatient. But also with the increased focus on preventative care that has occurred in cardiovascular services. 

Well, I'm really excited today to have a good friend and an individual I've known for quite some time, Dr. Nihar Desai. Dr. Desai, Associate Professor of Medicine and Vice Chief of Cardiovascular Medicine at Yale School of Medicine. He leads the research, operational initiatives, and focuses on a lot of the outcomes related to improving cardiovascular care, care delivery, and even value-based outcomes for Yale New Haven Health System. Nihar, welcome to the program! 

Nihar Desai:  

Thanks so much, Dan. It's great to be with you, and I'm very much looking forward to our discussion.  

Daniel Marino: 

So, Nihar, as was mentioned, cardiovascular services has really evolved over the last number of years. I mean, even thinking back 5 years where it's come from, and some of the services that it's evolved to today, you know, related to shifts in where care is being delivered, and, you know, as I mentioned, some of the preventative-type care, some of the therapeutics that are included in here. From your perspective, what are… what have you seen as some of the exciting trends or changes that have occurred over the last number of years within cardiovascular services? 

Nihar Desai:  

Yeah, Dan, I think that's a great place to start, and in many ways, we're in the golden age of cardiovascular medicine. I think there's never been a time where we've known more about the pathobiology of cardiovascular disease. We have a rising, you know, sort of prevalence. People really need cardiovascular disease prevention and cardiovascular care. We have an expanding toolkit, more treatments, more pharmacotherapies, more devices, you know, more things that we can do for the patients that we care for. And yet, at the same time, I think we find ourselves, you know, confronted by the more sobering, aspects of cardiovascular medicine and cardiovascular care delivery. We find, you know, quality is suboptimal, that variation, you know, lingers, disparities are too great, and costs continue to spiral. And so we have to confront  sort of these two things that are happening in parallel, that on the one hand, we've got more insights and more treatments and more things we can do. And yet, at the same time, we have some pretty profound challenges in terms of our operations, our care delivery processes, and the financing model that really brings us to much of our discussion, I think, around the push to value, but some of the inherent complexities and challenges that we have to face. I mean, I'll give you one, you know, maybe quick example on that front of you know, again, at the same time that we have all of these great things happening. We have more and more challenges in terms of access. Patients have a harder and harder time accessing, you know, services. Costs continue to spiral. We have very, very high fixed costs. Labor costs, especially on the hospital side of things, have gone up very substantially over the last, you know, 5 years. And revenues obviously have not kept up, and so the math really is starting to be quite, quite difficult when you think about the care model, the traditional care model that we have been, you know, kind of embedded in. And so, I think that really raises the specter of, how do we reimagine the experience of patients? How do we reimagine cardiovascular care delivery? how it's being done, who's doing it, where it's happening, what technology is being brought to bear to kind of facilitate and enable it, and I do think that that is what's required, is a true reimagination. 

Daniel Marino:  

Well, and I think we're going to continue to see, as we start to incorporate more and more innovation and AI, and I want to get to that in a second, but you're going to see continued shifts in evolution around cardiovascular medicine, right? And how it's being able to…how we're readjusting or taking care of the patients. But if you just think back. What's happened even over the last 5 years? I mean, I could remember working with a cardiology group and a cardiovascular medicine group, and, you know, there was a vast majority of the care that was being done inpatient, or at least, you know, where, if it wasn't being done inpatient, even some of the procedures and so forth were done in more of a 23-hour observation and so forth. And now you fast forward to where we are now, and it seems like much more is being done in the ambulatory arena. Much more is being done using therapeutics and so forth. How have you seen that shift? Or maybe the better question is, how have you adjusted to that trend and to that shift? 

Nihar Desai:  

Yeah, Dan, I think it's a great, you know, theme to touch on. I think we went through this phase, I think we're still in the midst of it, around an incredible amount of consolidation in healthcare, on the delivery side, and I think cardiology was really an important part of that story. 

Daniel Marino:  

Yeah. 

Nihar Desai:  

I think we had more and more providers that used to be in private, you know, community-based, you know, practices being absorbed into hospitals and health systems, and I think there were obvious, you know, financial reasons why those things happened. And yet at the same time, now we're seeing, in the same regard, that patients actually want care closer to home. 

Daniel Marino:

They do. 

Nihar Desai: 

That might be more convenient to them. They don't want to spend time, you know, in the hospital if it can be avoided. And now we're also seeing changes on the payment side when it comes to site of service where there might be more neutrality in terms of, you know, how payments are distributed, and so people are having to navigate these things. I will say, the other big, push that's happened in the field is that technology has now enabled things to happen in a fundamentally different way. What used to require a multi-day hospitalization can now be done same day. You know, what used to be a 4- or 5-day hospitalization for an acute coronary syndrome, even. You know, patients are seen in the emergency department, they may go to the cath lab that afternoon, and they might go home the next morning. And so we've seen a kind of a fundamental change in the technology in kind of how services can be rapidly mobilized for care. We see a demand on the side of patients to really have care that's closer to home, that's much more convenient and accessible. And we also have these changes on the payment side that are also sort of saying, hey, what's the right place for this care to happen, where it's most safe and effectively delivered, and most efficiently delivered. And the large, you know, tertiary quaternary care referral center may not be the optimal site of care for everything.  

Daniel Marino:  

Yeah, I would agree with you, and, you know, it's an interesting dynamic, as you laid this out, because you're absolutely right. We're seeing shifts in site of service to ambulatory, we're seeing our care being delivered more efficiently, right, with better outcomes, which has been great for the patients, but our costs continue to go up, right? And yet when you look at the level of reimbursement, and the reimbursement pressures that are being placed on cardiovascular services, it's not going up. As a matter of fact, it's going down. And I can't help but wonder, as you think about even your planning and how we begin to think about delivering care where it's needed around all of those areas that drive efficiency. If the revenue doesn't keep up with your expenses, you're gonna have a tough… a continued tough time to be able to hire and to maintain good staff, good physicians, good providers to support the care. 

Nihar Desai:  

Yeah, Dan, I think you hit it right on the head. I think, you know, Medicare has certainly, you know, telegraphed this to us. I mean, they're proposing additional cuts, you know, on the subspecialty side of things. There's budget neutrality, so there's obviously a relatively fixed, you know, pool of funds for that, and how those are distributed matters a lot. We've got to sort of think about, you know, the impact on equity and access and what that means for a large academic health system like ours. And I will also say, I think, you know, we're trying to make investments across the board. I mean, we're trying to grow and invest in hospital-based, you know, programs. In procedural and imaging-based, you know, modalities that we think represent the frontier of medicine, the best of what our patients want and deserve. And we also have to invest in the community, and we want to have, you know accessibility and offices, where people are, kind of looking carefully at the geography that we serve, where patients are coming from, to access our system, and if there's an opportunity for us to be in their community to provide, maybe, primary levels of service, and to even provide subspecialty service that's close to home, then we certainly want to be able to do that. Now, you're right that despite the all of these things, and all of the benefits that we see from that, if the revenue doesn't keep up, then that makes the math harder and harder and harder. It makes it difficult to build infrastructure, to make investments, to hire personnel, and at the same time, like we've sort of alluded to all along. We have incredible access challenges, and so if anything, we feel like we need to hire more. 

Daniel Marino:

Right. 

Nihar Desai:  

Both physicians, advanced practice providers, pharmacists, others members of the care team that can do different things, and that's sort of getting back to that reimagination of who's actually doing the care, but we certainly need more clinicians, you know. 

Daniel Marino:  

Yeah, to keep up with all the access challenges, no doubt about it. If you're just tuning in, you're listening to Value-Based Care Insights. I am here with Dr. Nihar Desai, Associate Professor of Medicine and Vice Chief of Cardiovascular Medicine at Yale School of Medicine, and we are talking about the impacts of cardiovascular medicine, and really the changes that have occurred, as well as the future trends. So, Nihar, I want to ask a question. As you were talking and describing the changes and the challenges, certainly with the payments. You know, the natural thing that comes to my mind is, you know, is value-based care now starting to really creep in as a way of being able to help better support the economic structure? In other words, are you tracking a lot of your outcomes? Not just your quality outcomes, but your performance outcomes in such a way that says, you know, hey, payer, you know, we need to share in the results here, right? Because, obviously, it's keeping costs down for them, it's keeping the premiums lower, you know, are you able to incorporate that into a lot of your value-based care agreements? So, it's helping to, I don't want to say subsidize, but create a new revenue stream, if you will, that are really aligned around what those incentives are. 

Nihar Desai:  

Yeah, Dan, I think that's a… that's a great point. I think it represents one of the true, kind of, fundamental questions that we're all going to have to confront, which is, we've been tethered mostly to traditional volume-based fee-for-service, and certainly on the hospital and academic health system side, that's where we've primarily been. And, you know, for lots of reasons, including many of the ones that you have said, we realize that the future has to be around population-based payments and value-based care and alternative payment models. And, of course, we've always had that to some degree. I mean, you can rewind the clock, you know, more than 10 years, and say, you know, we had the Affordable Care Act, we had Hospital Readmission Reduction Program, you know, we had payments that were at least, you know, tied to quality and outcomes, but increasingly, I think we're all realizing that the more of the ACO model, more of the population-based, you know, payments are going to be essential if we really can do what patients want, which is prevention, avoiding costly hospitalizations, that we can deliver all the preventative therapies that continue to emerge and can have impact for patients, but then to do so in a way that fiscally rewards, you know, payers. As well as those that are providing care. And obviously, things will continue to blur around that line of, you know, who is the payer and who is the deliverer as systems, you know, continue to take on more and more risk. Yeah, I think one challenge that we have to sort of confront, though, is You know, for many hospitals, we are still heavily tethered and connected to fee-for-service, that the business… 

Daniel Marino:  

Many hospitals, I mean, you're not any different. You see that across the country. 

Nihar Desai:  

Yeah, and so, you know, that model, you know, where you're really thinking about volume, you're thinking about capacity, you're thinking about throughput, versus a population-based model, where you really think about, you know, prevention and avoidance of, you know, costly utilization. I mean, they are a bit at odds. There's obviously a tension there. Now, I will say, we're quite, you know, eager and interested to see how CMS rolls out, you know, like, the ambulatory specialty model on the outpatient side, where heart failure is, you know, one of the, you know, key focus areas for that, you know, new initiative that's going to launch in, you know, in January. And so, I think we're eager, again, to start using some of our experience in those types of programs to learn to develop some additional muscle memory around how do we use data, how do we use that data to drive, you know, operational improvement to deliver the kind of care that our patients want, and then also to be, you know, fiscally and financially rewarded for delivering, kind of, on that value proposition. 

Daniel Marino:  

Right. Well, going all the way back to, you know, the beginning of time of population health, and even thinking about the early days of clinical integration, cardiovascular related comorbidities, or cardiology comorbidities, was always a driver, right? It still is today, right? When you think about managing patients with high blood pressure, or managing patients with CHF, or managing patients with coronary artery disease. You know, we all know that as you start to be… to introduce prevention, monitoring, all of those things could really help a lot of downstream, or save a lot of downstream costs, and not… as well as then really improve a lot of… a lot of the outcomes. So, you know, so when you're thinking about this, let's fast forward a little bit to the future. Artificial intelligence is really giving us a whole new avenue to begin to think about how we want to manage patients. And, you know, we're doing work right now with one organization where we're aggregating data, and not only are we helping them to think about, through this data, what's the right care plan, but probability models based on risk cohorts of different patients. But it's all built on those comorbidities of patients. Where do you see… where do you see cardiovascular services or cardiovascular medicine evolving to with the integration of artificial intelligence to kind of provide that level of knowledge, influence, care model changes, or what have you? 

Nihar Desai:  

Yeah, Dan, I think that… I think AI has a lot of promise in the cardiovascular realm for many of the reasons that you've said. I think in the here and now, we are… we're certainly using AI. I mean, we have, you know, communication tools that we're using to you know, kind of reimagine and re-envision our ambulatory practice, that, you know, a physician or a provider is having an outpatient visit, and, you know, when they go into their electronic health record, there's essentially a templated note that's kind of waiting. 

Daniel Marino: 

Yeah. 

Nihar Desai:  

You know, at the end of that, you know, at the end of that outpatient visit. I think more so to the future, as you kind of say, there's this idea of prediction. Kind of risk protection and early identification of patients that might have rising risk, that, you know, patterns that are invisible to the human eye, if you will, but that are very identifiable to a computer algorithm, or to an AI algorithm.I think will help us better align preventive therapies to rising risk. 

Daniel Marino:  

I think it's going to help tremendously. I think it could help tremendously, because what it does, especially when you look at cardiovascular medicine and those issues that impact patients. You know, there's, you know, there's the physical issues that relate to patients, but there's also a lot of social determinant factors. There's also a lot of factors that are lifestyle, influencers that oftentimes aren't necessarily as large of a focus as it should be. I think as you start to think about creating the right care plan, or even the right potential outcomes, I feel like incorporating some of that into an AI model, and certainly a prognostic or a probability-based model, would certainly give, you know, you and your colleagues, I think. Other opportunities to create more focused care plans. 

Nihar Desai:  

Yeah, that's right, Dan, because I think what we've learned, and I think as you get back to, sort of, a population health mindset and a value mindset, I mean, one of the things we always say to our team is, you know, doing everything for everyone is not a plan. We've got to be able to sub-segment, you know, population to really tailor interventions and care models to the risk that, you know, these populations have, the specific needs that individuals have. And I think AI has a lot of potential to help us with that. Its ability to refine and to, in a much more sophisticated way. Sub-segment, you know, populations to really help us identify the unique needs or the particularly important interventions or therapies that may be particularly beneficial. I think that's where, you know, some of the power of AI, you know, really can come. And so, yeah. 

Daniel Marino:  

I agree. 

Nihar Desai:  

I think we're all optimistic. Yeah, I think we're all optimistic that as digital tools continue to come, as we have more and more data streaming in, you know, about patients, that will need some of these adjunctive tools to help us, you know, distill and curate that information into actionable insights. 

Daniel Marino:  

Well, I would think… you have to be really looking forward to that, because I know working with you in the past, you love data, you love being able to understand the insights out of the data, and I would think being able to now aggregate it on a much higher level and incorporate that into different treatment plans and have us… having more focused care plans. I mean, I would think that's got to be very exciting to you and to many of your colleagues that you work with. 

Nihar Desai:  

Yeah, Dan, I think you're right. I mean, I think for us, we've been very bullish on, you know, trying to you know, stream different streams of data together, that that has to be part of the answer here, that bringing together clinical data with operational data and financial data, that's been part of our recipe for some time. I think, the advent and the ability of AI to even further that to kind of enhance that, to bring it together, and also couple it with much more deeply phenotyped data on individual patients. Like you said, not just about clinical factors, but maybe social determinants and other factors that we know are highly predictive with clinical events and outcomes. I think that really represents the frontier for us, yeah. 

Daniel Marino:  

Yeah, I agree. Do you think… you know, you mentioned access being a challenge. Access is a challenge for everybody, right? And I think we're really trying to figure it out, and I've… as I've said before, and I'm a firm believer of this, I don't think we're going to solve the access problem by just recruiting, because, you know. Yale School of Medicine, as well as every other health system in the country, is all vying for the same physicians that are coming out of school, right? But… so, what are your thoughts with access? Do you… do you feel like, you know, from what you're… from what you understand and what you see with AI, do you think AI has an opportunity to help solve the access problem? 

Nihar Desai:  

Yeah, I do, Dan, because I think, again, what we do now is, again, you know, we have to sort of appreciate just how stark the contrast is, that on. 

Daniel Marino:  

Yes, absolutely. 

Nihar Desai:  

On the biology and the pathophysiology and the treatment side, we're innovating so fast, and yet the delivery model for care essentially hasn't really changed. 

Daniel Marino:  

No, it's been very antiquated.

Nihar Desai:

Absolutely. Like, we still expect people to drive 45 minutes, to pay $8 to park, to sit for 20 minutes in the waiting room for a 15-minute visit with someone, and I think that model has to be fundamentally disrupted. Now, that might be the right care plan and site, and care delivery operation. For a particular profile of patient that has a specific kind of need, and wants and needs, and really deserves and benefits from that kind of care delivery might not be what everybody wants, and so I think we've got to be ready to reimagine what is that care, where is it happening, and who's doing it. A cardiologist obviously brings a lot of expertise and training, but we've got terrific you know, members of our care team, our advanced practice providers, we work side by side, shoulder to shoulder with them on the inpatient side and the outpatient side, in the procedural laboratories. We've got pharmacists and nurses and others that we all have to bring into this. And I think that mindset of a true multidisciplinary team of who's ready and able and willing to kind of help care for our patients in the way that they want and deserve? And I think there's a lot to be gained and a lot to be kind of reimagined, you know, through that work as well. 

Daniel Marino:  

That's such a great point. I mean, bringing the care team together in a way that you're really focusing that care to really that specific need of the patient, that's what's going to solve this, right? As well as then some of the innovative approaches that, like you said, we're going to have to figure out how we incorporate that differently than, you know, and moving beyond just the traditional model. Well, Dr. Desai, this has been fantastic. I, I really appreciate it. I love the conversation. You know, you certainly are at the forefront of a lot of the areas of cardiovascular medicine and cardiovascular services. For any of our providers that are listening or tuning in, any piece of advice you might share with them in terms of, you know, maybe what they should look for as they think about working with their physicians? 

Nihar Desai:  

Yeah, Dan, I think, you know, this has been a terrific conversation, and obviously one I'm eager to continue on for our, you know, for us and for our audience. You know, I would say, start pulling data together. Data too often is fragmented and isolated. There's sort of groups that use one type of data over here, and others that use different types of data over there. But I think if you bring it together and see it through the lens of the patient, you know, what is the patient's experience? What is their journey? How are they touching the system, and where are all the places where we can make things better for them? In the acute setting, in the longitudinal setting, in all the coordination and continuity of care that we have to provide to them, I think that is really the North Star that's going to get us out of this, is we need data, but we have to get through the patient's lens. 

Daniel Marino:  

Yeah, we have to look at data, but we have to use it as insightful insights, right? So we really begin to think about it and what's going to help the patient, so I couldn't agree with you more. Nihar, thank you so much for coming on the program. This has been a fascinating discussion. I think just… just great diving into this with you, and you know, best of luck to you and to your colleagues as you begin to move on, and, you know, we'd love to have you back on at some point down the road to even kind of hear how you've continued to evolve cardiovascular medicine. 

Nihar Desai:  

It sounds great. Well, thanks again, Dan, for the opportunity. You know, all best to you and our audience, and yeah, certainly look forward to more discussions like this. 

Daniel Marino: 

Great. Well, thank you, thank you again, and special thanks to all of our listeners for tuning in. If you're interested in learning more about this topic, or any of the topics that we've covered on Value-Based Care Insights, please go to luminaHP.com/insights, and you'll find just a vast amount of information there. Until our 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