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Maintaining Turf in the Managed Care Marketplace in 1998
with the guidelines by referring physicians tends to be high. The best malpractice defense for the usage of UM guidelines is that they are the standard of care in the community in which they exist. Such is best demonstrated through a high compliance rate with the UM system. In a fee-for-service environment, the use of a UM system will decrease utilization by as much as 10%, depending on the levels of over-utilization that currently exist in a particular marketplace. As a result of this, it is recommended that stringent UM guidelines only be utilized in markets where radiology capitation contracts are prevalent. Moreover, by the very nature of the service, interventional radiology procedures do not readily conform to most UM systems. Instead, many managed care companies have a policy of separately authorizing interventional procedures based on the judgment of their medical director(s).
2:55 pm New Medicare Initiative and Plans for Managed Care Robert L. Vogelzang, MD
3:50 pm Maintaining Turf in the Managed Care Marketplace in 1998 Gregory E. Guy, MD Learning objectives: The attendee will be able to: (1) Formulate a plan to convert a Vascular and Interventional Radiology (VIR) section into a clinical practice; (2) Understand the importance of developing a more comprehensive clinical VIR practice; and (3) Recognize the potential interactions and conflicts between a clinical VIR practice and professional colleagues and others (hospital administrators, health care insurers, etc.). DESPITE a history of consistent growth. Vascular and Interventional Radiology (VIR) has experienced erosion of its procedure base. This has been in part due to natural evolution and the emergence of newer technologies, but in part due to other subspecialties aggressively pursuing procedures that have been the domain of VIR for many years. While some of this erosion has taken place at the margins of the VIR foundation, the current "turf battles" are aimed at the core of our subspecialty practice and threaten to remove us from the realm of vascular disease. Maintaining turf in this setting is a complex topic; when current health care market elements are factored, the task of maintaining turf is daunting. It is the author's contention that, to thrive in the current environment, one must offer a consistent, reliable product (service) and must deliver that product at a competitive price. Traditional efforts at maintaining turf have focused on optimiZing the availability of the interventional radiologist, the acquience to the request of the referring physician, and the relative abilities of the physicians performing the interventions. These efforts
should not be categorically discarded but rather should be modified and added to more intensified efforts that are devoted to developing more comprehensive clinical practices. The product that VIR physicians offers must be more than haVing available, qualified physicians performing procedures on demand. The complete VIR clinical service must be able to admit patients to and discharge patients from the hospital, provide inpatient and outpatient follow-up for those who have undergone interventions, see patients in consultation (even at the exclusion of performing a procedure), communicate with referring physicians about their patients. The elements critical to the success of this evolution are the unwavering support of diagnostic imaging partners, the consistency of service within the VIR section, and the acceptance of this concept from other clinical colleagues and administrative staff. These elements serve as the major potential sources of resistance to the development of clinical VIR practices. The time and resource commitments required to perform the duties of a clinical practice are considerable. At the very least, full support of a clinical VIR service will shift the philosophical center of most diagnostic groups. At most, the diagnostic imaging group may not recognize the validity of nonimaging activities and/or may not be sympathetic to the manpower, scheduling, or fiscal needs of a clinical practice. Neither is the interventionalist immune to criticism. Some qualified interventionalists are not fully committed to pursuing this level of clinical responsibility. Additionally, "turf opponents" may attempt to derail the clinical VIR service by methods varying from lobbying to deny the issuance of admitting privileges to interventionalists to highlighting any shortcomings in the VIR service. Others, who are content with the traditional service orientation of most imaging groups, may not be supportive of a change in that traditional relationship with the VIR service. There are considerable gains to be had by establishing a clinical practice. Above all, it will, if done well, provide a superior level of patient care. It will also promote a high standard of procedural performance within one's institution. Quality assurance and outcomes projects will likely be more easily and consistently organized and completed. Perhaps most relevant to the current "market" aspects, having a legitimate clinical practice is also a necessary step for encouraging referring (specifically, primary care) physicians to send patients to your practice. In summary, the development of a clinical practice will address the past and current criticisms that truly qualified interventionalists do not perform a significant percentage of the interventional procedures and that radiologists are generally disinterested in patient care. In today's health care environment, hospital administrators and health care insurers play prominent roles in the delivery of health care services. Clinical VIR practices will be better able to communicate and negotiate with administrators concerning equipment, space, and per-
21
sonnel needs. Insurers, being interested in cost containment, are particularly receptive to patient or disease management plans. Interventionalists must work to position themselves to be involved along the continuum of such plans rather than being viewed only as a physician who performs procedures. The common theme in dealing with administrators or insurers is having a patient base and/or service line that helps manage patient treatment. In that regard, the interventionalist should consider being involved in the operation of a noninvasive vascular laboratory and a vascular rehabilitation program. The response to these challenges must be timely and definitive. Interventionalists must be committed to the goal of establishing clinical practices and must show resolve in providing consistent and exemplary care to patients, even in the face of resistance. We must also be open to the consideration of creative practice arrangements which may be needed to meet these objectives. This is not a call to abandon traditional diagnostic imaging group alliances: rather, it is a plea to not tolerate lower standards and suboptimal patient care as natural byproducts of those traditional arrangements. It is the tolerance of those byproducts that will result in more lost turf.
4:15 pm Credentialing----Strategies to Protect Your Interventional Department David Sacks, MD Learning objectives: 1) DistingUish tuif issues based on economics vs quality; 2) List five responses to tuif battles; and 3) List three quality indicators for percutaneous stent placement that may be useful in tuif issues. Tuif is the distinction between who does what. In the hospital setting, it marks the boundaries ofpractice between various physician specialties. Turfdecisions occur through hospital credentialing, which is the process by which physicians are determined to be both competent and permitted to peiform procedures. The granting of credentials is designed to protect patients and maintain quality. A physician may be competent, but still denied permission if the hospital determines that there is no need for another specialty to provide an identical service. Although tuiffights may arise because of economic factors, they should be resolved on issues of quality. Response How one responds to a turf threat depends on the reason to which one is responding. It is difficult to respond to what is usually the real reason-wanting to increase revenues-because this is usually not stated overtly. One needs to make responses based on quality. Beware that quality issues are specialty blind, as they should be. Any physician, regardless of specialty, who can provide high quality procedures and care can justifiably be credentialled for those procedures. Any physician, regard22 less of specialty, who cannot provide high quality pro-
cedures and care, should not be given credentials or should lose those credentials. The following quality arguments can be made. Some of the arguments will not apply to some practices. For the purposes of this paper the assumption is made that peripheral endovascular procedures are currently performed by radiologists and that either cardiology or vascular surgery is requesting credentials, but the arguments are intended to be independent of specialty. Pick and choose what is relevant to you.
1. Quality of Care a. Training The American Heart Association (AHA) (3) requires the following minimum training to perform peripheral PTA: 1. Performance of 100 peripheral arteriograms 2. Performance of 50 peripheral/renal PTA with 25 as primary operator 3. Performance of 10 peripheral thrombolysis with 5 as primary operator 4.
Obtaining 50 category 1 CME credits in peripheral angiography and interventions The AHA papers on peripheral vascular procedures are authored by multidisciplinary panels comprised of interventional radiologists, vascular surgeons, and cardiologists. The American College of Cardiology (4) and the SCVIR (5) have very similar requirements. The Society of Vascular Surgery has published its own, far more lenient, credentialing criteria (6). In this document, the claim is made that the credentialing criteria applied to one group of specialists (radiology) shouldn't apply to another group (vascular surgery). This claim actually violates the ]CAHO requirement that standards be applied uniformly regardless of specialty. The surgical paper asserts that there is such an overlap between vascular surgery skills and endovascular skills that minimal (10-15 cases) additional training is needed to be qualified to perform endovascular procedures. The requirement of performing diagnostic angiograms can be met through experience performing intraoperative studies. The weakness of the argument that familiarity with the tools of peripheral interventional radiology quality one to become an interventionalist can be demonstrated by analogy. A gynecologist with expert laparoscopy skills for gynecologic procedures is not considered competent to perform laparoscopic cholecystectomies. Nor is an interventional radiologist with expert catheterization skills considered competent to perform coronary angiography. The additional skills and knowledge can be acquired, but not in a few weeks or months. An even higher level of training, knowledge, and experience is demonstrated by the Certificate of Added Qualifications (CAQ) in vascular and interventional radiology issued by the American Board of Radiology.
2:55 pm New Medicare Initiative and Plans for Managed Care Robert L. Vogelzang, MD
3:50 pm Maintaining Turf in the Managed Care Marketplace in 1998 Gregory E. Guy, MD Learning objectives: The attendee will be able to: (1) Formulate a plan to convert a Vascular and Interventional Radiology (VIR) section into a clinical practice; (2) Understand the importance of developing a more comprehensive clinical VIR practice; and (3) Recognize the potential interactions and conflicts between a clinical VIR practice and professional colleagues and others (hospital administrators, health care insurers, etc.). DESPITE a history of consistent growth. Vascular and Interventional Radiology (VIR) has experienced erosion of its procedure base. This has been in part due to natural evolution and the emergence of newer technologies, but in part due to other subspecialties aggressively pursuing procedures that have been the domain of VIR for many years. While some of this erosion has taken place at the margins of the VIR foundation, the current "turf battles" are aimed at the core of our subspecialty practice and threaten to remove us from the realm of vascular disease. Maintaining turf in this setting is a complex topic; when current health care market elements are factored, the task of maintaining turf is daunting. It is the author's contention that, to thrive in the current environment, one must offer a consistent, reliable product (service) and must deliver that product at a competitive price. Traditional efforts at maintaining turf have focused on optimiZing the availability of the interventional radiologist, the acquience to the request of the referring physician, and the relative abilities of the physicians performing the interventions. These efforts
should not be categorically discarded but rather should be modified and added to more intensified efforts that are devoted to developing more comprehensive clinical practices. The product that VIR physicians offers must be more than haVing available, qualified physicians performing procedures on demand. The complete VIR clinical service must be able to admit patients to and discharge patients from the hospital, provide inpatient and outpatient follow-up for those who have undergone interventions, see patients in consultation (even at the exclusion of performing a procedure), communicate with referring physicians about their patients. The elements critical to the success of this evolution are the unwavering support of diagnostic imaging partners, the consistency of service within the VIR section, and the acceptance of this concept from other clinical colleagues and administrative staff. These elements serve as the major potential sources of resistance to the development of clinical VIR practices. The time and resource commitments required to perform the duties of a clinical practice are considerable. At the very least, full support of a clinical VIR service will shift the philosophical center of most diagnostic groups. At most, the diagnostic imaging group may not recognize the validity of nonimaging activities and/or may not be sympathetic to the manpower, scheduling, or fiscal needs of a clinical practice. Neither is the interventionalist immune to criticism. Some qualified interventionalists are not fully committed to pursuing this level of clinical responsibility. Additionally, "turf opponents" may attempt to derail the clinical VIR service by methods varying from lobbying to deny the issuance of admitting privileges to interventionalists to highlighting any shortcomings in the VIR service. Others, who are content with the traditional service orientation of most imaging groups, may not be supportive of a change in that traditional relationship with the VIR service. There are considerable gains to be had by establishing a clinical practice. Above all, it will, if done well, provide a superior level of patient care. It will also promote a high standard of procedural performance within one's institution. Quality assurance and outcomes projects will likely be more easily and consistently organized and completed. Perhaps most relevant to the current "market" aspects, having a legitimate clinical practice is also a necessary step for encouraging referring (specifically, primary care) physicians to send patients to your practice. In summary, the development of a clinical practice will address the past and current criticisms that truly qualified interventionalists do not perform a significant percentage of the interventional procedures and that radiologists are generally disinterested in patient care. In today's health care environment, hospital administrators and health care insurers play prominent roles in the delivery of health care services. Clinical VIR practices will be better able to communicate and negotiate with administrators concerning equipment, space, and per-
21
sonnel needs. Insurers, being interested in cost containment, are particularly receptive to patient or disease management plans. Interventionalists must work to position themselves to be involved along the continuum of such plans rather than being viewed only as a physician who performs procedures. The common theme in dealing with administrators or insurers is having a patient base and/or service line that helps manage patient treatment. In that regard, the interventionalist should consider being involved in the operation of a noninvasive vascular laboratory and a vascular rehabilitation program. The response to these challenges must be timely and definitive. Interventionalists must be committed to the goal of establishing clinical practices and must show resolve in providing consistent and exemplary care to patients, even in the face of resistance. We must also be open to the consideration of creative practice arrangements which may be needed to meet these objectives. This is not a call to abandon traditional diagnostic imaging group alliances: rather, it is a plea to not tolerate lower standards and suboptimal patient care as natural byproducts of those traditional arrangements. It is the tolerance of those byproducts that will result in more lost turf.
4:15 pm Credentialing----Strategies to Protect Your Interventional Department David Sacks, MD Learning objectives: 1) DistingUish tuif issues based on economics vs quality; 2) List five responses to tuif battles; and 3) List three quality indicators for percutaneous stent placement that may be useful in tuif issues. Tuif is the distinction between who does what. In the hospital setting, it marks the boundaries ofpractice between various physician specialties. Turfdecisions occur through hospital credentialing, which is the process by which physicians are determined to be both competent and permitted to peiform procedures. The granting of credentials is designed to protect patients and maintain quality. A physician may be competent, but still denied permission if the hospital determines that there is no need for another specialty to provide an identical service. Although tuiffights may arise because of economic factors, they should be resolved on issues of quality. Response How one responds to a turf threat depends on the reason to which one is responding. It is difficult to respond to what is usually the real reason-wanting to increase revenues-because this is usually not stated overtly. One needs to make responses based on quality. Beware that quality issues are specialty blind, as they should be. Any physician, regardless of specialty, who can provide high quality procedures and care can justifiably be credentialled for those procedures. Any physician, regard22 less of specialty, who cannot provide high quality pro-
cedures and care, should not be given credentials or should lose those credentials. The following quality arguments can be made. Some of the arguments will not apply to some practices. For the purposes of this paper the assumption is made that peripheral endovascular procedures are currently performed by radiologists and that either cardiology or vascular surgery is requesting credentials, but the arguments are intended to be independent of specialty. Pick and choose what is relevant to you.
1. Quality of Care a. Training The American Heart Association (AHA) (3) requires the following minimum training to perform peripheral PTA: 1. Performance of 100 peripheral arteriograms 2. Performance of 50 peripheral/renal PTA with 25 as primary operator 3. Performance of 10 peripheral thrombolysis with 5 as primary operator 4.
Obtaining 50 category 1 CME credits in peripheral angiography and interventions The AHA papers on peripheral vascular procedures are authored by multidisciplinary panels comprised of interventional radiologists, vascular surgeons, and cardiologists. The American College of Cardiology (4) and the SCVIR (5) have very similar requirements. The Society of Vascular Surgery has published its own, far more lenient, credentialing criteria (6). In this document, the claim is made that the credentialing criteria applied to one group of specialists (radiology) shouldn't apply to another group (vascular surgery). This claim actually violates the ]CAHO requirement that standards be applied uniformly regardless of specialty. The surgical paper asserts that there is such an overlap between vascular surgery skills and endovascular skills that minimal (10-15 cases) additional training is needed to be qualified to perform endovascular procedures. The requirement of performing diagnostic angiograms can be met through experience performing intraoperative studies. The weakness of the argument that familiarity with the tools of peripheral interventional radiology quality one to become an interventionalist can be demonstrated by analogy. A gynecologist with expert laparoscopy skills for gynecologic procedures is not considered competent to perform laparoscopic cholecystectomies. Nor is an interventional radiologist with expert catheterization skills considered competent to perform coronary angiography. The additional skills and knowledge can be acquired, but not in a few weeks or months. An even higher level of training, knowledge, and experience is demonstrated by the Certificate of Added Qualifications (CAQ) in vascular and interventional radiology issued by the American Board of Radiology.