The heart and science of medicine. The Heart Team Essential Components, Administrative and Financial Perspectives UVMHealth.org at the University of Vermont Health Network July 18, 2018 Christopher Dillon, MBA Network Director Cardiovascular Service Line Network Director of Integration
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University of Vermont Health Network Formed 2011 Statistics: 33,000 Discharges (1/6 Cardiovascular) 130,000 ED Visits 26,000 OR Procedures 768 Beds in Service 1,200 Physicians, 2,800 Nurses 4
OneCare Vermont ACO 5
Structures to Integrate Care Across Network Structure Attributes Examples Network Departments Clinical care, research, and education functions integrated network-wide Reporting to Network Chair May have regional/institutional Vice Chairs Radiology Pathology and Laboratory Medicine Specialty Councils Reside within departments Focus on standardizing care across sites within a single clinical field Led by Clinical Director reporting to Chair Emergency Medicine Hospitalist Service Service Lines Focus on integrating cross-departmental clinical services Led by Clinical and Administrative dyad Matrix reporting to Chairs, Hospital Presidents Cardiovascular Musculoskeletal Pediatrics Primary Care Foundation Catalyst of UVM s Integrated Delivery System Focus on Access, value based care management All departments moving to Network Departments over time 6
Cardiovascular Service Line Established 2014 Cardiovascular Services General Cardiology CVSL Operating Model Interventional Cardiology Cardiac Surgery Heart Failure Vascular Surgery Structural Heart Stroke Service Line Goals Optimize Quality network-wide Refine operational strategy to enhance quality and efficiency 7
Example Cardiovascular Initiatives Building a Network Approach to Cardiovascular Care Consolidation to 1 Cardiac Surgery program Expansion of 2 nd Cardiac Cath site, NY STEMI resource Development of Hub and Spoke Network Stroke program with TeleStroke support Integration of Vascular interventional and diagnostic programs Continuous improvement of Network Heart Failure program Expansion of Cardiology diagnostic testing footprint across region Dramatic CRM cost reduction Significant expansion of Quality infrastructure Significant growth of interdisciplinary programs, like Structural Heart 8
Structural Heart Timeline CoreValve Trial TAVR Intermediate Risk Trial ASD/PFO and Watchman also part of UVMHN Structural Heart program, not depicted here 9
Heart Team Supporting Structural Heart Procedures Cardiac Surgery Interventional Cardiology Anesthesiology Cardiology / ECHO Bruce Leavitt, MD Harry Dauerman, MD Jake Martin, MD David Schneider, MD Ana Parsee, MD Ed Terrien, MD Mitch Tsai, MD Marc Tischler, MD Fuyuki Hirashima, MD Faye Straight, RN Peter VanBuren, MD Frank Ittleman, MD Johannes Steiner, MD Operational Focus: Growth Consultations Procedures Primary vs. Secondary Operator Access type (percutaneous vs. cutdown) Operational Focus: Efficiency Optimize time in procedure TEE TTE General anesthesia Sedation While Maintaining Focus on Quality 10
Structural Heart Operational Changes TAVR Changes Pre-Procedure 2 Cardiac Surgeon consultations Moving from surgical risk documentation in note to full consult Device sizing / CTA interpretation Radiology chest team removed in 2016, completed by Heart Team Radiology 3D imaging lab utilized 2018+ Pre-procedural diagnostic cath, etc. completed close to home NY patients can receive diagnostic services in NY Highest risk patients still travel to Burlington for workup First contact to TAVR consult: < 2 weeks TAVR procedure: < 30 days 11
Structural Heart Operational Changes TAVR Changes Peri-Procedure All TAVR completed in Cath Lab: Eliminated Hybrid OR in 2017 No Pump Team: Removed in 2016; in building, available to crash on in Cath Lab General Anesthesia Conscious Sedation No Central Line / A-Line Helps achieve 3 cases per day TEE TTE: Conducted by Cardiologists, not Anesthesiology Interventional Cardiologist leads traditional / percutaneous access cases ~85% Cardiac Surgeon leads alternative access / cutdown cases ~15% 12
Structural Heart Operational Changes TAVR Changes Post-Procedure SICU PACU Only alternative access and complications go to SICU > 50% of patients discharged 2 days or less Back to Primary Care within 2 weeks More follow up conducted in local community 13
Structural Heart Operational Flow Adhering Closely to JACC Published TAVR Guidelines and Distributing Care Yellow highlighted activities completed throughout network First Contact to TAVR: 30 Days Slide courtesy of Harry Dauerman, MD PCP Follow Up: 2 weeks Catherine M. Otto et al. JACC 2017;69:1313-1346 14
Structural Heart Operational Changes Significant Reduction of TAVR ICU Utilization CVSLsupported operational change 15
Structural Heart Operational Changes Significant TAVR LOS Reduction 16
Structural Heart: TMVR Operations Moving Past Pilot Phase Operations Interventional Cardiologist driven procedure No cardiac surgeon in room Echo / Cardiology attending conducts TEE in every case Every case currently goes to SICU Streamlining pre-procedural consults to mimic TAVR Interventional Cardiologist Cardiac Surgeon (1) Heart Failure specialists (Cardiology) Coordinated into Single Day at Single Location 17
Structural Heart Financial Strategy Facility Side Both SAVR and TAVR are profitable SAVR currently more profitable than TAVR, per case Driven by high cost of TAVR implant Continuing to drive cost-side TAVR improvements to close gap Operational efficiencies Device contracting Will seek to replicate with TMVR With lower-risk indications coming, TAVR / TMVR likely to cannibalize SAVR 18
Structural Heart Financial Strategy Professional Side Cardiac Surgery Interventional Cardiology Anesthesiology Cardiology / ECHO Robust Reimbursement: Focus on Growth, Sharing among Participating MDs Weaker Reimbursement: Focus on Efficiency Consultation(s) to track wrvus Primary vs. Secondary Operator Continued area of work for UVMHN Optimize time in procedure, 3 procedures/day Anesthesiology benefits from more procedure starts General anesthesia Sedation Reducing Anesthesiology time TEE TTE Reducing Echo Cardiologist time 19
Structural Heart Financial Strategy Sustainability? Aggregate valve growth hides tradeoffs Limited indication overlap so far Low surgical risk patients? Moderate stenosis? Historical growth sources More indications = more eligible patients Expanding geographic reach 20
Structural Heart Financial Strategy Summary of Short-Term and Long-Term Views (TAVR) PARTENER 2A Trial Cost Difference (TAVR SAVR) Index Hospitalization (1) -$2,888 24mo Post Discharge (2) $9,303 Per Patient (life, est.) $7,949 1. Cost factors during index stay TAVR device 6x cost of SAVR device TAVR 2 hour shorter procedure time TAVR 4+ days fewer LOS TAVR 2+ days fewer LOS S31 Registry (3) Cost Difference (TAVR SAVR) Index Hospitalization $4,000 12mo Post Discharge $15,511 Per Patient (life, est.) $9,692 2. Cost factors at 24mo TAVR lower readmission TAVR lower SNF 3. Recent changes supporting trend Jancin, B. TAVR wallops SAVR in cost effectiveness for intermediate risk patients. Cardiology News. Nov 2 2017. Better TAVR valves More femoral access Justifies Higher Technology Costs Better clinical processes 21
Structural Heart Financial Strategy Summary of TMVR Approach Planning: Financially reliant on Halo TMVR alone not projected to break even 25 TMVR +12 Surgical mitral valves 2018 Annualized Data has us hitting these targets +22 Medically managed valve patients Reducing Heart Failure admissions (-3% 2018 YTD) Serving patients in need 22
UVMHN Structural Heart Strategy 1. Highest quality care 2. Most patient-centric care: Rapid access, right treatment for right patient 3. Maintain / Expand geographic reach Pre- and Post- Op close to home Coordinated consultation across services Continued collaboration, communication, education with referring providers 4. Be a part of leading change in the field: Research 23
Thank You Contributors David Schneider, MD Cardiology Chief and Network Cardiovascular Service Line Clinical Director Harry Dauerman, MD Network Director of Interventional Cardiology Ana Parsee, MD Cardiothoracic Surgeon Mitch Tsai, MD - Anesthesiologist Faye Straight Structural Heart Coordinator Theresa Fortner Cath Lab Nursing Manager Joe Schmoker, MD Cardiothoracic Surgeon, Former Chief of CT Surgery 24