I'm going to look at two cardiologists, interventional cardiologists, and how their practice is affected by depending on which model they are participating in and how they get reimbursed. Both these cardiologists are in large groups. They are benefiting from large referral bases, including general cardiologists in the area, their local PCP groups. The practice types are very different. One is aggressive, one is conservative, and both are very familiar with the current literature, including the ischemia trial, but they interpret it a little differently. So when DT sees the patients, she is counseling the patients, tends to emphasize the high crossover rates of medical management into diagnostic and CAT, PCIs, and how it benefits in terms of angina relief at one year, when she sees 100 consecutive patients, she ends up taking about 75 of those directly to CATs, and then 40 of them end up getting PCIs, and of those managed medically, five additional patients undergo PCI during that year. Now when it comes to LB, he has a more conservative style of practice. He tries to aggressively manage patients with medical therapy, and he emphasizes on the risks and complications of PCI. Of the 100 consecutive patients he usually ends up seeing, he ends up with only 50 CATs performing 25 PCIs, and over the rest of the year, those in the medical group, about 10 of them undergo PCI at the end of the year. So with this practice, DT collects about $6,700 more in physician fees that year. Total cost of care for the patient when managed by DT is about $110,000 more than when it's managed by LB, but how would they fare in reimbursement overall, depending on the type of model they would be in. So if they were in a fee-for-service model, then DT definitely made $6,700 more that year. However, if they are treating ACO patients, and all these 100 patients were ACO patients and they're out of network, so they are not participating in the ACO, definitely for that year, DT is definitely earning $6,700 more compared to LB. However, over the second year, these ACOs, which are looking at cost reduction, they find DT's style of practice a little more expensive, so she stops getting referrals, and that has an indirect effect on her next year's reimbursement. So let's say she loses about $10,000 next year because of loss of referrals, whereas LB is conservative, the ACO groups love him, there's cost saving, and his referral base remains the same. Next year, he continues to make the same reimbursement. Now, if both of them are participating in an integrated ACO model, so the cardiology practice itself was an ACO, DT would definitely get called out on being an outlier who's performing too many procedures, including the cost of care, and on the other hand, LB would actually be praised because of the reduction in cost and would receive his quality bonus, depending on whatever the contract is structured. So he'll definitely get his quality bonus that year, but DT will not get her quality bonus. So keep in mind that ACOs are operating on a one-year cycle, and they're not really looking at the long-term cost of care from a particular disease entity itself. Most of the conditions we take care of are chronic and change over time. Now, in the case of the ischemia trial, there were many crossovers that occurred after the one-year time point. And then if you're conservative and looking at the cost of care, and if you feel like a patient is stable, you're not doing as many CT scans as would be required. If you looked at the ischemia trial itself, every patient got a CT scan before they were randomized. And then, you know, when you're counseling, you always give them the risks and benefits of both, like, PCI-CAT versus medical therapy and ask the patient to choose. And as Lyndon had pointed out earlier, too, patient choice is kind of relative to how they're feeling, time of the day, how you're feeling, whether they ask you to give your input into their management, so on and so forth. And ACOs are primarily, the intent is to design variation in care of patterns, and kind of seems like, you know, one-size-fits-all kind of therapy algorithmic. However, this kind of approach, you know, it basically, any outlier is considered to be wrong. And that may not be necessarily true because you might be a provider who is seeing a certain group of patients who have certain high requirements, and that is not being adjusted for. And that is something we have to consider when we are looking into the ACO practice. So going to the bundled payment model, and if you compare two systems, and how they would be reimbursed. So both the systems have same three-year average 90-day cost for acute MI of about, say, $50,000. Both systems have signed up to participate in a bundled payment model, advanced payment model for myocardial infarction. So if you look at system A, it's a hospital with diverse medical staff. They partner with a lot of community physicians. Most of the specialists participating are independent with their own PSA contracts, or the hospital's group. And system B is a large integrated hospital with multi-specialty groups, which are all employed. So in system A, they have, as earlier said, multiple cardiology groups. They cannot agree upon which stent they like to purchase, some like X stent, some like Y stent. So there are multiple stents on the shelf. One cardiology group has an operator with an excess complication rate and two unexpected mortalities that year. Some of the interventional cardiologists still prefer to dictate their notes in the EMR meeting, which limits capture of comorbidities and risk adjustment. And hospitals have understaffed, and length of stay has increased by about 0.75 days on an average due to all this. Now in the integrated hospital system B, the interventional cardiologists is a single group. They all agree 90% of the times, which allows them to get the same stent, better pricing When they purchase the product, the physicians are given extensive education on documentation for optimal risk adjustment on a regular basis. Hospitals are educated on the 30-day readmission penalties. And the cardiovascular group develops a program to utilize advanced practitioners for acute MI patients to have hospital follow-up within seven days of discharge. So if you look at cost-wise, the system A, the actual cost increases to an average of $51,000 per episode. And as we stated earlier, the DRG was $50,000. Due to higher than expected mortality, there is a quality penalty that the system gets and additional penalties are applied for excess days in the acute care due to long length of stay. As a result of this, due to an adjusted penalty, payment per episode for them reduces to $48,000 and hospital actually pays out $3,000 per episode back to the payer. The system B, on the other hand, actual cost decreases to $47,000 per episode because of all the savings that they have made with purchase prices, so on and so forth, length of stay. Lower than predicted mortality, days in acute care and readmission, and positive adjustments that they get for quality performance. So due to savings and quality, the hospital receives back additional $3,000 from the payer. So LB works for hospital system A and he has had several patients with complications, increased cost, required post-discharge care, readmission, and he typically tends to refer patients back to the ED if they call in the clinic as there are issues with follow-up visits being set up. And because of this, his score of quality measures on excess days in acute care post-MI is poor and he does not receive a quality bonus that year. On the other hand, DP who is participating in the integrated system has no complication rate, has an APP who sees patients within seven days of discharge. The same APP also has multiple spots during the day that people can be urgently scheduled and don't have to necessarily go to ER to address that issue. And her hospital bases her bonus on quality metrics and she receives the maximum bonus for the year so she's probably going to do a little better than LB is doing in his practice. So at this time, I'm going to stop and see what questions we have. Yeah, great job, Deepali. And I do want to emphasize we worked on those slides a little together and one of the things to bring out is all of those numbers are theoretical because it depends a lot on the model, you know, and how things are divided up. And as we've alluded to multiple times, there's a number of different models out there and they change rapidly so it makes it difficult to actually do the accounting for any given provider to look at what they're doing and try to actually predict how the numbers are going to fall out. So I know we're at the top of the hour, but I answered one question in the chat box, but would really love to see if anyone in our audience has questions for the panel. Yeah, the model most friendly for beginners. Anybody want to take that one? So I think there's definitely models where you have less risk up front. Jim, you were going to say something? Well, the EPCI advanced is one where it's all done by the hospital administration or the group administration. As an individual, you really don't have to do anything. The way that you can influence outcomes is by, interestingly, not by taking a conservative approach and not doing a procedure. This is, in a sense, almost like fee-for-service and that every time you do the procedure, you're going to get paid for it. But the way you work on it is by providing economical, efficient care after you've done your procedure or had your initiating event. But again, you don't have much control over that. So from the standpoint of the person participating, it's pretty easy, especially if you're the person doing PCI and then you walk away. There's really nothing more for you to do. It's all done by the hospitals or the intensive care docs, although that does not guarantee a good outcome. And also, which model benefits you best as a beginner depends on your kind of practice, right? If you're an integrated system versus you're a solo practice, which probably is something going to be very challenging to be participating in these kind of programs versus a small private practice group versus a large private practice group. And I think a lot of it's got to do with investment that you're going to require up front from the reporting standpoint, as well as like over time, you will be penalized if you are not able to meet the value-based care metrics that are being set in that particular model. I think one thing that's kind of special about that is as a new, a recent graduate, you can kind of see this as an opportunity to participate in new care models because you have no opportunity costs and you don't have a history of doing this. This may be an opportunity to capture new patients like we talked about and new care models. And so whereas thinking about the challenges, there is certainly challenges. There are challenges in every part of healthcare. But I think taking this and looking at it as a unique opportunity to differentiate yourself may be something that is maybe allow you to have an edge, which may be a competitive edge, which you don't have with 15 years of having done 15,000 procedures, right? And this is a way to get those patients and do that. And I think any way to distinguish yourself is always an advantage. So I would look at it as an opportunity. Yeah, I would just argue, Lyndon, that the majority of the work that needs to occur is really regardless of what model you choose. And quite frankly, the models today may not be the models in 2030. But the body of work that needs to occur in the conversations and the compensation and the commitment to it has to occur and can only benefit you in the long term. One other question I'll speak to, and then we may have to wrap up, which is the question, are HMO practices a part of this model? So when I first was being introduced to accountable care organizations, I was like, oh, this is an HMO. And it's not. They're actually, so an HMO, you get a certain amount of money to care for a population. And it's all about what's left over at the end. And as these were designed, a lot of the pushback against HMOs from the past, was part of what led to the development of accountable care organizations. Because the idea was, it was to be more patient focused, more about outcomes and quality. And through efficiencies and care coordination, you would also have savings. So there are some distinctions, at least in spirit, from the HMO model. But the other thing, I just want to wrap it up by saying that, one, thank you to all of the panelists who, you know, we got out of our usual comfort zone of talking about stents and balloons and valves. And here we are, you know, talking about a topic that really is hard to grasp, I think, because of all the moving parts, as you've seen. My plea to the audience and to our interventional community is to realize, you know, as it's been pointed out over and over again, that this is what's coming down the pipe. And we, as an organization, need to be engaged. And we need our members to be engaged. You know, it's kind of like what Hafnan brought up, is to really, you know, everyone go back and be a leader in your own hospital, in this space, in the development of the accountable care organizations. Because if not, I think, you know, we would easily not do well when everything's being divided up at the end of the day. So I would say my real admonishment to everyone is to, you know, take this as a starting point and then hopefully go back, learn more on your own, and be engaged in your own hospitals. So, all right. Well, thank you, everyone. Thanks for those that stayed on and really appreciate the opportunity to do this. Have a good evening.

practice models

reimbursement

interventional cardiologists

fee-for-service model

accountable care organization (ACO)