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Interventional cardiologists should be compensated for the time they spend on call for treating ST-segment elevation myocardial infarction (STEMI) patients, a move that would benefit not only physicians but also patients and hospitals, according to commentary published in the May 2013 issue of Catheterization and Cardiovascular Interventions on the Society for Cardiovascular Angiography and Interventions (SCAI) President’s Page.
The article was written by SCAI president J. Jeffrey Marshall, MD, of Northeast Georgia Heart Center (Gainesville, GA), along with Peter L. Duffy, MD, of FirstHealth of the Carolinas (Pinehurst, NC), Srihari S. Naidu, MD, of Winthrop University Hospital (Mineola, NY), and K.C. Kurian, MD, of Florida Hospital Flager (Palm Coast, FL).
SCAI “supports a strategy of supplemental reimbursement for interventional cardiologists who participate in emergent call for patients suffering [a STEMI],” Dr. Marshall and colleagues write.
In e-mail communication with TCTMD, Thomas D. Stuckey, MD, of the LeBauer Cardiovascular Research Foundation (Greensboro, NC), agreed that the issue is gaining traction, especially given recent drops in reimbursement. “The role of the STEMI physician has expanded, and the service is undervalued,” he said. “Moreover, the service is of high visibility to hospitals.”
A Timely Conversation
Interventionalists are increasingly called to balance the needs of their existing patients with those of urgent STEMI cases, the authors note. Such demands are becoming ever more common with the advent of STEMI transfer networks and emphasis on appropriate use criteria, they say, adding that the rising overhead costs of private practices and declining levels of reimbursement also put financial pressure on physicians.
In a telephone interview with TCTMD, Dr. Duffy said that compensation for STEMI call is “a controversial subject, obviously, and a thing that a lot of our members are interested in.”
The current model is becoming “less and less economically sustainable,” he noted, and trends toward clinicians working more closely with hospitals represent a “nice segue into being able to do something [about it].”
Signed into law in March 2010, the Patient Protection and Affordable Care Act (PPACA) is also a good catalyst for discussion, Dr. Duffy added.
Dr. Marshall and colleagues point out that the recent legislation “ties formally the performance of providers directly to payments made to hospitals.” The Centers for Medicare and Medicaid Services, meanwhile, has instituted a 2% payment penalty for hospitals that exceed the guideline-recommended 90-minute window for door-to-balloon time in STEMI patients.
According to the article, paying physicians for STEMI call helps them align directly with the objectives of the hospital, “synergy” that in turn promotes achievement of national quality and outcome standards.
“Incentivizing STEMI call creates a win-win-win (patient-hospital-physician) scenario that benefits the overall reputation of the hospital, its patients, and the community it serves,” Dr. Marshall and colleagues write. “Done correctly, it contributes to the fiscal viability of the hospital and the sustainability of the cardiology practices in its community.”
Taking the Next Step
Thus far, hospitals have showed varying levels of enthusiasm for the idea, Dr. Duffy reported. “Some hospitals are proactive and do recognize that they’ve got to get their physicians on board. Some, for example, just have employed physicians. That makes it a whole lot easier to create this type of program,” he explained, noting that others have a mixture of employed physicians and multiple practice groups or other models.
“So really it’s going to be up to each individual hospital as to how it deals with that,” Dr. Duffy said. “Our point was just to be able to support our members [and interventionalists more generally, to give them something] that they could go to the administration with and say, ‘This isn’t just my idea. This is a good idea, and here’s why it’s a good idea. Our society is strongly in support of this.’”
Importantly, the idea is not without precedence, the paper notes, citing a 2005 survey conducted by the American College of Physicians Executives that found “46.6% of respondents’ hospitals paid specialists to take ER call,” while half of the remainder had “considered the matter recently.”
As Seen from the Trenches
Dr. Stuckey said payment for STEMI call is rare and depends in part on the availability of providers. “In areas where services are limited, physicians have been paid much more in the form of standard contracts to provide these services. In large cities, there are often too many providers,” he explained.
“Eventually I think that physicians will need to go down the road that both insurers and hospitals have—consolidation way beyond traditional limits—in order to provide the leverage to prevent undervaluing of services,” Dr. Stuckey concluded, adding that cardiac surgeons did not choose this route. “However, [STEMI care] is a high skill service, and the skill sets necessary to provide the service cannot easily be replaced. It will be interesting to see how this all plays out.”
In an e-mail communication with TCTMD, Ajay J. Kirtane, MD, SM, of Columbia University Medical Center (New York, NY), said that, as a clinician at an academic medical center, he does not encounter this debate very often. “One way or another (either through base salary or specific payments), many hospitals do support primary PCI programs in this way,” he said.
As the PPACA begins to make its impact known, Dr. Kirtane predicted, “I think that there will be a groundswell of [support for reimbursement], especially if doctors are required to be in house.”