Interest in operational control, turf wars, and patient care have been driving interventional radiologists, vascular surgeons, and interventional cardiologists to develop vascular centers with increasing frequency. The concept of an ideal center has been studied since 1999 at annual conferences hosted by the Society for Cardiovascular and Interventional Radiology (SCVIR), the Society for Vascular Medicine and Biology, the Society for Vascular Surgery/North American Chapter, the International Society for Cardiovascular Surgery, and the American College of Cardiology. But if there is an ideal model, it is still unknown. In fact, there is not yet even a uniform vision or concept of a vascular center.
“This is a field with three players in it and no one has a dominant position,” says Barry T. Katzen, MD, medical director, Miami Cardiac & Vascular Institute, Miami. “Vascular centers offer a way in that context to create an entity that has a little of everything, because everyone gives up a little something to be part of something else.”
There may be more potential power in vascular centers, but what is the best way to harness that power? What works, and what does not? What are the qualities of a successful center?
“If you’ve seen one vascular center, you’ve seen one vascular center,” says Paul Pomerantz, executive director of the SCVIR, one of four sponsors of the annual conference on Vascular Centers of Excellence. “There is no one model.”
The SCVIR began to try to define a model when it was approached by members looking to develop centers, either on their own or in conjunction with vascular surgeons.
“Interventional radiologists’ motivation was a defensive one. They thought that if they put together a center where they could establish higher visibility, offer a full range of vascular interventions, and market the program better, they would be able to fend off competition from other specialties,” Pomerantz says.
That turned out not necessarily to be the case, and Pomerantz says that approaching a center in a defensive posture is a key to failure.
“It doesn’t work. What works is when the center is approached as a strategic initiative,” he says. “The vision must be built around strength in treating vascular disease as an inclusive approach. There must be a business plan, consideration to required resources, and a strong partnership with a sponsor.
“This is a new trend, and there is a lot of interest but little experience,” Pomerantz says. “Each vascular center is different. Many are doing well, and many are not doing well. We are all in the early stages of trying to figure out where we are going analogous to trends in other areas of medicine where institutions are focusing resources in identified disease management areas.”
Even defining what a vascular center is has been elusive. An audience poll at the 2000 Vascular Centers of Excellence conference showed a range of arrangements in existence, from single specialty physician offices to shared clinical space arrangements to clinically and economically integrated multi-specialty arrangements. In “Vascular Centers: Are They the Future or an Unrealistic Dream,” a report by Pomerantz on the findings of the conference, it was determined that where vascular centers have been established, 94% incorporate vascular surgery, 84% incorporate interventional radiology, 65% incorporate cardiology, 38% incorporate neuroradiology/neurosurgery, and 28% incorporate vascular medicine.
Further, the conference poll found that most vascular centers spring up in academic settings, where they represent a union of academic departments. Although there definitely is an interest in community or private settings, independent groups must purposefully come together to form such arrangements. Some centers are economically integrated, while others prefer a more traditional arrangement, and credentialing and training issues are prevalent.
“One of the issues we face is people often come to us for help and our position is that it’s really best to think not in terms of a specific model, but a specific process,” Pomerantz says. “It is really important to develop a consensus locally of who will be involved, what the objectives are, and how best to meet them. It’s hard to apply a cookie-cutter approach.”
The Miami Model
One of the oldest and largest cardiovascular centers is the Miami Cardiac & Vascular Institute, which was established in 1987 as part of the nonprofit, four-hospital Baptist Health Systems. Approximately 100,000 patients are served annually by the center’s 300-member medical and professional staff, which includes more than 100 physicians representing specialties such as interventional cardiology, interventional neuroradiology, interventional radiology, cardiology, cardio-thoracic surgery, and vascular surgery, plus more than 200 nurses, technologists, social workers, nutritionists, and other support staff.
All interventional radiologists are members of the radiology group, while the rest of the specialists belong to several different groups. None of the groups are multi-specialty, with the exception of cardiologists and interventional cardiologists.
The physicians are not employees of the hospital system and are not paid by the hospital for their services. Physicians from different partnerships and specialties do not share or distribute earnings among other specialties, ie, cardiologists do not share with radiologists. Each group or specialty is responsible for its own billing, accounting, and distribution of earnings among its members. The physicians do not share office space, and though patients are referred to other specialties when necessary, fees are not split.
“You have to compare vascular centers that are simple marketing entities to those that are changing the way patients are treated,” Katzen says. “Being ahead of the curve is always a good position to be in. We put together our center for the right reasons, and we did it before a lot of conflicts developed.
“Our goal is definitely to change patient care, and we have always felt we want to achieve a better quality product, and better outcomes. The way we take care of patients is what this is all about,” he says. “Other things will work themselves out if we take care of that.”
Sacred Heart Medical Center
A similar integrated center, although it eliminates any cardiology aspect, is currently in development at Sacred Heart Medical Center in Spokane, Wash. Recently, a 34-member radiology group merged with a four-member vascular surgery group in that center to form a vascular group. Such an arrangement was attractive because it afforded continuity of care from clinical evaluation through noninvasive vascular laboratory work, through interventional and surgical treatment, to follow-up and rehabilitation. The group is already totally integrated, both economically and clinically.
“We’re just getting into the development of our center, and it will all be different a year or two from now,” says Rodney Raabe, MD, an interventional radiologist. “We are focused on developing a pathway that is efficient for patients, and easy for the primary care physicians to follow too.”
Though Raabe says the group would like to develop a better working relationship with the cardiology groups in the community, those physicians prefer to be independent.
“We are still discussing whether there are ways we can collaborate, but it works only if each element brings value to the whole. Why do something with someone else if you can do it all yourself?” Raabe says.
“It could be that radiologists are much more socialistic in the way we approach things, while vascular surgeons are more entrepreneurial,” Raabe says. “We’re much more willing to share the pie, while surgeons have more of an eat-what-you-kill approach.”
The group is starting out with a good referral base, largely because of the relationship that exists between the interventional radiologists and the vascular surgeons.
“Whenever we had cases that were appropriate, we primarily sent them to those four surgeons,” Raabe says. “The radiology group as a whole has been involved forever at that level, so we brought that referral market along.”
By being economically integrated, Raabe says, the surgeons and interventional radiologists are able to make incentives as a group, and the way an individual patient comes through the center does not matter. The model is working so far, because the group is seeing more patients together than it had individually beforehand
“Right now all procedures are done at Sacred Heart. We are branding a center. The hospital is supporting it by providing equipment, but not active in terms of forming it,” Raabe says. “We are keeping our options open about having a freestanding center versus being part of the hospital.
“Hopefully, we will add in cardiology eventually, because we can all benefit by working together,” he continues. “We would like not to exclude anyone. It’s better for the community and it gives the center sustaining power. Our focus is on providing better health care by offering what’s best for the community as far as delivery of services.”
New England Medical Center
What is best for the community is usually the best yardstick for how to develop a center, rather than examining how others are doing it.
“There are no really good models, and not yet such a thing as a vascular center of excellence,” says Neil J. Halin, DO, chief of cardiovascular and interventional radiology, and assistant professor of radiology at Tufts University-New England Medical Center, Boston. “No one center is done the best way. It is different in every state, and every hospital.”
The vascular center model evolved from an already close alliance between interventional radiologists and vascular surgeons. Tufts-New England Medical Center is a closed-staff hospital with one vascular service. The medical center is part of the nonprofit New England Healthcare Foundation, and there are radiology and surgery subcorporations.
What makes the Tufts vascular center different is that it is not going to inhabit a physical space. It will instead consist of a single-entry portal, with one phone number and one secretary to do bookings for all the vascular work-up and treatment.
“We simply needed a streamlined patient experience, not necessarily a new entity,” Halin says. “What we will be doing is making a third entity that will be funded by those two departments.”
Participants in the center include three vascular surgeons, two full-time angiographers, three part-time and one full-time interventional radiologists, plus a receptionist. Fellows from the academic infrastructure will take part in the center as well. At this time, the model does not incorporate interventional cardiologists, who Halin says tend to be more interested in being aggressive with the territory.
Though the center is a virtual entity right now, Halin says the participants have talked about making a merged department of interventional radiology and surgery in the future.
“I don’t know if it will happen,” Halin says. “There is a lot of commonality between the two departments, and eventually we are talking about merging them, but there is a complex political process that must be gone through first.”
Although there is no competition among the radiologists and vascular surgeons for patients, Halin says it would be difficult to integrate the center economically because each practitioner works for a different corporation, and they are all salaried by the university. The only factor that would force a central model, Halin says, is reimbursement, specifically if it pays only a single fee for stent grafts.
“We’re moving ahead, but things move slowly in large academic medical centers,” he says. “We are dedicated to this model and having the pieces in place, but we haven’t created a single entry point with its own name yet.
“We don’t feel challenged that we have to fight for any given case. We cross-train each other’s fellows, and there are combined decision-making and management conferences,” Halin says. “It’s a very cooperative venture as it is now.”
Vascular Center at Mercy Medical
While a cooperative model is certainly in evidence at many vascular centers, there are some that eschew that approach. Luis Queral, MD, is director of the Vascular Center at Mercy Medical, Baltimore, which opened 3 years ago in an annex of Mercy Medical. The center currently has two vascular surgeons on staff and is adding a third. While there are a number of interventional cardiologists and interventional radiologists working at Mercy, Queral specifically does not utilize them in the center.
“I don’t see any advantage to them at all,” he says. “Vascular surgeons can carry out all that needs to be done.”
In order to function without interventional radiologists, the center is equipped with an operating room with full angiographic capabilities, and the surgeons have complete catheter skills. The center also employs two full-time and one part-time registered technologists, a full-time vascular nurse, an office manager, a vascular center administrator, and four secretarial staff members.
The center is not economically integrated, and each surgeon is responsible for his own patients. In fact, Queral sees no economic advantage for vascular surgeons with significant practices to be part of a cooperative vascular center model.
“The majority of people don’t practice from major university centers, so that model is not applicable to most practitioners in this country,” he says. “There are vascular centers cropping up in a lot of places, and the majority are run through vascular surgeons. The involvement of radiologists or cardiologists is varied.
“Interventional radiologists are in a real bind because they have no clinical skills,” Queral continues. “They can’t admit patients and take care of them. They just want to do procedures.
“Interventional radiologists love the joint approach because they get a lot out of it but the surgeon doesn’t. All I’m doing is diluting my work and they bring little to the table,” he says.
“It’s very nice for somebody to tell you they are all one happy family, but the fact is the surgeons attract the work. It makes no sense to give up procedures when all the complications and follow-up belong to us,” Queral says. “That model will never work unless the other two groups are attracting large volumes of work. So if interventional radiologists come in and can guarantee they will attract a large amount of work, that’s great. Otherwise, they are being parasitic.”
Queral still supports the concept of a one-stop center for complete vascular care, however.
“The optimal way to take care of patients is to have everything centralized. That way patients can come in, be seen, be tested by a noninvasive vascular lab, then be directly scheduled for procedures,” Queral says.
“This structure works very nicely here and it hasn’t changed in 3 years of operation,” he adds. “In fact, we’re growing at a tremendous rate.”
Defining Success
Regardless of their structure, successful vascular centers will have a few things in common, such as strong physician leadership and strong institutional support. Likewise, vascular centers destined to fail have some shared properties.
“There are certain key ingredients to a successful vascular center, though we’ve been better able to identify why things fail rather than why they succeed,” Katzen says.
“Some centers have failed, though they wouldn’t really say they failed. What happens in my observation is that those groups didn’t really have a business model,” Pomerantz says. “They put together the space and marketed it as a vascular service.”
Pomerantz reports that politics and personal agendas followed by lack of multi-disciplinary cooperation are the most limiting factors to the development of a vascular center.
“Centers need a vision, a strong business plan, strong leadership, and adequate capitalization,” Pomerantz says.
Katzen stresses that combined credentialing should be in the treatment guidelines, and says training is also a crucial issue. Pomerantz adds that too strong a focus on training is not necessarily the best use of a center’s resources.
“We have been looking at the future of interventional radiology and among the things we are trying to determine is what the specialty is going to be as it matures,” Pomerantz says. “Some are thinking about the concept of a hybrid speciality, while others are formulating an idea to train each other a little bit so vascular surgeons learn to do some interventional work and vice versa, and each becomes a more complete vascular specialist.
“Many institutions have cross-training at the fellowship level, while some are geared at the practicing physician level,” he continues. “But based on what I’ve seen, if the focus is on the training component, that is not strong enough to hold a center together.
“There are a lot of developments in health care right now that seem to suggest vascular centers are where we should be heading, but it’s very early and we don’t know for sure,” he says. “We are encouraging a lot of data sharing so we can develop a knowledge base about where this is going and what works best.”
“We’re figuring out the best models for centers in response to local politics and local needs,” Katzen says. “Each one is using bits and pieces from everything and using new relationships to solve their own problems.”
And although for many the concept of vascular centers stemmed from issues of who would get what business, the key to creating a successful venture has grown outside the boundaries of that one-dimensional view.
“People developing centers to resolve turf battles are missing the boat,” he says. “That may be a secondary benefit, but the center ultimately has to be patient care-driven or you have nothing of substance.”
Liz Finch is a contributing writer for Decisions in Axis Imaging News.
