The new era of hospital acquisition: How private cardiology can survive

I've been in private cardiology practice for over 20 years: my plan—for now—is to stay the course.

I joined the practice of a seasoned jack-of-all-trades cardiologist, Jim H Whiteside, MD, FACC, who preceded me by seven years. He navigated solo, established the first CCU, echo service, and delivered the first thrombolytic in the state of Kentucky. He did the first pacer implant in our hospital. On the opening day of our cath lab back in 1991, I did three caths back-to-back with television cameras rolling, the hospital gambling on good PR because we were going against the grain: cathing with no in-house surgery safety net beneath us.

Things went well in our cath lab that day and still do. Serving a grateful community, we rolled along together for another seven years, sharing every-other-night emergency cardiology calls, with an internist filling in for rounds every few weekends. It was not a perfect solution, but it was our best effort to survive a tough schedule. I remember one 36-hour period when I did 19 cardiology consults in our 120-bed hospital. The schedule was definitely rocking.

With the addition of an excellent interventionalist to our group, we worked together for seven more years, becoming nearly as close as brothers and sisters. Then a miracle happened. A new CEO came to town—one with vision and compassion. He cared about the appearance of the hospital and the well-being of the employees. His priority was a team approach, with that team consisting of everyone from the surgeons to the valet-parking crew. We focused on the goal of developing primary PCI without surgery on-site for the entire state of Kentucky along with the Ephraim McDowell Regional Medical Center in Danville. It took us six years, three governors, and multiple cabinet-level and state-hospital-association meetings to pass it. We celebrated and supported our wonderful interventionalists at both hospitals as they completed the first state-approved primary PCIs in Kentucky without surgery on site. There with high-fives all round. A dedicated and hard-working cath-lab crew stood by our side at all hours of the night. We knew we had the community's back and they had ours. It was a marriage made in heaven.

As unexpected and destructive as an earthquake, our beloved CEO fell victim to sudden death, ushering in a dark period for our whole team. To further affect our routines, like everywhere else in the US, reimbursement patterns shifted, the noncardiology hospitalists came to town, and, like Pac-Man gone viral, gobbled up the admitting duties of many private-practice family-medicine and internal-medicine groups.

Then, they gobbled up our beloved friend and interventionalist. We got the invite as well, but we declined. Leery of big-corporation politics and keen to retain control of the day-to-day inner workings of our office—the hiring of staff, their bonuses, and time off—we are still on our own, although from time to time we consider reexamining the invitation. We have not totally ruled it out for the distant future, and we accept that sudden changes in health, family dynamics, or further change in reimbursement legislation could be the catalyst.

So how is our practice of nearly 40 000 patients navigating all the upheaval?

Things are different. There are two teams now; the hospital-employed and the independents. The new interventionalist, however, is kind and considerate, a pleasure to work with. Patients are loyal to us, but some on each team get caught in the net of uncertainty from time to time. The new nurse practitioners on the hospital-acquired team are doing their best to help balance it all, but both teams at times walk around the telemetry unit not knowing if there has been some sort of a rift if a patient is not admitted to the correct team, a mistake in naming the correct team, or just benign neglect of continuity of care. Just as in all other hospital venues, there is great haste on behalf of the noncardiology hospitalists to get the "chest painers" with negative troponins to an outpatient status. Oftentimes, formal in-patient cardiology consults aren't requested. There are both good and bad aspects of that habit.

The night call is definitely easier, but catching up on what happened in the hospital is sometimes a little more challenging in the office. Since reimbursement reigns as king, all subspecialties are sometimes pushed to discharge patients who should have stayed for a cath or other workup. It's a new era, where patients are sometimes allowed to go home still feeling poorly, with no answer as to the etiology of their symptoms, just as long as it's deemed "safe" and a good outpatient workup is planned. The benevolent edge of American medicine is being dulled by legislation and politics. Patients loathe not having their primary-care physician as their attending in-house doctor. The hospital census is lower for many facilities. The models that work for tertiary centers and large cities do not seem like an optimal fit for suburban or rural America.

One cardiologist who, like me, is concerned about what is happening to private-practice cardiologists all over the country put it like this. "What really baffles us," he began, "is the lack of loyalty. They forget that for years, we were the team that got up at night to take care of patients and missed loads of family time in dogged dedication to the hospital's needs. Though the stance seems to be, 'You were paid well for your time, and you should be grateful for that much,' it's still difficult to imagine that the hospital and even other physicians whose patients we have served well have forgotten our past service. I know one patient got three echos ordered in one month, simply because one hand did not know what the other was doing. If they had called us first, we could have saved the patient time and money. Recently, though, we were informed that the hospital instructed their new hires to send all testing to the hospital."

Another seasoned private-practice cardiologist related it in a different way. "The hospital governing board and members of the administration have been told over and over again about issues in the department—lack of staffing, wait times of up to several weeks just to get a stress exam performed, lack of communication with outpatients regarding life-saving dietary instruction, hypertension education, smoking cessation, etc—but no one steps up or makes an effort to improve things. Private-practice cardiologists who've worked in our city for years are told that they cannot make suggestions for positive change unless they go through the newly anointed figurehead. There is a decline in quality of communication that could positively impact patient care, and nothing happens."

These days, my partner often points out that he is in a different place in life's journey from me. He has the option to retire, but for the love of the game—and rightly so for a former star Vanderbilt running back—he still plans to play for many years to come. Although I have other options and can practice in a different region of the US or pursue other interests, I am in love with cardiology. My family and my husband's family live here in south-central Kentucky. I have so many grateful and wonderful patients that I am motivated to at least retain Glasgow, KY as my home base.

But what is the firmly established private-practice cardiology team to do in this new world of hospital acquisition? In the late 1980s, when I finished med school, my parents gave me what I still think is the best advice. "Always work hard. Smile and support others when they do a good job. Shake hands with your patients warmly, and dedicate yourself to making them feel better both physically and emotionally. Let them know you are happy to see them, and the rest will come naturally. If you do these things, with the best intentions, you will be successful. If others are not behaving honorably, their actions will catch up with them."

My parents' formula for success should work for everyone, not just cardiologists: it's excellent advice that should hold up through the ages. But the rules of the medicine game are changing—are hard work and best practices rewarded? Is the patient, rather than the hospital or the physician, the center of everything we do? Some days, in some places . . . I wonder. 

See also:

Hospital bound? Private-practice cardiology in uncertain times

Your comments

	The new era of hospital acquisition: How private cardiology can survive
	# 1 of 8	October 20, 2011 02:25 (EDT)
	stephen pollock	physicians have lost control of their destiny and their professional lives.  We have allowed reimbursement to decline without an answer.  Many of us have found the security of an employed position easier. That is a short term relief.  The decline in reimbursement will simply be passed on to each of us in our  " new " contracts"  Until cardiologists as a group ( no one can do it alone ) stand up and demand that we be allowed to charge what we feel is fair ( without penalty of loss of all medicare pts) there will be no change.   We do not have the leadership to do that.  I continue to ask, how is it that the govt passed a law that says, if I do not participate in medicare ( not just accept assignment) then my pts will not be reimbursed for their visit.  If pts saw the discrepancy between our fee and medicare reimbursement we could develop a constituency to force better and fairer payments.  I am not optimistic that we are near a tipping point to get cardiologists to act.
	# 2 of 8	October 27, 2011 12:12 (EDT)
	doctorg	Recently, though, we were informed that the hospital instructed their new hires to send all testing to the hospital." This would be a violation of the Anti-Kickback statute on the hospital's part.
	# 3 of 8	October 27, 2011 06:33 (EDT)
	Melissa	I'm sure it was just a misunderstanding!! :) Melissa
	# 4 of 8	October 27, 2011 09:24 (EDT)
	EnriquemxE Guadiana	Hi Melissa, Your parents give you an excellent advice, you are in the correct path, not the easy one. The USA is the best country and you stand in the shoulders of people who fought for the American dream and for freedom. Freedom to work, to elect, to live your live. This is not a new idea. If you decide to give your back to the free market, with time you will pay the price. This is not the first time someone try to manipulate the reimbursement without taking in consideration the profession. With time who wil be left to always work hard? Who will smile and shake hands? Who will be loyal? Who will make suggestions for positive change? With time the best and the bright will leave and many have forgotten or they just want to forgot that the so call health industry was build around our profession not the other way. Without good doctors, loyal, with vision, compassion and the best intention they will never be successful. They just need time to learn the lesson. Tomorrow is another day and the sun will rise. Keep up the good work. Regards,  E. Guadiana
	# 5 of 8	October 27, 2011 10:14 (EDT)
	Melissa	Thanks E., Your encouragement is appreciated. I think it's important that at least in our community,  private practitioners organize and support each other. I think we should keep our practices running with maximum efficiency and withstand this horrible era in local medical politics. Hopefully, when the 5 year honey moon runs out with all of the new hospital hires, then we can all become a cohesive medical community again and work alongside each other with respect and mutual consideration. I've never seen a more heart breaking turn of events. In many places,  the current climate is horrible for patient care and it's horrible for those of us who have to navigate through all of the crap on an hourly basis. It's not only a day at a time, it's an hour at a time, just wondering how we will get through it. I am not exaggerating to say that I am disappointed on a daily basis in human nature. I also do not understand why patient care  and safety are not at the forefront of this movement. Those things seem a distant second in some arenas.    If it weren't for a supportive family and a grateful community of loyal patients, I don't now what I would do. Only God will help navigate it.  Melissa
	# 6 of 8	October 28, 2011 01:50 (EDT)
	Enrique Guadiana	This is the worst of time and the best of time. Keep the fire of the beacon up, so the sailor navigating in the worst storm keep the hope. When I was in training I was all the time with my mentor from 06:00 to 24:00, after a few months I ask him if he has a family and when he saw them. He respond me, almost never, and that was one of the things if he had a second chance to correct he will do it. Why do you weak up every morning? At the end you will be measure for your family and friends, not your money, and looks that you already have them. You are bless. Take this time like a vacation, enjoy your family and friends, try new things, keep your integrity. If everything goes well we will have a good story to tell our grandchildren, if not, you will not loose anything since you have everything..... your family.  Regards   Enrique Guadiana
	# 7 of 8	October 28, 2011 07:31 (EDT)
	Melissa	"You have everything....your family". No truer words were ever spoken Enrique. Thank you so much. Melissa
	# 8 of 8	November 18, 2011 04:27 (EST)
	Melissa	DoctorG, I contacted a physician, not a cardiologist who recently signed a contract with his hospital for hire. He told me he definitely noted in the contract a built in $10,000/year incentive to refer to other physicians hired by his hospital.  I don't think anywhere in medicine I've ever seen a more agregious incentive.  It might not seem like a lot of money, but the amount of reimbursement shifts in some communities could be devastating to well established private surgical subspecialties for instance.  I don't see the patient's well being anywhere in this clause. Melissa

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