The Institutional Model for Practice: An Interventional Neurovascular Program within an Academic Neurological Surgery Department
Objectives: After completing this chapter, the reader should be able to explain how to integrate an endovascular surgeon into an academic neurosurgical department.
Accreditation: The AANS* is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education for physicians.
Credit: The AANS designates this educational activity for a maximum of 15 credits in Category 1 credit toward the AMA Physician’s Recognition Award. Each physician should claim only those hours of credit that he/she spent in the educational activity.
The Home Study Examination is online on the AANS Web site at: http://www.aans.org/education/books/controversy.asp
* The acronym AANS refers to both the American Association of Neurological Surgeons and the American Association of Neurosurgeons.
“The secret of success in an institution . . . is to blend the old with the new, the past with the present in due proportion, and it is not difficult if we follow Emerson’s counsel: ‘We cannot overstate’, he says, ‘our debt to the past, but the moment has the supreme claim; the sole terms on which the past can become ours are its subordination to the present.’”
—Sir William Osler1
Background
With this reminder from a brilliant innovator of modern medicine, we detail a single institution’s effort to establish and maintain a state-of-the-art interventional neurovascular program. Like politics in Chicago, everything is local. The local politics may facilitate or hamper the success of one program’s model.
Loyola University Medical Center and the Loyola Health System in Maywood, Illinois is a Catholic, tertiary/ quaternary healthcare provider. The Center/System consists of a 523-bed acute care hospital (ranked in the top 20 nationally among academic institutions for patient acuity), 22 ambulatory sites, and a 600-person faculty; it is affiliated with a major rehabilitation facility and long-term ventilation care hospital. The Health System and the Loyola University Physician Foundation (which includes the 600-person faculty) are highly aligned and share many common resources and liabilities including a joint malpractice subsidiary. The common relationship of the entire faculty within one foundation circumvents issues related to the Stark Law*, while providing a single billing and collection agent. Financially, each department within the Physician Foundation is an independent cost center responsible for its expenses as well as faculty management, compensation, and bonuses. The departments of neurological surgery, neurology, otolaryngology, and psychiatry participate in the neuroscience service line within the health system and function as a unit for marketing services’ purchases, hospital budget and management, and resource allocation. It is within the framework of this environment that the interventional neurovascular program was launched.
History
It was apparent by the mid-1990s that interventional management of cerebrovascular disease was here to stay.2 Technological advances in delivery systems and embolic devices such as the Guglielmi detachable coil (GDC) system had improved efficacy. A social milieu reflected more toward minimally invasive procedures. Issues of informed consent relating to treatment alternatives were on the malpractice horizon. Cerebrovascular programs providing the full spectrum of treatment (surgical and interventional) were changing patient–physician referral patterns.3
It Takes a Vision: Groundwork
In the fall of 1997, the Department of Neurological Surgery with the consent of the Department of Radiology approached the Health System administration through the Vice President of Service Lines with a proposal for a joint interventional neurovascular program. A key element for programmatic success was to identify an administrative champion who would partner with the physician leaders to shepherd the program through the complex financial and organizational review process. This process was data driven; it required access to sensitive Health System, as well as local–regional health care data, which was accessible through the office of the Senior Vice President of System Development. In the health care economic environment, where margins can be 1 to 2%, there is substantial economic risk when establishing a new program. Interventional neurovascular programs have substantial facility, technology, marketing, and personnel start-up costs. The administrator champion understands the language of financial productivity and method of formatting the data for senior administrator evaluation.
An initial SWOT (strengths/weaknesses/opportunities/ threats) analysis provided a framework for the establishment of a Health System task force to assess the feasibility and viability of the proposal. The administrator champion headed the task force, which consisted of representatives from relevant clinical departments (Neurological Surgery, Radiology, Neurology, Cardiology, Cardiovascular Surgery, Peripheral Vascular Surgery, Anesthesia, Pharmacy, and Emergency Room), Health System and hospital administration (including Marketing and Finance), Nursing, and Support Services.
The task force initiated a quality planning process that encompassed a comprehensive analysis of financial, operational, and clinical outcomes and indicators. A detailed financial analysis was performed based on patient volumes, payer mix, and procedural codes. The analysis included an examination of ICD-9 (International Classification of Diseases, 9th Edition/Revision),4 DRG (diagnosis-related group), and CPT (the American Medical Association’s current procedural terminology) codes, and the institution’s historic payer mix. It is important to understand the economic realities: (1) the difference between fee schedule and payer reimbursement, (2) the difference between physician reimbursement and hospital reimbursement, (3) the difference of payer mix and profit, and (4) the difference between charge and cost as it relates to the revenue statement for your program.
The clinical and operational analysis included facilities, technology, personnel, and system coordination needs. The establishment of the program coordinated both existing and anticipated resource needs. Existing resources included a dedicated 13-bed neuroscience intensive care unit, a 40-bed neuroscience medical–surgical floor, monitoring equipment, transcranial Doppler and cerebral blood flow technology, and a biplane angiographic suite. The required resources included a second 3D biplane angiographic suite; an interventional team of dedicated technologists and nurses; a database for tracking volumes, outcomes, and resource utilization; vendor meetings to establish price and stock; patient education/discharge and social work interface; and a marketing plan. The quality planning process took ~6 to 9 months and resulted in a comprehensive business and operational plan. The program opened in July 1998.
Key Philosophical Considerations: It Is Not What You Get but What You Are Willing to Give Up That Counts
The most comprehensive and viable business plan is all for naught if core philosophical issues are not resolved. One of the key rules to success is to face reality as it is, not as it was or you wish it were. This program’s success is based in part on the melding of two unique and quite different specialties—Neurological Surgery and Radiology.
Neurological Surgery and Radiology: Perspectives
To begin with, a strong neurosurgical chair can direct policy regarding “the rites of first attempt.” Much can be learned from microcatheter analysis and even attempted coiling regarding operative surgical anatomy.
Neurosurgical residency and practice is rich in critical care, inpatient floor management, and outpatient clinics. Traditionally, radiologists have limited exposure and experience in these areas. The interventional patients are often sick or can become so quickly. The vast majority of patient management and complications fall to neurosurgery to manage.
The cerebrovascular surgeon must view the neurointerventionalist as a partner, not a competitor. The cultures must meet at the patient. The interventionalist and the neurosurgeon must make their rounds of their patients together, talk to the families, and make the treatment decisions together. Neurosurgeons should attend their patients’ neurointerventional procedures to participate in decisions, intervene if necessary, or proceed to surgery. Interdiction cannot happen after the fact. Calling for neurosurgical support in a crisis is a “no-win” situation; making the decision together permits sharing in the joys of success and the burden of complications. Likewise, the interventionalist should attend all operative interventions and participate in the intraoperative angiography. These shared experiences enrich mutual respect and mutual understanding of programmatic capabilities and limitations. The result of this is that the interventionalist is a first-class citizen in both departments and provides each patient with optimal care.
The neurointerventionalist in our case is a radiologist. He has a joint appointment in neurological surgery and a physical office in both departments. He is fully integrated into the neurosurgery faculty and educational program. Our residents participate in a 3- to 6-month interventional rotation where they perform and participate in catheter angiography, interventional vertebroplasty, and diagnostic interpretation. Residents acquire an understanding of the capacity and capabilities of interventional procedures, which aids in clinical judgment. This experience can also count toward their interventional fellowship. A monthly joint cerebrovascular conference for neurosurgery, radiology, neurology, and medicine is held. The neurointerventionalist attends all faculty meetings and morbidity and mortality conferences and interviews resident applicants.
Core Financial Philosophy
It is not about the money—it is about the money. Many interdepartmental relationships and, for that matter, marriages fail due to finances. The environment at Loyola, being a unified practice plan with a single billing agent, simplifies the matter greatly. Collected dollars are paid to the Physician Foundation, which can distribute them by negotiated formulae.
In collaboration with the chairman of the radiology department, the following financial formula was arranged. Base salary is split 60/40 radiology/neurological surgery to reflect the additional non-angiographic neurodiagnostic work. Each department pays their bonuses according to their individual policy: radiology has a set, shared department plan; neurosurgery has an incentive plan based on individual productivity above expense. The practical application of this formula is accomplished by providing three separate physician billing codes: (1) non-angiodiagnostic (100% to radiology), (2) transcranial Doppler/cerebral blood flow (TCD/CBF) readings (100% to neurosurgery), and (3) interventional and catheter diagnostic work (50/50 split radiology/neurosurgery). Historical tracking of collections demonstrates a 60/40 (radiology/neurological surgery) return. This formula removes financial competition. Its justification, in part, comes from the concept of the CPT code, which embodies a technical component, an administration component, and a patient care component. The distribution of collections honors each program member’s contribution.
Philosophical Summary
The removal of financial concerns changes the “mine–mine” to an “ours” concept of turf. “Win–win” does not mean one department wins twice but, rather that both departments win. Most importantly, the patient benefits from programmatic expansion of treatment options. Viewing each other as partners, not competitors, consolidates the turf and gives the program a competitive advantage. The lessons are:
• It’s not about the money—if you are willing to share.
• “Win–win” does not mean you win twice but, rather that the patient wins all the time.
• The rites of first attempt go to the interventionalist; valuable information and experience are gained even from a failed attempt.
• Extract the best of each culture. Neurosurgeons have a robust clinical acumen. Use it. Neurosurgery residents must have exposure to hands-on training in neurointerventional techniques. It is part of the future of cerebrovascular neurosurgery.
• The neurosurgeon should attend at least the decision- making part of an interventional procedure. It enhances understanding, builds teamwork, and can avoid complications.
Related posts:
Implications of Trends in the Marketplace for Neurovascular Diseases
Surgical Treatment of Extracranial Vascular Occlusive Disease
Regionalization of Neurovascular Medicine
The Departmental Model for Practice
Intracranial Atherosclerotic Disease
Developing the Neurovascular Surgical Specialists of the Future
