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Procedural shift: Cardiac care refocuses on less-invasive processes

Advances in technology have meant better outcomes for patients. But they also can move business toward a new specialty, forcing physicians to adapt.

By Mike Norbut, amednews staff. Dec. 1, 2003.

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There was a time -- just a few years ago, actually -- when the heart surgeons affiliated with one of Southern California's largest cardiology groups got all the referrals they needed internally.

Business waned, however, as patients who used to be candidates for bypass surgery instead were undergoing less invasive catheterization procedures. Suddenly, being affiliated with one cardiology group was no longer profitable for the surgeons, and after 4½ years of association, they recently decided to break away in an effort to secure more referrals and keep their volumes high.

"We all keep saying, 'Life used to be a whole lot simpler,' " said Ali Gheissari, MD, a cardiothoracic surgeon and president of the new three-surgeon group. "The way I see it, things are tougher now than they were 10 years ago."

Technology, it seems, is what's changing those physicians' lives as their patients' lives change, too. New advances and improved equipment mean better outcomes and the ability to treat patients with more complicated health problems. But they also can blur the lines between doctors who in years past had clearly defined roles -- and revenue streams.

"Technology clearly is a very real plus-and-minus factor, depending on what side you're on," said Rick Kunnes, MD, vice president for clinical and operations consulting for VHA Inc., a national health care cooperative based in Irving, Texas. Cardiology is the latest and best example of this phenomenon, with the development of better catheterization technology and drug-eluting stents shifting more work from surgeons to interventional cardiologists. The market for drug-eluting stents, for example, is expected to triple from $2.1 billion in 2003 to $6.3 billion in 2008 as it becomes the treatment of choice, according to Front Line Strategic Consulting Inc., a San Mateo, Calif.-based life science market analysis company.

According to the American Medical Group Assn., general cardiologists saw their median compensation levels increase 16.9% from 1999 to 2002, while interventional cardiologists saw their compensation increase 17.8%. Cardiac and thoracic surgeons saw their incomes increase only 2.8% over the same period.

The trend is evident in procedures as well. The Society of Thoracic Surgeons reports coronary artery bypass procedures have declined from their peak of 192,543 in 1997 to 143,180 last year, though society officials say patient outcomes have improved. Conversely, the American Heart Assn. reports cardiac catheterizations have increased 341% from 1979 to 2000, with more than 1.3 million inpatient catheterization procedures performed in 2000.

Not just hearts

Of course, this trend has not been limited to heart treatments, with plenty of technological advancements in other specialties. For example, the development of stereotactic needle biopsies allowed radiologists to see more breast cancer patients who previously had visited surgeons, said William F. Jessee, MD, president and CEO of the Medical Group Management Assn. But radiologists have lost some cardiac imaging business to cardiologists and ultrasonography business to a variety of specialists because of technological advances, he said.

This cyclical, cause-and-effect nature of advancements has some experts speculating about where the benefit roulette wheel will stop.

"In the long run, the surgeon may be the beneficiary," said Jim Connor, PhD, assistant director of the National Museum of Health and Medicine, part of the Armed Forces Institute of Pathology on the campus of Walter Reed Army Medical Center in Washington, D.C. Just like the development of radiology has opened up whole new regions of the body to surgeons, advancements such as telemedicine and Web-based guidance systems should allow them to perform more long-distance and even battlefield procedures, he said.

While cardiothoracic surgeons ultimately may find technology working in their favor, they currently find themselves in one of the valleys of the cycle. Not only are they seeing fewer surgical candidates, but the patients they ultimately do see usually are older and sicker, with more complicated cases.

"What we're seeing is that in the middle ground, where the line used to be fairly clearly drawn between cath lab and surgical therapies, there's a shift towards catheter-based treatments," said Alfred S. Casale, MD, surgical director of The Geisinger Heart Institute in Danville and Wilkes-Barre, Pa. Just because patients are shifting, however, "doesn't mean the days for surgical intervention are over," he said.

The extremes are still clearly marked, Dr. Casale said. Someone with single-vessel disease is an obvious candidate for interventional techniques, while someone with several diffusely blocked arteries and weakened heart muscle would benefit more from surgery.

Cardiologists agree, adding that there are some patients who don't respond to interventional techniques, and some for whom the technology still is limited. A catheterization procedure still can treat only one vessel at a time, physicians said.

Yet interventional cardiologists are getting busier. Cardiovascular Associates PSC, a 23-physician practice in Louisville, Ky., recently increased its number of catheterization specialists from two to five because of the rising patient volumes, said William C. Dillon, MD, an interventional cardiologist with the practice.

"We're able to do things we weren't able to a few years ago," he said. "We're hoping the new stent will help get patients through that Achilles' heel, restenosis."

Meanwhile cardiac surgeons are "hungrier than they used to be," Dr. Dillon said.

When surgeons do get a case, it often takes longer to work on that patient because of weaker vessels and other complications. Combine that with a rise in liability premiums, increasing overhead costs and declining reimbursements, and surgeons are under "massive pressure," said Shauna R. Roberts, MD, a cardiothoracic surgeon and medical director of the Genesis Heart Institute, a part of the Genesis Health System and located in Davenport, Iowa.

"If time bears out that [interventional techniques] are more successful, we have to be big enough to say, 'Wow, that's great for the patients,' " Dr. Roberts said. "We still need to see and understand more."

The problem is, technology can be similar to new drugs when it comes to testing its efficacy, said Sidney Levitsky, MD, a cardiothoracic surgeon, professor of surgery at Harvard Medical School and director of cardiothoracic surgery for CareGroup in Boston, which includes Beth Israel Deaconess Medical Center. Drug studies inevitably are positive, he said, because drug companies fund them, and leading innovators of technology often push their devices the same way.

"There's a question of a fair arbitrator," said Dr. Levitsky, the second vice president of the Society of Thoracic Surgeons. "I would like to see side-by-side studies of different therapies and see which one is the winner."

Changing technology

These types of studies may not be very frequent because of the changing nature of technology. Just when some physicians become skilled at a new procedure or understand the limitations of a new device, there seems to be something new taking its place.

Last month, for example, a study was published in the Journal of the American Medical Association revealing a new synthetic component of HDL cholesterol did a remarkable job on a small scale of removing plaque from coronary arteries. Surgeons also have their next expansion on the horizon, as ventricular assist devices for congestive heart failure patients become more available.

"This is going to offer tremendous opportunities for revenues," Dr. Kunnes said. "Can they translate CABGs into VADs? We'll see, but the financial outlook for these surgeons is they'll do just fine overall."

Cardiologists, meanwhile, also feel comfortable with their position on the technology spectrum. Catheterization procedures and devices are being improved constantly, but cardiologists don't think that the technology will become so commonplace that a physician with less training and knowledge could -- or would want to -- treat a patient with heart problems.

The way other physicians, notably primary care doctors, could affect cardiologists' incomes is through advancements in preventive medicine, cardiologists said. Family physicians are more likely to prescribe medication to address early symptoms of heart disease than they are likely to perform angioplasties, said Daniel Eisenberg, MD, a cardiologist with Foothill Cardiology/California Heart Medical Group Inc. in Los Angeles.

"That's where the impact will come," said Dr. Eisenberg, who also is director of cardiology at Providence St. Joseph Medical Center in Burbank, Calif., and associate clinical professor of medicine at the University of Southern California Medical School, Los Angeles. "It will be through prevention of hypertension, that sort of thing."

Eventually, everyone would like to see medicine practiced the way it was by "Bones," Dr. Leonard McCoy, on "Star Trek," Dr. Roberts said. In the movie "Star Trek IV: The Voyage Home," the crew travels back in time to the 1980s. Dr. McCoy, realizing that Commander Pavel Chekov is about to undergo surgery, leads a rescue mission to save his comrade from the "medievalism" of 20th-century medicine. On his way to Chekov, Dr. McCoy applies his 23rd-century medicine to two kidney patients.

"Bones sees [the patients] on dialysis and says, 'How barbaric!' " Dr. Roberts said.

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