Trend in Hospitalizations

1
Trend in Hospitalizations
Primary or secondary diagnosis of HF
Gregory D, Delgado R, et al., Premier Database
2
Hospital Discharges for Congestive Heart Failure
by Sex United States 1970-2000
AHA Heart Disease and Stroke Statistics 2003
Update
P 23
3
Treatments in Heart Failure
ICDs
CRT
VADs
ARBs
Aldo blockers
Beta blockers
ACE inhibitors
Hydralazine-nitrates
Diuretics
4
Proposal for Secondary Subspecialty Certification
in Advanced Heart Failure Cardiology Rationale

• A large and growing problem
• Rapid expansion of diagnostic and treatment
  (drug- and device-based) modalities documented to
  influence clinical outcomes
• Increasingly complex selection and sequencing of
  management options
• Diversity in characterization of HF specialist,
  with no certification option
• Interest by other groups in defining a HF
  specialist

5
Proposal for Secondary Subspecialty Certification
in Advanced Heart Failure Cardiology Rationale

6
Secondary Subspecialty Advanced Heart Failure
Cardiology

• Key Findings
• Current compensation
• Joint HFSA and APC Survey of AMC Chiefs
• Economic Value
• Longitudinal data from a single AMC
• Current and prospective training programs
• HFSA Survey of Training Programs

7
Secondary Subspecialty Advanced Heart Failure
Cardiology

• Key Findings
• Current compensation
• Joint HFSA and APC Survey of AMC Chiefs
• Economic Value
• Longitudinal data from a single AMC
• Current and prospective training programs
• HFSA Survey of Training Programs

8
HF Specialists Compensation SurveyResponses
from 24 AMCs
9
55 of the academic heart failure cardiologists
time was devoted to clinical care and 80 of that
time was for E M services.
Allocation of Heart Failure Cardiologist Time
Allocation of Clinical Care Time
Note Percentages represent weighted averages
across up to 3 cardiologists time allocations at
each institution. Totals do not sum to 100 due
to averaging over multiple sites
10
Heart Failure Specialists Determinants of
Compensation
Determinants of Compensation
Determinants of Productivity
11
RVUs increase as clinical time increases
(440/10?), and RVUs decrease as EM code share
increases (627/10?).
12
Heart Failure Specialists RVU and Compensation
Comparisons
Source MGMA, Physician Compensation and
Production Survey,
Source Association of Professors of Cardiology,
2003-2004 Salary Survey Mean interquartile
range
13
Heart Failure Specialists RVU and Compensation
Comparisons
Source MGMA, Physician Compensation and
Production Survey,
14
Survey Conclusions

• HF MDs compensation is largely determined by
  clinical productivity
• Clinical productivity
• reflects both EM codes (80) and procedures
  (20)
• increases by 440 RVUs for each 10 increase in
  clinical time
• decreases by 627 RVUs for each 10 increase in
  proportion of time allocated to EM codes
• is comparable to non-invasive cardiologists when
  adjusted for time allocation to clinical work
• Compensation
• is comparable to the distribution of income for
  AMC Assistant Professors
• does not reflect outreach efforts
• Differential distribution in RVUs based on
  activity may be incentivizing a shift away from
  evaluation and management services
• Aligning HF MD compensation to outreach could
  improve the quality of clinical care and hospital
  economic performance.

15
Secondary Subspecialty Advanced Heart Failure
Cardiology

• Key Findings
• Current compensation
• Joint HFSA and APC Survey of AMC Chiefs
• Economic Value
• Longitudinal data from a single AMC
• Current and prospective training programs
• HFSA Survey of Training Programs

16
Expected Cumulative (3-year) Revenue Per New Pt
Referral Transplanted Patient 200k
Non-Transplanted Patient 50k.
Gregory D, DeNofrio D, Konstam MJACC
2005466606
17
Expected Cumulative Contribution Margin Per
Patient was 48k for a Transplant Patient and
10k for a non-Transplant Patient.
Gregory D, DeNofrio D, Konstam MJACC
2005466606
18
Impact of Adding 100 New Advanced HF Patients Per
Year on incremental contribution margin Year 1
Cumulative, Survival Adjusted Hospital Revenue
and Contribution Margin Additional 100 Heart
Failure Patients Per Year
Gregory D, DeNofrio D, Konstam MJACC
2005466606
19
Impact of Adding 100 New Advanced HF Patients Per
Year on incremental contribution margin Year 2
Cumulative, Survival Adjusted Hospital Revenue
and Contribution Margin Additional 100 Heart
Failure Patients Per Year
Gregory D, DeNofrio D, Konstam MJACC
2005466606
20
Impact of Adding 100 New Advanced HF Patients Per
Year on incremental contribution margin Year 3
Cumulative, Survival-Adjusted Hospital Revenue
and Contribution Margin Additional 100 Heart
Failure Patients Per Year
Gregory D, DeNofrio D, Konstam MJACC
2005466606
21
Secondary Subspecialty Advanced Heart Failure
Cardiology

• Key Findings
• Current compensation
• Joint HFSA and APC Survey of AMC Chiefs
• Economic Value
• Longitudinal data from a single AMC
• Current and prospective training programs
• HFSA Survey of Training Programs

22
Heart Failure Training Programs
Based on two 2005 HFSA surveys sent to 170 U.S.
cardiology training programs
23
Identified US HF Training Programs
Allegheny Gen Hosp Boston U Brigham and
Womens Case Western Cornell/Weill Med
Ctr Cleveland Clinic Duke U Emory U Henry Ford
Hosp Jefferson Med Coll Johns Hopkins U of Utah
Long Island Jewish Mass Gen/Harvard
MayoRochester Ohio State U Ochsner
Clinic Oregon U Penn State U St Lukes/Baylor
U Stanford U TuftsNew Engl Med Ctr Tulane U
24
Identified US HF Training Programs
U of Alabama Birmingham UCLA UCSD UCSF U of
Chicago U of Cincinnati U of FLGainesville U of
FLJacksonville U of Maryland U of Miami/Jackson
Med Ctr U of Minnesota
U of North Carolina U of Oklahoma U of
Pennsylvania U of Pittsburgh U of Rochester U of
Texas SWDallas U of Wisconsin Vanderbilt U Wash
Hosp CtrWash DC Washington University Yale U
25
Training Programs that Would Consider Developing
a HF Program
Texas AM/Scott White UCLAVA Greater
LA UMNDJNJ Med School U of Connecticut U of
Iowa U of Kentucky U of Missouri Kansas City U
of Washington
Brown University Cedars-Sinai Med
Center Geisinger Health System Lankenau
Hospital MayoScottsdale Jackson Health
System NYU Hosp M C Queens/ Cornell U Med
Cemter St John Hosp HCC
26
Location for Procedural Training
Based on 2005 HFSA questionnaire responses N 40
27
Proposal to ABIM for a Secondary Subspecialty in
Advanced Heart Failure Cardiology

• Developed by the Heart Failure Society of America
• Discussions with
• Cardiovascular Board
• American College of Cardiology
• Association of Professors of Cardiology

28
HFSA Ad Hoc Training/Certification Committee
Members

• Marvin A. Konstam (Boston, MA), Chair
• John D. Bennett (Albany, NY)
• Mariell L. Jessup (Philadelphia, PA)
• Mandeep R. Mehra (Baltimore, MD)
• Ileana L. Piña (Cleveland, OH)
• Marc J. Semigran (Boston, MA)

29
Advanced Heart Failure CardiologyProposed
Certification Requirements
30
Inpatient and Outpatient Experience with the
Following Patient Groups

• Patients with
• Heart failure, regardless of ejection
  fractioni.e., those with dilated and those with
  non-dilated LV
• New onset heart failure
• Acute decompensation of chronic HF
• Heart failure and cancer
• Heart failure who are pregnant or recently
  post-partum
• Heart failure and congenital heart disease
• Heart failure pre- and post-operation
• Geriatric patients with heart failure

31
Inpatient and Outpatient Experience with the
Following Patient Groupscontd

• Patients with
• Heart failure, regardless of ethnic group, with
  attention to specific diagnostic and therapeutic
  issues within specific ethnic groups
• Inherited forms of cardiomyopathy
• Infiltrative and inflammatory cardiomyopathies
• Hypertrophic cardiomyopathies
• Heart failure and arrhythmias
• Heart failure and other organs transplanted
• Heart failure on mechanical assist
• Devices, such as ICDs or CRT devices
• Patients undergoing cardiac transplant

32
Skill Categories

• Prevention
• Evaluation
• Management
• Procedural competencies

• Disease management strategies
• Basic mechanisms
• Clinical research

33
Procedural Competencies

• Formal instruction, clinical experience
  demonstrated proficiency
• Patients
• Evaluated for transplant or LVADs ( 30)
• Undergone transplant ( 30 5 init. hosp.)
• On assist devices ( 10 2 peri-op)
• Evaluated for ICDs ( 50)
• Evaluated for CRT ( 50)
• Device interrogation and interpretation in ICD
  or CRT pts ( 100)
• Endomyocardial biopsies ( 30)

34
Location for Procedural Training
Based on 2005 HFSA questionnaire responses N 40
35
COCATS 2006 Revision Task Force 8 Training in
Heart Failure

• James B. Young, MD, FACC, Chair
• William T. Abraham, MD, FACC
• Robert C. Bourge, MD, FACC
• Marvin A. Konstam, MD, FACC (HFSA Representative)
• Lynne Warner Stevenson, MD, FACC

36
COCATS 2006 Revision Task Force 8 Training in
Heart Failure

• Level I
• All trainees
• Within 36-month general Cardiology training
• Core competencies in pathophysiology, prevention,
  diagnosis, and treatment
• Level II
• Fellows seeking special competency in HF
  management
• Within 36-month general Cardiology training
• 4 months of dedicated inpatient and outpatient HF
  rotations
• Level I additional exposure / competency /
  didactics / research
• Level III
• Advanced training, including EM competencies for
  patients undergoing device implants and
  transplantation.
• Additional 12 months beyond general Cardiology
• May be satisfied with rotations at a transplant /
  VAD center
• Concordant with proposed ABIM Secondary
  Subspecialty of Advanced HF Cardiology

37
Secondary Subspecialization in Advanced Heart
Failure Key Events to Date

• Formation of Ad Hoc Training/Certification
  Committee of HFSA
• Definition of Advanced HF Cardiology and
  articulation of its components
• Meeting with ABIM, submission of initial proposal
  for secondary subspecialty
• Submission of revised proposal to CV Board of
  ABIM for review and feedback
• Submission of revised proposal to ABIM Executive
  Committee for October review

2005
2006