May 14, 2018

Community hospitals add complex procedures amid push for higher revenue, improved patient access

HBJ Photo | Bill Morgan
HBJ Photo | Bill Morgan
Manchester Memorial's proposed cardiology partnership with St. Francis Hospital and Medical Center would bring together two teams that previously worked with each other for a decade. Pictured in a St. Francis cardiology suite in Hartford are several team members, including Manchester Memorial cardiologists Dr.†Saquib Naseer (left) and Dr.†Chandra Sachetti (right). St. Francis cardiology chief Dr.†Daniel Diver (center) would oversee the partnership.
HBJ Photo | Bill Morgan
Dennis McConville, ECHNís chief strategy officer (left), with Dr. Daniel Diver outside the Hoffman Heart and Vascular Institute of Connecticut inside St. Francis.

Manchester Memorial's proposed cardiac services

Diagnostic catheterization: This is how doctors diagnose any heart problems. The process involves passing a catheter to the heart to look for problems with heart function, valves and blood vessels.

Elective angioplasty: Of the three, this service is the most rare in hospitals that don't have openheart surgery available on-site. It is a scheduled procedure that uses a balloon to open up a narrow or weak artery to improve blood flow. It often involves the insertion of a stent to keep the artery open.

Primary angioplasty: This is similar to an elective angioplasty, but is done in an emergency situation, like when a patient arrives in the emergency room during a heart attack. As this procedure has the best outcomes when it is performed as soon as possible, more community hospitals have been approved to offer it than elective angioplasties.

As healthcare technology and practices evolve, community hospitals are yearning to offer more complex procedures that were once housed only within the walls of their larger competitors.

Efforts to add services like robotic and vascular surgery have been made by community hospitals in recent years as they look for more lucrative business lines and to bring care closer to patients.

The latest example is Manchester Memorial Hospital, which has jointly proposed with St. Francis Hospital and Medical Center to construct a $3.1 million lab in Manchester that would offer heart-disease patients advanced diagnostic and interventional cardiology services.

They include elective and primary angioplasty, which surgically restores blood flow to blocked arteries using a carefully threaded catheter, and the diagnostic catheterization test that precedes those procedures.

Though smoking cessation and statins like Lipitor have driven a longer-term decline in the need for those services, Manchester Memorial executives say they expect demand to continue crawling upwards due to an aging population.

Connecticut hospitals performed 23,925 angioplasties and diagnostic caths last fiscal year, up nearly 9 percent from two years prior, according to data filed with state regulators.

Manchester Memorial, which is owned by California-based Prospect Medical Holdings Inc. and part of the Eastern Connecticut Health Network, estimates it could grab 929 cases annually once its facility is fully open.

That would translate to about $8.4 million in new revenue and $2.3 million in additional net income, the hospital estimates. The project still needs state regulatory approval.

"This is a service that brings in serious revenue," said Dennis McConville, ECHN's senior vice president, chief strategy officer and formerly a cardiac nurse.

Dr. Dennis Diver, chief of cardiology and director of the cardiovascular service line at St Francis, would be medical director of the new Manchester lab. Diver said St. Francis views Manchester as a key ally.

"They're an important clinical partner of ours and there are some benefits to the patients having [services] locally," Diver said.

The two hospitals previously worked together for about a decade to offer diagnostic catheterization at ECHN's Rockville General Hospital campus, which ended around 2012.

The program had a good safety record, but not having angioplasty to accompany the diagnostic offering ultimately led to the service line being discontinued.

Manchester Memorial has been wanting to offer the diagnostic tests along with angioplasty for some time, McConville said, but needed capital. Prospect's acquisition of ECHN in 2016 helped make the project possible.

He said Manchester Memorial needs the expertise of St. Francis because it's a high-volume provider of such services and can arrange to treat more complex patients and provide emergency coronary bypass surgery, if needed. Some Manchester Memorial cardiologists are on St. Francis' staff and already practice the procedures at the larger hospital in Hartford.

Manchester Memorial would pay St. Francis an undisclosed one-time fee for its help developing the lab, as well as $250,000 a year in ongoing fees. St. Francis would also receive referrals of more complex or higher-risk patients, and the arrangement could lead to other future partnerships, officials said.

In addition to business considerations, Manchester Memorial says its patients have to travel too far — often to Hartford — to receive such services. In some cases it can take patients 30 minutes or more to access emergency heart angioplasty.

Its service area also has a higher-than-average incidence of heart disease — about 9 percent of adults suffer from it.

While a number of community hospitals in Connecticut do diagnostic catheterization and primary angioplasty, which is done on patients in the midst of a heart attack, elective angioplasty is rare in community settings because they don't offer open heart surgery on-site if something goes wrong. Outside of major hospitals, only Lawrence + Memorial Hospital has been approved to offer the elective service.

However, a 2012 John Hopkins University study of nearly 19,000 patients in 10 states who received elective angioplasty found that there was no difference in death rates at a community hospital vs. a major hospital.

The partnership

The proposed Manchester Memorial cath lab would in many respects be an extension of St. Francis' cardiac services. Diver, St. Francis' chief of cardiology, said that it's more common to move such advanced services to community settings because it's become safer.

That's largely due to the evolution of stents, which are wire mesh tubes inserted into arteries during an angioplasty to keep blood flowing through.

Now, the odds of running into complications during an angioplasty, such as a sudden artery collapse — which would require emergency surgery — have fallen to somewhere around 1 percent or less, he said. It used to be as high as 6 percent.

In addition, Manchester Memorial's and St. Francis' partnership includes procedures for rapidly transferring patients to Hartford if needed, Diver said.

The state Office of Health Care Access still must approve the proposed lab. OHCA's decisions can boil down to geography. If a proposed service would take away too many cases from a nearby competitor, OHCA could deny an application.

That's not the case here, says McConville. Though Manchester Memorial would likely win some market share from Hartford's major hospitals, both have volumes that are high enough that it wouldn't trigger OHCA thresholds, he said.

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