Change in US Cardiology Will See Emergence of the 'Physician Executive'

Cardiologists must embrace change, including management training

April 02, 2011

April 2, 2011 (New Orleans, LA) - The sea change that is occurring in US healthcare is altering the face of cardiology in America, and doctors will have to be prepared to evolve to adapt to this new environment, attendees at the American College of Cardiology (ACC) 2011 Scientific Sessions heard today. A key issue is the "chasm" in cardiovascular leadership that will occur if more physicians are not properly trained in management skills within the next few years, a host of speakers stressed.

Most practices are led by doctors over the age of 50, and almost half of all cardiologists are 55 or older, so "we've got to get our 35-, 40-, and 45-year-olds to step up to the plate and lead," says Dr C Michael Valentine (Cardiovascular Group Centra Stroobants Heart Center, Lynchburg, VA), one of the chairs of a recent ACC initiative, the Cardiovascular Leadership Institute (CLI). "The college feels a tremendous responsibility to train the leaders of the future; if we don't start training them, the system will fail," Valentine told heartwire . "We believe the development of the physician executive is perhaps one of the most important things that can happen in the next two years, to help lead the healthcare system transformation, both academic and private."

We believe the development of the physician executive is perhaps one of the most important things that can happen in the next two years.

And ACC president-elect Dr William Zoghbi (Methodist Hospital, Houston, TX) told the audience: "As we are exposed to change, it is good but challenging. We need to help our physicians get to where they want to be, and it is most likely we will have a mixture of various employment options, including private practice, academic, and integration between hospitals and physicians."

90% of private practices will integrate with hospitals in next five years

Speakers told the meeting that while 60% of cardiologists were still in private practice in 2010, many factors mean that more and more are integrating with hospitals.

In a survey by MedAxiom--which has an alliance with the ACC--in January 2010, 15% of cardiology practices had integrated with hospitals, 49% were considering integration, 30% were not considering it, and 6% "would never consider integration," MedAxiom president Patrick White told delegates. But just nine months later, in September 2010, 21% of practices surveyed had integrated, 60% were considering integration, 17% were not considering integration, and just 2% would never consider it, he noted. By 2016, it is predicted that 80% to 90% of practices will have integrated with hospitals.

Among the pros for hospital integration include: the fact that hospitals have money; they have provider-based billing; they want the business and referrals and focus that cardiology practices bring; and cardiologists want the money and opportunities that only hospitals can provide. "If you've got a good hospital partner, they are going to realize what you bring to the table," says White.

For those practices remaining independent, observers predict there will be very little margin left, with capital resources shrinking, nonessential services being discontinued, and a reluctance to hire new physicians despite a huge workload--all of which will require professional management to handle.

Will private cardiologists be able to maintain compensation levels? We don't know.

"There has definitely been this feeling among Congress, the public, and others that perhaps we were in business to make money and not do what's right clinically, and that's unfortunate," White told delegates. "Five years from now, we will be feeling that heat more than ever. Will private cardiologists be able to maintain compensation levels? We don't know, because there are regulations and issues that are going to put pressure on you."

Dr George P Rodgers (Heart Clinic of Austin, Texas) commented: "It's pretty easy to lead a practice when you have big margins, but when they are razor thin" it's much more difficult. "The old guard is leaving--whether through hospital integration or independently--we have to accept that. New leaders will need professional skills to manage, with the ability to understand finances."

We have all got to get on the same team. . . . We don't all have to integrate, but we have to realize it's not the hospital vs your group anymore.

Key to the success of cardiology going forward, most agree, will be the recognition of the important role that primary care can play, with doctors, nurse practitioners (NPs), nurses, and other healthcare providers working together to supply the most efficient, successful, and economical care for their patients, a number of speakers said. For example, "We need to learn how to use mid-level staff for things like lipid management," White observed.

Dr Howard T Walpole (St Thomas Health Services, Nashville, TN) said that while it is true that there are many skills cardiologists can bring to the table, there "are also many talents that we are going to have to learn." White agrees, pointing out that a key area where cardiologists need guidance is on how to change people's behavior: "I'm sure most of you have never had any training in health-behavior modification," he noted.

"What is most important is that we have all got to get on the same team, and teamwork is not something we embrace," Walpole added. "We don't all have to integrate, but we have to realize it's not the hospital vs your group anymore. All the focus is on quality care, and we have to focus on three things: what is going to be best, eventually, for the patient; involving everybody; and making sure that all decisions are data-driven."

Academic centers: a time of rapid change

There are also numerous issues ahead for academic heart centers, the meeting heard. Importantly, there is no standard business model for academic centers. "When you've seen one academic center, you've seen one," observed Dr Pamela S Douglas (Duke Clinical Research Institute, Durham, NC), who along with Valentine chairs the CLI. She outlined what she sees as the major challenges to MD leadership in academic centers, in what she dubbed "a time of rapid change."

"A physician leader needs to be a wizard and a warrior, a visionary who can tell a story, weave a spell, and inspire, but also get down and dirty with the spreadsheets and with the fights over space and overhead: you need to be both of those things at the same time," she observed.

A physician leader needs to be a wizard and a warrior, a visionary who can inspire, but also get down and dirty with the spreadsheets.

"You also need to be a faculty champion, and this is true in a private practice too," she added. "You need to be effective in large and complex organizations, and no matter what everyone says about value, it's all about the money. If you don't have the money to pay your faculty to do the work, to recruit, if you don't have the space, if you can't pay your fellows, you're not going to have a good program for long." She noted, for example, that "recruitment packages for talented basic scientists are in the millions of dollars--that's a lot of money. How do you invest in that when you don't control your own bottom line?"

It's also therefore important to "love thy 'frenemies'--your boss, that's the one sucking the money out of your bottom line; these are the people you need to work with," she stressed.

"I've painted probably a much too depressing picture," Douglas concluded, "because I love academics; it's incredibly invigorating and incredibly important to who we are as professionals, but it's a complex job. If you thought we might be coming out of the white water, it's clear it's just beginning."

No matter what everyone says about value, it's all about the money.

Dr Joseph A Hill (University of Texas Southwestern Medical Center, Dallas) said there are "six unique challenges" for academic heart centers, including: the business structure of the organization; the training-intensive environment; the costs associated with education; the need to restructure provision of care--"where it is pretty clear the primary-care physician is going to be the nexus" around which things will turn; the traditional academic governance--"turf battles and fiefdoms"; and the mission to conduct research.

"Spiraling costs, aging populations, the deteriorating lifestyles of our patients and of our faculty, together with a societal mandate to rein in growth" will all play a role in shaping the future, he said.

Training required: Physician executives will be key

Valentine says the CLI is attempting to address the identified gaps with a number of core focus areas in cardiovascular leadership excellence: early career and fellows in training (FIT); women and minorities; college leadership; academic leadership; and physician executives.

"The transformation of the healthcare system in regards to all specialties, but specifically cardiology, has been so profound in the past 24 months that physicians and hospitals are not prepared for leadership in the new models that are happening, both in academia and in private practice," he told heartwire .

The training of physician executives is key, he believes: "We are developing a formal relationship with the American College of Physician Executives, which offers not only MBA training but also certificate training. It will go through all phases of a physician's career." Training objectives will include: leadership, healthcare economics and finance, quality, enterprise management, physician performance management, and health law and ethics.

"We are going to train these leaders to get the skills needed to run integrated systems, to look at different options of practice, to work with their administrators, and to become advocates for cardiology and for their patients," Valentine concludes.

Douglas reports receiving consulting fees/honoraria from Elsevier, Medscape, the Genomic Medicine Institute, WebMD, CardioRx, Pappas Ventures, BG Medicine,, and upToDate. She has ownership/partnership interests in CardioDX and research grants from Abiomed, Viacor, Novartis, Edwards Lifesciences, and Atritech, and "other financial benefit" from the David H Murdock Research Institute. Rodgers disclosed consulting fees/honoraria from United Health Care; he is president of Championship Hearts Foundation and on the board of directors for Paragon Health and has ownership/partnership interests Biophysical. Valentine lists no disclosures. Walpole disclosed receiving a salary from Zoll Medical.


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