In March, Advisory Board gathered over twenty leaders from across the health care industry to discuss a topic that is top-of-mind for all cardiovascular (CV) leaders: site-of-care shifts away from the hospital. Attendees represented a range of stakeholders—health systems, physician practices, device manufacturers, pharmaceutical companies, digital tech, and payers—to provide their unique perspectives on what the future of CV site-of-care shifts could look like, and what it will take to deliver the best CV care for patients out of the hospital.
We’ve synthesized the key takeaways from our discussion below, including new opportunities for supplier-provider partnerships.
1. We all know where CV care is going, but we’re not aligned on why.
When we asked attendees to share where CV care will be delivered in five years compared to today, there was cross-industry consensus that it will be shifting further toward non-traditional ambulatory settings (e.g., home, virtual, ambulatory surgery centers [ASCs]).
However, when we asked what drivers would have the greatest impact on shifting CV services, there were different perspectives. While all attendees agreed that purchasers were the greatest influencer of the shift, when taking that option out of the equation, providers (blue checkmarks) largely agreed it was patients, while non-providers (green checkmarks) felt it would be the CV physicians. This may reflect the current reality providers are facing of patients seeking ambulatory care during the pandemic, as opposed to suppliers having conversations directly with physicians on the ASC opportunity. In fact, we have seen examples recently of CV physicians leaving employment to pursue an ASC opportunity, as well as independent groups encouraging local health systems to joint venture to keep referrals, and agree this trend is likely to accelerate going forward.
2. The benefits to patients are clear, as long as safety and appropriateness are maintained.
All stakeholders were quick to recognize the possible benefits of CV ambulatory care delivery—both in-person and virtual—to patients: lower out-of-pocket cost, convenience, experience, access, and ability to avoid the hospital altogether (and thus risk of exposure to Covid-19 or other communicable diseases). The group also discussed the ability to better manage complex, chronic care needs for patients, such as through virtual cardiac rehab, as well as reserve hospital capacity for the most acute cases
At the same time, attendees agreed upon the importance of ensuring safety and appropriateness, particularly as more procedures shift to ASCs and office-based labs (OBLs). Given the reality of this ambulatory shift, health systems in particular noted the importance of extending the hospital’s quality and appropriateness infrastructure to freestanding sites.
3. But we have to overcome misaligned incentives to capitalize on this opportunity.
The discussion was much more complicated when it came to the potential benefits to health systems and suppliers. Attendees agreed that misaligned incentives are the greatest hurdle. CV procedures are reimbursed at a significantly lower rate in ASCs than hospital outpatient payments. This impacts not only the health system finances, but also CV device manufacturers supporting these cases. Telehealth coverage and reimbursement will also be an ongoing challenge post-pandemic.
Under fee-for-service payment, it can be difficult for health systems to justify proactively shifting services out of the hospital, whether it’s diagnostics to a physician practice, procedures to an ASC, or outpatient visits to virtual. It’s a delicate balance currently to negotiate access and lower cost against revenue opportunity.
“As care shifts there are winners and losers.” – CV service line administrator
“It really is a SWOT analysis where an opportunity for one party is a threat to another. It’s a classic model of innovation – who is innovating, and who is being displaced.” – Leader at a CV device manufacturer
But through deeper discussion, there was consensus that this hurdle would have to be overcome in order to provide better patient care. And in fact, the group shared several examples where providers and suppliers could benefit from the shift beyond a reimbursement play:
- Hospitals can open lab and bed capacity to higher-acuity services that require on-campus care, such as TAVR and high-risk PCI
- New partnership opportunities between health systems and employed or independent physicians, such as through joint venture ASCs
- Increased potential for early patient identification by offering more accessible diagnostics in the community
- Ability to reduce total cost of care to succeed under bundled payments and appeal to cost-sensitive purchasers/consumers
- Reduced readmissions through accessible virtual care management and remote monitoring
- More opportunities for supplier innovation to deliver more efficient ambulatory care
- Potential for new types of provider-supplier partnerships in this evolving landscape
4. While ASCs are the hot topic, we can’t take our eyes of the opportunities of telehealth and remote monitoring.
Much of the discussion inevitably veered toward the shift to ASCs. This is understandable given the significant impact on financial performance of all industry stakeholders. However, there is continued innovation in telehealth and remote patient monitoring that has the ability to not just disrupt finances, but actual care models. We encouraged leaders to not let the telehealth gains of the pandemic backslide, and to explore sustainable models to deliver accessible care to patients virtually when appropriate.
5. Ambulatory care requires new supplier-provider partnerships.
The primary goal of this discussion was to develop cross-industry solutions. Leaders identified several areas in particular where suppliers could support providers in delivering high-value care for patients outside the hospital, including:
- Create ambulatory-specific guidelines and care pathways for your devices/medication
- Help providers improve procedural efficiency and same-day discharge to prepare for ambulatory care
- Design easy-to-interpret patient education material for patients with shorter-stays or virtual visits where patients may have less face-to-face time with providers
- Support patient advocacy programs to increase awareness of risk and treatment options, particularly for underserved communities
- Co-develop quality standards for freestanding sites
- Expand telemedicine access in rural areas
- Collect and share patient-reported outcomes data and real-world evidence to better understand the efficacy of treatment options across care settings
- Tailor operational support, such as supply chain or distribution, to the unique needs of non-hospitals