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W2085754527 abstract "Cardiac surgery has developed over the past four decades in the United States as an important component of the entire health care industry. When analyzed as an industry, it is apparent that cardiac surgery is transitioning from its emerging or rapid growth phase to that of a mature industry. This transition, when combined with the global changes occurring in all of health care, has caused payers to reassess the value of cardiac surgical services and they have been targeted as overvalued and consuming a disproportionate share of health care resources. Several options are available to cardiac surgeons as to how they may potentially respond to the changes that are occurring in the external environment and reshaping the practice of the specialty. The active adaptation strategy appears to be the preferred choice but will require a substantial shift in the way cardiac surgery is practiced and reimbursed in the future. Cardiac surgery has developed over the past four decades in the United States as an important component of the entire health care industry. When analyzed as an industry, it is apparent that cardiac surgery is transitioning from its emerging or rapid growth phase to that of a mature industry. This transition, when combined with the global changes occurring in all of health care, has caused payers to reassess the value of cardiac surgical services and they have been targeted as overvalued and consuming a disproportionate share of health care resources. Several options are available to cardiac surgeons as to how they may potentially respond to the changes that are occurring in the external environment and reshaping the practice of the specialty. The active adaptation strategy appears to be the preferred choice but will require a substantial shift in the way cardiac surgery is practiced and reimbursed in the future. It is an interesting but challenging task to contemplate the future of cardiac surgery as we rapidly approach the 21st century. By the year 2000, the specialty to which many of us have devoted our professional lives will have been in existence for approximately one half of a century. Cardiac surgery's growth has been spectacular and its positive impact on the treatment of both congenital and acquired heart disease has been well documented. Few would argue that the benefits of cardiac surgery to society have been positive, but most believe that the way it will be practiced in the 21st century will be substantially different from the present or past. My purpose is to examine some of the factors that have driven the growth of cardiac surgery in the past and suggest what forces may be influential in changing the nature of the specialty in the future.Factors Driving ChangeTo determine the factors that physicians believe are influencing change in health care and more specifically in cardiac surgery, I informally surveyed colleagues in primary care, cardiology, and cardiac surgery. Each was asked to list the factors that he or she thought would most influence the specialty of cardiac surgery in the future. All of the people surveyed were asked to avoid personal bias and rather than stating what they thought was most influencing their own practice, to focus on those factors that they thought would influence cardiac surgical practice from the perspective of the overall health care system. The responses showed a remarkable consistency and were substantially in agreement with a list that had been developed through discussions with colleagues at Duke. This was not a scientifically constructed survey but rather an opinion poll to either confirm or refute my own observations.Not surprisingly, all of the respondents thought that reimbursement issues that were being driven by the economics of health care would have the greatest impact on future cardiac surgery practice. Most respondents thought that there would be an increasing emphasis on accountability for outcomes, and cardiac surgeons would be less autonomous and function more as members of a team within an integrated delivery system than in the past. The specialists who practice in academic centers thought that decreased federal support for cardiovascular research would have an important impact, but this was not a factor frequently cited by those in private practice. In spite of the concerns over funding of research, most of those surveyed cited the impact of emerging technologies such as gene therapy, molecular biology, and organ substitution in the form of either support devices or transplantation for end-stage cardiac disease as being driving factors in future cardiac surgical practice. Two other areas were mentioned by the majority of respondents in all three specialties as being of great importance. The first was that there would be a growing emphasis on preventive medicine and that advances in genetic analysis would influence the patient pool by risk modification in targeted high-risk populations. The surgeons and cardiologists all thought that there would be a trend toward replacing traditional “open heart” operations with procedures of a less invasive nature, and many suggested that this would result in alliances between cardiologists, surgeons, and radiologists.Based on the results of this informal survey and my own thoughts, I applied some of the analytic techniques described by Michael Porter in his classic book Competitive Strategy: The Techniques for Analyzing Industries and Competitors [1.Porter M. Competitive strategy: the techniques for analyzing industries and competitors. The Free Press, New York1980Google Scholar] to trace the evolution and future prospects of cardiac surgery as an industry. There is little doubt that both health care in general and cardiac surgery in particular can be viewed as “industries” and have been among the most profitable and successful ventures of the 20th century. Both have enjoyed monopolistic power and relative immunity from the usual market forces that have affected most industries. That era appears to be drawing to a close, and this has caused a great deal of anguish and concern. My focus will be to suggest some of the factors influencing cardiac surgery's future, but I hasten to point out that there are many similarities between those factors that will affect health care generally and cardiac surgery specifically. Those who so violently opposed the health care reforms proposed by the Clinton Administration must now confront those same market forces that apply to every other industry. There will be many changes as payers shift from the open ended, or what decision theorists would call pareto-optimal, condition of a fee-for-service environment to a zero-sum game where there is competition for fixed resources, which puts health care providers at risk. This is a common business scenario that health care has never faced before but must now confront.Emerging Industry PhaseIn its early years, cardiac surgery was an emerging industry that was created by technological innovation, which was fostered and supported by economic and sociologic changes in the form of Medicare, Medicaid, and health care insurance. These circumstances created a viable business opportunity, which was recognized and seized upon. Other industries were developing at the same time, such as biotechnology, telecommunications, and personal computers. These industries provide some basis for comparison, because each has followed the typical life cycle of most market-driven industries.The characteristic feature of any emerging industry from a strategic viewpoint is that there are no established rules of the game. This absence of established rules presents both risks and opportunities, and the question is how to maximize opportunity while minimizing risk. Cardiac surgery had the advantage of being born in the environment of scientific inquiry and laboratory trial, and much of the risk was reduced through research and development in academic centers. This allowed the development and testing of operative techniques, extracorporeal circulation, safe anesthetics, and anticoagulants before they were applied to clinical practice. The strategic error of the United States automobile industry in the 1970s supporting large instead of small cars was based on evidence from market research that was incomplete or faulty and could not be scientifically tested. Failures occur as a result of the technological uncertainty in every emerging industry, but the impact was far less in cardiac surgery because of its basis in science and laboratory research.The strategic uncertainty presented by alternative competitors is another important factor to be considered in every emerging industry. In the case of cardiac surgery alternative therapies, such as drugs, had little impact other than to defer the need for operation for a period of time and by the mid-1970s the role of cardiac surgery had become well established. A new alternative therapy in the form of angioplasty appeared a decade ago and has had a much greater impact. The mobility factors that limit most emerging industries did not have an important impact on cardiac surgery for several important reasons, and the specialty flourished because of the absence of traditional restraints that inhibit other industries. There was no proprietary technology, and information was freely shared and exchanged. Access to distribution channels was not limited, and hospitals were anxious to develop and capitalize cardiac surgery programs, which were looked on as being highly profitable. Regulatory factors such as Certificates of Need presented little barrier in most areas to the development of cardiac surgery programs, and skilled surgeons were made available through training programs that were rapidly developed at academic centers. Most importantly, risk for the industry was minimized by generous reimbursement available through private and governmental payers with minimal regulatory control in spite of erratic quality in many instances. There was another very important difference between cardiac surgery and other emerging areas such as consumer electronics and fiberoptics: all of these emerging industries were characterized by high start-up cost due to an initial large capital outlay and a steep learning curve. This was followed by rapid, steep cost reductions after the initial learning phase was past and subsequent low marginal costs. This typically resulted in market competition with falls in pricing and profit margins that became dependent on volume and efficiency. This was not the case in cardiac surgery, or medicine generally, which held a monopolistic position and was able to institute progressive pricing increases in spite of increasing volumes. The reimbursement system of fee-for-service did little to encourage cost reduction and encouraged growth in utilization. Historically, some privileged emerging industries with revolutionary new technology or social welfare benefits such as solar energy or health care have received governmental subsidies. Although initially very welcome by stake holders, these subsidies add great instability to an industry and make it dependent on political considerations that can be quickly reversed or modified. In the end, cardiac surgery along with the rest of health care was able to avoid the usual market forces and enjoy the privilege of being a monopolist that was also subsidized. The problems of access and cost that have developed have caused many to question the uniquely privileged position of the United States health care system. As health care financing is reshaped and private and government subsidies end, the impact is likely to be substantial and result in great change.Transition to a Mature IndustryIn the natural evolutionary process, many industries pass from periods of rapid growth to the more modest growth or what is called industry maturity. Maturity does not occur at any fixed point in an industry's development, and it can be delayed by innovations, environmental forces or subsidies. Those forces may restore a mature industry back to the status of a rapid-growth emerging industry. Several events have occurred in cardiac surgery that have had this impact, including the introduction of coronary bypass surgery [2.Favaloro R.G. Saphenous vein graft in the surgical treatment of coronary artery disease: operative technique.J Thorac Cardiovasc Surg. 1969; 58: 178-185PubMed Google Scholar], myocardial preservation advances [3.Gay W.A. Ebert P.A. Functional, metabolic and morphologic effects of potassium-induced cardioplegia.Surgery. 1973; 74: 284-292PubMed Google Scholar], and landmark clinical studies demonstrating the value of cardiac surgery in certain populations [4.Coronary Artery Surgery Study (CASS). A randomized trial of coronary artery bypass surgery. Circulation 1983;68:951–9.Google Scholar, 5.European Coronary Artery Surgery Study *Group. Long-term results of prospective randomized study of coronary artery bypass surgery in stable angina pectoris. Lancet 1982;2: 1173–9.Google Scholar, 6.Takaro T. Hultgren H.N. Lipton M.J. et al.Veterans Administration cooperative randomized study of surgery for coronary artery occlusive disease. II. Subgroup with significant left main lesions.Circulation. 1976; 54: 107-120Google Scholar]. At some point, however, a transition to maturity occurs and possibilities for forestalling such a transition are exhausted. Cardiac surgery appears to be reaching this point again and there appear to be no revolutionary breakthroughs or subsidies on the horizon that will reestablish it as an emerging and rapid-growth area in this country. An important environmental factor will be the aging population, which will have some effect in offsetting the influence of competing technologies.The transition to maturity is nearly always a critical period for the stakeholders (ie, surgeons, hospitals, perfusionists, suppliers, etc) in an industry. Transition to maturity signals important changes in the competitive environment, which may include:1.More competition for market share.2.More sophisticated and experienced purchasers of service.3.Greater emphasis on cost and service.4.Overcapacity in facilities and personnel.5.Changes in methods of providing service, marketing, pricing, and research.6.Falling profits.7.Decreasing subsidization.It is apparent that cardiac surgeons along with the rest of the health care system must come to some reconciliation with societal concerns to develop a strategy as to how we can adapt and reposition ourselves to the changes underway. To wish for the clock to be turned back is not realistic, although it is the most commonly expressed sentiment and dominates the rhetoric of our national meetings. Industries survive by contributing value to their customers, and although we think of patients as being the customers, this is not true in a business sense. Patients are the recipients of service, but the true customers who will negotiate for and assess the value of our services are payers, usually employers or the government. Insurance companies are blamed for the problem, but merely act as brokers in the transaction process. The current system of health care has created extraordinary expectations on the part of both providers in the system and the recipients of service. The ability of the old health care delivery system to meet these expectations is being challenged by customers who must compete in a global economy where the current cost of United States health care is unacceptable.We must recognize that health care, and cardiac surgery in particular, has lived in a bull market atmosphere for four decades, and this is different from any other enterprise. We have never seen a downturn in our professional lives and have enjoyed the same optimistic viewpoint that characterized brokers and investment bankers who suddenly confronted the reality of the market crash of October 1987. The fact that there is a lot of money to be made in health care has not escaped a new breed of entrepreneurs. Health care began and will end the 20th century primarily as a cottage industry, and physicians and hospitals remain largely unorganized, principally charitable or private endeavors. The opportunities for organizing and capitalizing health care are attractive to Wall Street, and we already see that the migration of health maintenance organizations from local, nonprofit competition to national scale and public ownership is nearly complete in less than a decade. The next targets will be hospitals and then physicians who will work in a market-disciplined for-profit environment. These Wall Street-driven enterprises have set a new standard of competition in every sector of every market in which they compete and grow relentlessly at the expense of less organized and poorly capitalized traditional hospitals and physicians.Responding to ChangeThe final question to be considered is how cardiac surgery should respond to the changes that are occurring in the external environment and reshaping the practice of the specialty. One option is not to respond but to conclude that the changes that are occurring are not that bad and will in the long run be of benefit to all of the involved stakeholders. This would be what I will choose to call a passive adaptation strategy and will be the choice of many who are willing to accept the probable long-term outcome of cardiac surgery becoming a commodity that can be bought and sold in the market for the best price. There will be some security for those who choose this path, at least over the short term. There are many down sides to this strategy, but one of the more concerning will be the tacit assumption that like other market commodities there will be a focus totally on cost and an acceptance of lower quality.The second option will be to adopt a political strategy. This is predicated on the premise that in spite of our fear of governmental control there is a recognition that politics and the government set the tone for much of what happens in the practice of medicine. Medicare reimbursement as it existed in the past looks increasingly good to both doctors and hospitals. The projections for future cuts in Medicare reimbursement are concerning not only because of their direct impact on that population of Medicare patients, but more importantly because this action will set a precedent for other payers to take the same action. The professional societies have adopted a political strategy and are aggressively recruiting contributions from their members to mount a political action campaign to restore the cuts that will have an impact on a number of the procedurally based specialties. Cardiac surgery has been targeted for the most severe lowering of reimbursement for procedures, and plans to mount an intense lobbying effort to try and restore or modify the planned decreases. Although this may be a reasonable short-term strategy, it is already obvious that every other specialty plans to do exactly the same thing and it is likely that the only real benefactors will be the lobbyists. Cardiac surgery is a small group that has been targeted as providing a service that is overvalued and consuming a disproportionate share of health care resources. Until that notion can be dispelled, there is little hope, in my opinion, of the political strategy having any long-term impact.A third option, which I have termed the active adaptation strategy, is based on certain lessons from industries that had entered the maturity phase and were facing the decline phase. Examples of those who did not respond would include the steel and consumer electronic industries in the United States. Examples of industries that have gone into a steep decline and returned to growth are sparse, but the most obvious example would be the United States automobile industry. Individual corporations are capable of reinventing themselves and creating new industries. IBM and 3M Corporation are examples of companies who faced severe decline but were able to reinvent themselves by actually creating new industries. Their resilience and success can be attributed to the adoption of several principles: (1) short-term solutions do not sustain survival; (2) competition creates value; (3) innovation drives continuous quality improvement; (4) incentives drive innovation; and (5) we are part of a system and our responses must be designed to improve the entire system.There is little doubt that academic medical centers can survive only if they develop an active adaptation strategy, and I suspect it will also be a viable choice for others in health care. The requirements for the design and implementation of an active adaptation strategy are demanding and will require a substantial shift in the way medicine and cardiac surgery are practiced and reimbursed in the future. In the past, the risk in health care was largely assumed by the purchaser (employer or government) and both the payer (eg, insurance company, health maintenance organization) and provider (eg, physician, hospital) enjoyed a position of minimal risk. This position is changing, and as the risk shifts the new risk takers have now begun to exert influence in the form of the for-profit enterprises that have made important inroads into both the hospital management and physician practice areas. In spite of all their rhetoric, the for-profit organizations have an underlying economic incentive to curtail expensive services and an obligation to maximize returns to their investors. These plans have focused their quality improvement efforts on measurements of population-based health care delivery and the processes of delivering care to the whole population covered. They have neglected deficiencies in the care of sick patients, particularly those with expensive, serious, and chronic illnesses. It is far easier to focus quality measures on preventive care in healthy people than to undertake the complex task of measuring quality of care in complex illness, where it matters most. A goal of physicians who deal with complex and chronic illness must be to develop reliable measures of outcomes of care in this population that will be sensitive enough to individual variation to provide a solid basis for incenting providers according to case mix. Current pressures of the marketplace dictate more attention to selecting the healthy and discouraging those with chronic and serious illness who find short visits with their primary care physician and limited access to specialists unsatisfactory. Efforts to benchmark and evaluate the outcomes of care in complex illness are underway, but they are in their infancy and as of now there are few reliable measures or benchmarks that deal with variations in the severity of illness and individual complications.The lessons of industry would suggest that a restructuring of our current system into specific disease-focused clusters may be the most cost-effective manner of delivering health care to those with chronic and serious illnesses. It should come as no great surprise that events such as acute myocardial infarction can be best managed by those with specialty training in cardiology [7.Jollis J.G. DeLong E.R. Peterson E.D. et al.Outcome of acute myocardial infarction according to the specialty of the admitting physician.N Engl J Med. 1997; 335: 1880-1887Crossref Scopus (319) Google Scholar, 8.Goldman L. The value of cardiology.N Engl J Med. 1997; 335: 1918-1919Crossref Scopus (23) Google Scholar, but such observations have had minimal impact on the evolving system, which is focused on cost and process. Because the current system of managed care is focused on the healthy who require little other than maintenance care, health systems discourage risky people from enrolling or make them want to leave by placing impediments to their care to improve the bottom line. Although physicians decry this practice, many are unwilling to risk the financial consequences of protesting too vehemently. This option is not available to specialists such as cardiac surgeons whose training has prepared them to deal with those who have a serious illness. The options available to cardiac surgeons are to accept what happens, to be politically aggressive, or to attempt to restructure the system based on the value added to the health care system by the care provided by cardiovascular specialists.What appears to be in short supply are risk-based measurements of function (do the right thing correctly) and outcome (get the right result) as opposed to process-driven measures. Only through well-designed incentives to reward performance that are based on risk assumption by providers for demonstrable long-term outcomes and benefit can we hope to overcome the predilection of United States business to focus on short-term, bottom-line-oriented planning. The goal of our strategy and planning must be to demonstrate the relationship between health care and human performance and its long-term advantage to employers and society as a whole. This goal is not as easy for business to accept as the immediate benefit of a cheaper health care plan. It will require the development of more organized delivery systems that are willing to assume risk, listen to society's needs along with those of customers and patients, develop the ability to translate data into meaningful information that will establish accepted practice criteria and outcomes, establish metrics to determine quality and cost-effective care, and valuate the services delivered on the basis of appropriateness and outcome rather than mere performance of the service.The health care delivery system was slow to change until economic pressures were brought to bear in response to soaring costs. The majority of change that occurred was driven by technology that in some instances truly did add value to the health care system but often was poorly conceived and yet was rapidly accepted through massive marketing efforts rather than the processes of testing and evaluation that characterized early advances in areas such as cardiac surgery. Procedures have been accepted for general use and marketed before there is any evidence of their ability to improve measurable outcomes using established benchmarking. The current marketing blitz supporting minimally invasive coronary bypass surgery is an example.Meaningful innovation in health care must be supported in a well-planned and effective manner. This innovation includes not only the research component, which is threatened by the progressive decreases in support from all sources, but also the educational component, which must adjust to the changing roles of physicians, nurses, and all other health care workers. Those who blame the increasing cost of health care on new technology must understand that it is not the technology but those who employ it improperly, overuse it, and unnecessarily reduplicate it that are causing the problem. The value of services delivered by cardiac surgeons in the future will depend on our ability to demonstrate the worth of what we do through thoughtful development of the evidence-based practice of surgery. We should go at risk by designing an incentive system that is based on not only doing something but also demonstrating that it was the proper thing to do, that it was done properly and that it has produced a measurable benefit that can be valuated according to established guidelines.As Pauly [9.Pauly M.V. Effectiveness research and the impact of financial incentives on outcomes.in: Shortell S.M. Reinhardt U.E. Improving health policy and management. Health Administration Press, Ann Arbor1992: 151-193Google Scholar] has pointed out, there are two broad approaches to studying the question of combining guidelines with incentives. The first is to study combinations that have been used in practice to see whether these natural experiments suggest some techniques to be more successful than others. The other approach tries to develop a conceptual framework for linking financial incentives to guidelines. In a world where guidelines were perfect and risk was absent, designing such incentives would be simple. If the care did not meet guidelines, it would not be paid for. If it met guidelines, it would be paid for at market price. The problem is that no practice guidelines are perfect, sometimes suggesting care that is worth less than its cost and sometimes proscribing care that is worth more than its cost. Providers are at risk for nonpayment of care that actually was appropriate for the patient and patients are at risk for nonreceipt of care that would have had benefits adequate to justify its cost. The obvious problems that arise in this approach are that designers of financial incentives will need to build in a kind of insurance coverage against errors in the guidelines and determine whether individual physicians or groups of physicians should be put at risk for deviance from the guidelines. Although one can foresee many problems in developing such guidelines and monitoring their compliance, the idea has merit and should be considered. In the case of procedures, such as cardiac surgery, there will be cases in which it is unequivocally the best choice but will cost a lot more. How should such guidelines be written? The answer appears to lie in the financial approach taken by businesses to assess the value of projects and will require that a monetary value be placed on outcomes and a decision made as to how much an improved outcome is worth. This creates a problem in that consumers, employers, and insurers may legitimately differ on how much they think things are worth. Establishing a consistent set of payment policies based on explicitly stated monetary values for health outcomes has a virtual rationality, but the defects of bluntness and insensitivity. This most difficult task will have to be confronted by all decision makers, public and private, and eliminating those gra" @default.
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W2085754527 title "Cardiac Surgery in the 21st Century" @default.
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