Developing a successful EP service line / practice Steven J. Kalbfleisch, M.D. Medical Director Electrophysiology Laboratory Ross Heart Hospital Wexner Medical Center The Ohio State University Evolution of the Electrophysiologist 70 s Academic Centers HIS Bundle Recorders 90 s The Academic Electrophysiologist 80 s Academic Centers The Electrophysiologist Ablation/ICD The 90 s EP Explosion 90 s Private Practice Tilts Cardioversions Device-ologist Extractor Implanter Blue-Collar Ablation Ablation-ologist Afib Specialist Y2K Devices / extractions Ablations VT Specialist (epicardial space) 1
A Full Service EP Service Line What is Mandatory for a Level 3 center Arhythmology Device EP Clinics General vs Specialty Diagnostic EP studies Tilt Table testing Cardioversions, DFT checks Ablations Basic SVT, AF, VT, Epicardial Inpatient Service / Consults CRM device therapy PCMK, ICD, SQ ICD, CRT, LINQ Device clinic Remote monitoring Inpatient management (OR, MRI) Extractions Hospital EP Programs A General Categorization Level 1 Basic Device Therapy (PCMK and ICDs) Just need an OR and a device rep Level 2 Diagnostic EP, simple ablations, CRT therapy The Hospital has to invest in Basic EP equipment Level 3 (A tertiary center program) Complex ablations (AF, VT), extractions Hospital has to buy mapping and extraction equipment. This requires anesthesia and thoracic surgery support / backup 2
What you have to address to set up an EP service line Outpatient clinics Inpatient care (post procedure) and consults Device follow-up outpatient and inpatient management EP lab setup Patient flow into the practice What services will take your program to the next level A Research Section (best way to stay current) Advanced Ablation therapy (AF, VT) Hybrid Lab (extractions, LAA device therapy) Collaboration with thoracic surgeon Specialty EP clinics (look for niche opportunities) AARx monitoring clinics (Pharmacy driven) Arrhythmia Genetics (LQT, Brugada, CPVT ) Sarcoid / HCM / ARVD / Adult congenital dz Syncope clinic Outreach sites (clinics, procedures, consults) True Service You need to make it easy to get into your system! 3
EP service line value EP generates patient referrals / volume EP physicians do high technical and professional revenue generating procedures EP programs have a large halo effect in the system Recurrent device checks / replacements / revisions / extractions Event / holter monitoring Ablation therapy: Imaging TEE, LA CT, CMR Who is involved in the service line? EP physicians EP Lab nursing and X-Ray techs Outpatient EP clinic nurses Dedicated device nurses EP NPs (inpatient care and outpatient clinics) If you are a solo EP you should request this support EP floor nursing (Dedicated EP floor?) Anesthesia / Thoracic surgery Recovery room staff Pharmacists? A luxury you may not have 4
Electrophysiology Lab 2017 Stuff to Buy You probably can t have it all! So you want to Buy an EP lab Room Costs New Build = 2M, Remodel = 1 M Fluoroscopy 750 to 1M 3D Mapping / Ablation system 225 to 300K EP / Hemodynamic recording 150K Stimulator 20K Ancillary equip. (defibs, shields, BP monitor.) 100K Cryo-Ablation console 85K ICE Unit 120K Grand Total. Approx 2.5 to 3M No one cares about the cost until they are told No! 5
AF Ablation Programs The most significant reason for EP volume increases over the last decade. In most large EP programs AF ablation accounts for approximately 50% of ablation volume. It is now mandatory to have in almost every reasonably sized EP program. Can now be done safely, effectively and efficiently. It is the straw that stirs the drink. How to Justify an AF Program Guidelines, Contribution Margin, spin off HRS guidelines AF RFA is a class I recommendation for AF therapy after failed medical Rx, class II rec. for first line Rx. It is now a standard of care therapy Every high volume procedure needs to be profitable to survive. No Margin, No Mission. If it contributes on it s own then you can also talk about spin off and halo effects. This is very hard to quantify 6
January 8 th 2015 Double Jeopardy Another reason PVI is now mainstream Category Body Check $2000 Question; A treatment for atrial fibrillation is PVI, short for this vein isolation Our Groups Ablation Procedures 2001-2016 1000 900 800 700 600 500 400 300 200 100 0 2001 2003 2005 2007 2010 2013 2016 Basic RFA Afib RFA Total RFA AF Ablation growth limited by availability of resources Lab space and time / Anesthesia / EP Physician time / willingness AF Ablation can become a bit mind numbing sometimes comfortably numbing 7
Growth in AF Ablation Industry Estimates 1% Ablated 68,000 Ablations 6% Ablated Asymp. 40% Failed Rx 30% Rx Effective 30% 2013: Ablations Catheter 65,000 Surgical 15,000 2021: Industry estimate an Total 80,000 Additional 26% growth 8% Ablated 10% Ablated 2004 2010 2013 2021 Bottom Line Currently you could put an AF ablation program almost anywhere and have patient volume Hospital Cost and Margins AF Ablation AF Ablation Medicare 2013 (Catheter) (Surgical) Average Direct Cost $13,589 $29,012 Average Reimbursement $18,504 $47,964 Contribution Margin $4,645 $19,952 The Bottom Line Catheter AF Ablation is a net positive but could be easily become negative with additional direct costs. You need to try to understand and help control costs! The Advisory Board Company 8
What do you need to start an AF ablation program Support staff Clinic nurse pre and post patient care / support EP lab staff (nurses and RTs 3 to 4 /case) Advanced EP lab 3D electro-anatomic imaging ICE Multimodality integrated screen viewing Anesthesia for RFA, maybe not for Cryo Imaging support (CT, CMR, echo) Emergency backup Thoracic surgery (fortunately rarely needed now) Dedicated pre and post procedure areas What data should you track at your program Every program needs QA and compliance oversight Mandatory - ACC-NCDR ICD registry participation, LAA closure registry if doing watchman Pacemakers similar info to ICDs AF ablation / Extraction need to document indications, techniques, complications, and outcomes (1 yr for AF) 9
How to build patient volume Who are your best referrings? A general cardiologist who is willing to see syncope and Afib patients. A general cardiologist who does basic device work. (You can t stop it, so don t try). ER Doctors (they see PSVT / WPW first) Thoracic surgeons (they also bail you out) Interventional cardiologists willing to look at a monitor (they hate arrhythmias!) Primary care with an interest in cardiology Hospitals / Systems in you region that don t do advanced cardiac care Most important question What does the outreach site want? Procedures (Device and ablation)? Clinic? Inpatient consultation? Procedures are the easiest limited follow up. Just need hospital privileges. Clinic is the hardest requires a support structure (nurse / device) and follow up. Is legally more complex to set up. Do not promise something you can t or don t want to deliver 10
Hospital EP Programs A General Categorization Level 1 Basic Device Therapy (PCMK and ICDs) Just need an OR and a device rep Level 2 Diagnostic EP, simple ablations, CRT therapy The Hospital has to invest in Basic EP equipment Level 3 Complex ablations (AF, VT), extractions Hospital has to buy mapping and extraction equipment. This requires anesthesia and thoracic surgery support / backup The ideal outreach site Medium sized hospital 100 to 200 beds i.e. not enough to support and EP doc full time Active cath lab with or without open heart surgery capabilities 2 to 5 cardiologists With an active device follow up clinic with at least 1 device implanting physician, since then they often won t want to hire a full time EP 500 to 1000 cath procedures / yr The 10% Rule Basic EP / ablation, device and referral volumes are each approximately 10% of cath / PCI volume. Procedure only care with same day DC 11
How to build a successful EP practice / program How did you get patient referrals? How much of your practice is device vs ablation? Hospital vs outpatient? Do you get / do all the device work or do other CV specialists do some of the work? Was the hospital admin helpful in getting you what you wanted / needed? Who is the most helpful to you in your daily work? What was the easiest thing about building your practice? Hardest? 12