Specialty-hospital efficiencies are challenging for CHI in Nebraska

Standardization isn't easy.

Tom Appleget learned that lesson when he tried to export the cost and quality innovations developed at a doctor-owned heart hospital in Nebraska to a group of general acute-care facilities providing the same services elsewhere in the state.

Appleget, director of invasive cardiology, ran the catheterization laboratory at the Nebraska Heart Hospital in Lincoln, a physician-owned hospital acquired by the national not-for-profit system Catholic Health Initiatives in 2011. The healthcare reform law's nationwide ban on building new doctor-owned hospitals or expanding existing ones paved the way for the acquisition.

Given the hospital's lower costs and better outcomes, CHI asked Appleget to teach his new colleagues at three other CHI hospitals in the state about techniques to control costs and boost care quality in cardiac catheterization. “I am responsible for four different campuses, and the cost is different at each campus,” Appleget said. So was the quality—at least at the two CHI hospitals in Nebraska that voluntarily reported their 2011 readmissions data on the CMS' Hospital Compare website.

What Appleget found was the same thing Modern Healthcare documented in its recent analysis of hospital data on percutaneous cardiac procedures in a dozen U.S. healthcare markets: Different hospitals provide differing levels of quality of care, and at widely varying costs, for even routine procedures such as angioplasty and insertion of cardiac stents. (Oct. 28, p. 18)

CHI's 260-bed general acute-care hospital in Lincoln, St. Elizabeth Regional Medical Center, for instance, was seeing 13.3% of its patients with angioplasties and other percutaneous coronary interventions (PCIs) return to the hospital within 30 days in 2011, according to a risk-adjusted analysis. The comparable rate at 52-bed Nebraska Heart Institute and Heart Hospital—Appleget's facility—was 9.1%, making it one of a dozen hospitals nationally that were officially cited as being better than the national average of 11.7%.

The Modern Healthcare analysis of financial statistics provided by the American Hospital Directory says the specialty hospital spent an average of $7,900 to provide an inpatient PCI procedure in 2011, less than half of the $16,300 it cost St. Elizabeth for the same procedures.

Dr. Deepak Gangahar, a co-founder of the hospital and its president, said it was clear from the start that CHI officials were interested in more than making the heart hospital a regional center for the system's cardiac care. It wanted to spread its knowledge across CHI's other hospitals.

However, Gangahar said it hasn't been easy adapting a specialty-hospital model to an acute-care setting. “They have no incentive to do it one common way,” he said.

Doctors at community hospitals have to get used to the idea that their personal preferences come with related costs—a notion that physician-owners with a direct financial stake in their hospital have long acknowledged.

Appleget and Gangahar said their innovations included development of single-vendor contracts for supplies, which eliminate wasteful variation in surgical tools and implants. That often irritates physicians who are used to hospitals supplying whatever items they prefer regardless of cost.

Similarly, standardizing surgical and interventional techniques removes variation and cuts down on errors. However, it requires the physicians to re-learn techniques they have been honing over their careers. “You can eliminate some practices where one practitioner practices one way, and his costs may be as much as double someone else's,” Appleget said.

A year after junking “physician preference cards” and replacing them with standardized procedures, the critics are starting to embrace the ideas fully, Appleget said. “I think it's taken that time for them to say, yes, that can be replicated here at our facility,” he said.

Follow Joe Carlson on Twitter: @MHJCarlson