Harry Jacobson, MD, Founding Chairman of Cardiovascular Care Affiliates, shares the vision that shapes CCA. Dr. Jacobson is Vice Chancellor for Health Affairs at Vanderbilt University. He recently discussed the future of outpatient cardiovascular care in an interview.

Q. Dr. Jacobson, it is really an honor to speak with you about Cardiovascular Care Affiliates (CCA). The trend in modern healthcare is increasingly moving towards stand-alone centers. What are the advantages of this as a business model, and for patients?

Dr. Jacobson: They are focused on the care of patients with a particular problem, where nothing else competes for attention. If you are focused and innovative, then you can really become best of class in delivering a specific healthcare service.

Q. Is that the goal of CCA?

 Dr. Jacobson: No question. The goal of CCA is to be the leading provider of evidence-based diagnostic and therapeutic cardiovascular care that is delivered by cardiologists—and in some cases delivered in partnership with the cardiologist's surgical colleague—and to be the leader in the appropriate use of new technologies.

 Q. How do you define appropriate use?

 Dr. Jacobson: The major problem we have in healthcare today is that it is highly variable, depending on where you are in the country. This variability leads to overuse and misuse of resources. A protocol guideline based on scientific evidence should drive what you do.

Of course, you know that the fear of the payers is that when doctors get involved in these specialty focused ambulatory care ventures, it will lead to overuse.

Q. What is your opinion of that?

Dr. Jacobson: I think that you can standardize it if people really follow evidence-based guidelines.

Q. Let me ask you a broader question, about how technology has affected healthcare over the past 10 years. Has technology improved patient care, or has it only made healthcare more expensive?

Dr. Jacobson: There is no question that if you look at healthcare from the consumption side, and you look at just the cost side, technology can raise the cost. But the important question is: What is the return on that extra cost?

If you take a look at the economic benefits of some of these technologies, you can ask: What is the economic benefit of reducing the death rate of heart disease by 10% in people under the age of 65? You can look at the cost but you also have to look at the economic benefit.

There is a wonderful book by two economists from the University of Chicago, Measuring the Gains from Medical Research : An Economic Approach by Kevin M. Murphy (Editor), and Robert H. Topel (Editor), where they talk about the economic returns on research technology and healthcare.

They note that during the 20th century there was a 30-year increase in the average life expectancy in the United States from 46 to 76 years. If you take a look at the widespread use of statins to lower cholesterol, the return on that will be another 10 years coming; and then we can see if the death rate from cardiovascular disease is lower in the US, or at least in populations that had access to those drugs, versus populations that don’t.

The economic value of a 30-year increase of life, using a conservative estimate of what the value is of an additional productive year of life, is equal to the combined GDP of the entire country for those 100 years.

The same is going to be true for certain types of cancer treatments. There is actually early emerging evidence that with respect to our 5-year survival rate in breast cancer, we are looking better than any other country in the world.

Having said all that, we still spend too much per capita on healthcare here, and it's driven by variation and practice and a lot of overuse and misuse of resources. One of the things CCA has to do is be a leader in the judicious use of evidence that drives how cardiologists treat patients in their facilities. That, in the end, is going to be the winning principle: you have to do what is right for the patient first.

Q. Are you saying that a consistent approach is generally better for the patient?

Dr. Jacobson: Yes, absolutely.

Q. Let’s talk a little bit about the advantages, in your opinion, for cardiologists considering partnerships with CCA?

Dr. Jacobson: Well first of all, CCA is going to have a primary dedication to clinical quality. By and large, where cardiologists take care of their patients now is in a hospital, where they have very little control of how it is run or who gets hired, what equipment is being used, and what the service culture of the place is like.

With CCA, cardiologists will have the ability to control all of that, so their much more in control of their destiny. They will have ownership in the facility, a company focused on the clinical outcomes, and the ability to have control of their destiny and of the management of their patients.

There are also the practical aspects, like access to the best technology. The ability to share clinical information and the outcomes of best practices with affiliated cardiology practices is very much like what we have done with Renal Care Group, where we have all the best outcomes for dialysis patients. We are the leader there, both in the proprietary dialysis industry as well as across independent and hospital owned dialysis. At Renal Care Group we have a very strong medical advisory board, we do clinical research, and we are always innovating on how to get better outcomes with the patients. Being part of an organization that is focused on doing that, so it's not just your own practice, you get to compare yourself with and to exchange ideas with and to see how you stack up with cardiologist groups around the country.

Q. Do you feel that the CCA business model affects the whole reimbursement issue in a positive way?

Dr. Jacobson: Well that is a really good question. If we are paying too much per capita, you can ask if it is the volume or the pricing that’s driving it, or a combination. We spend $5,400 per capita in healthcare in this country, and the closest to us is Switzerland with $3,700. Almost everybody is lower than that. If you analyze it, it depends on what specialty you are in and what disease category you are in. But pricing is an issue; there is no question that pricing is an issue.

A freestanding facility doesn't carry the full overhead of a huge multidiscipline inpatient facility. One should be able to offer the payer better pricing for the management of patients. If you look at it from the macroeconomic point of view, this ought to be good. In certain patients, this setting ought to lower the cost of doing a coronary and peripheral interventions, and the savings ought to passed on to the payer, so payers should, I think, look at this positively.

 Q. Focusing on the individual cardiologist, do you think the CCA business model allows them to spend more time actually practicing medicine, versus all the other aspects of running a practice?

I think they will be able to have greater productivity, because there will be greater predictability for them on access to the cath lab and technology than they currently have. In a hospital setting, you have to sort of jockey for scheduling patients, and sometimes you may get bumped because of an emergency. I think the individual productivity of one's schedule in taking care of patients will be significantly better in a facility like this than it would be in the current circumstance for most cardiologists.

Q. What are some of your reasons for picking cath labs for the cardiovascular specialty for the freestanding business model of the outpatient concept?

Dr. Jacobson: There are several reasons. First of all, the emerging technology is going to allow more and more procedures to be done as safely in an outpatient setting. In 1968, dialysis was only done in a hospital. Today, we have better machines to have someone’s blood traveling outside their body while it is being dialyzed. It has become perfectly safe and routine to take care of dialysis patients in the outpatient setting.

Cardiologists are entrepreneurial; if you think of some of the most entrepreneurial specialties, cardiologists are right there at the top. Cardiologists have shown over the years that they are early adopters of technology, and they become very expert in using technology in the management of their patients. Lots of things in other specialties are now being done by surgeons or being done by radiologists and so forth, and cardiologists have kept their hands in all of the technologies that apply to the diagnosis and treatment of their patients.

Having a technology-driven movement in the outpatient setting and having cardiologists be entrepreneurial and willing to adapt new technology and become very proficient at it in the care of their patients are really the main drivers.

The other thing that is a driver for any kind of physician today is that physician reimbursement is going down, and we pay doctors for piece work. Doctors generally get paid for seeing patients, but we don’t get paid for the overall care of the patients. The payers are trying to lower payments to the physicians, so all physicians of all specialties are looking to stabilize income or grow income. One way, of course, is to be able to benefit economically and legally from ancillary revenue. Cardiologists are able to do that with cath labs, and nephrologists are able to do this with dialysis units. There are a few areas where you can do that legally, because it is considered an extension of the doctor's practice.

Driven by technology, driven by entrepreneurialism, and driven by the need to stabilize income, cardiologists are perfect for a migration to a focused ambulatory facility. I think they have been ready for several years

Q. So your opinion of the future of cath labs is highly optimistic?

Dr. Jacobson: Well there are about 3,500 cath labs in this country. 100 or so are freestanding. The others are all in hospitals. I think in a decade there will be over 1000 freestanding cath labs.

Q. Do you see CCA as a leader in that field?

Dr. Jacobson: We certainly feel we should be a leader. We won’t be alone. I think that others will see that this is something to do, much like ambulatory surgery did, much like dialysis did, much like outpatient imaging, and some of the other facility-based ancillary service opportunities.

Q. Do you have any other comments you’d like to make about CCA?

Dr. Jacobson: Well I wanted to make sure that I got the point across that it’s a physician-driven company that is focused on what is best for the patient.

Whatever decision we make, the first question we ask is: What is best for the patient?

If you talk about buying a certain technology or adopting a certain protocol, the driver has to be what’s best for the patient. I believe that the whole debate about for-profit, not-for-profit, and specialty hospitals versus non-specialty hospitals are the wrong issues. The issues are the quality of the product and the integrity of people who are delivering it. We intend to have the highest integrity, and the highest quality. If you do that, you’ll do fine financially.