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Developing a successfulEP 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’sAcademic Centers

“HIS Bundle Recorders”

80’sAcademic Centers

“The Electrophysiologist”

The 90’s EPExplosion

Ablation/ICD

90’s The Academic Electrophysiologist

Device-ologist Ablation-ologist

Blue-CollarAblation

Extractor Implanter

Afib Specialist

90’sPrivate Practice

Tilts

Cardioversions

Devices / extractions

AblationsY2K

VT Specialist(epicardial space)

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A Full Service EP Service LineWhat is Mandatory for a Level 3 center

Device Arhythmology

CRM device therapyPCMK, ICD, SQ ICD, CRT, LINQ

Device clinicRemote monitoringInpatient management (OR, MRI)Extractions

EP ClinicsGeneral vs Specialty

Diagnostic EP studiesTilt Table testingCardioversions, DFT checksAblationsBasic SVT, AF, VT, Epicardial

Inpatient Service / Consults

Hospital EP ProgramsA 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

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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!

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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

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Electrophysiology Lab 2017Stuff 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”!

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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 ProgramGuidelines, 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

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Another reasonPVI is now mainstream

January 8th 2015

Double Jeopardy

Category “Body Check”

$2000 Question;“A treatment for atrial fibrillation isPVI, short for this vein isolation”

Our Groups Ablation Procedures2001-2016

0

100

200

300

400

500

600

700

800

900

1000

2001 2003 2005

Basic RFA Afib RFA Total RFA

20162007 20132010

AF Ablation growth limited by availability of resourcesLab space and time / Anesthesia / EP Physician time / willingness

AF Ablation can become a bit mind numbing – sometimes comfortably numbing

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Rx Effective

30%

Asymp.40%

Failed Rx30%

6% Ablated

1%Ablated

68,000 Ablations

2013: AblationsCatheter 65,000Surgical 15,000Total 80,000

2021: “Industry” estimate an Additional 26% growth

2004 2010 2013 2021

Growth in AF AblationIndustry Estimates

Bottom Line – Currently you could put an AF ablation program almost anywhere and have patient volume

8% Ablated 10% Ablated

Hospital Cost and Margins

AF Ablation AF AblationMedicare 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

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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)

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How to build patient volumeWho 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 questionWhat 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

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Hospital EP ProgramsA 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

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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?