Vikram S. Kashyap, MD, pushes back against a recent editorial from Vascular Specialist medical editor Malachi Sheahan III, MD, in which the latter called into question the value of heart and vascular centers to the vascular surgical specialty.
I am risking professional harm debating Dr. Mal Sheahan. After witnessing his wit, charm and persuasiveness firsthand, I know I may never recover from writing this commentary. However, as the chair of the Frederik Meijer Heart and Vascular Institute (HVI), I feel obliged to respond to Dr. Sheahan’s piercing commentary published in Vascular Specialist in May 2025. He argues vehemently how HVIs are bad for vascular surgeons. I will try to convince you that is not uniformly the case. I have worked at three institutions with HVIs—Cleveland Clinic, University Hospitals/Case Western Reserve University and Corewell Health—and each has been different in structure, strategy and operational effectiveness. There are multiple reasons that HVIs can function well and will likely be the dominant organizational structure going forward.
First, Dr. Sheahan focused on the vascular surgeon and how HVIs negatively affect us as a group. If you look at HVIs from a patient’s viewpoint, there are many positives. Healthcare can be confusing, even for those of us in medicine. Patients must navigate a complex matrix to find the right doctor and get the right care. Coordinating and simplifying the delivery of care is accomplished when cardiovascular care is under one roof. Patients are not subjected to disparate, poor quality and inappropriate care when all cardiovascular specialists (cardiology, cardiothoracic surgery, vascular surgery and affiliated areas) are aligned to the same strategic goals. Aligning goals and ensuring the highest quality care is more feasible in an institute or service line model, and this benefits patients.
Organizational structure in a HVI is critical.1 We have more than 1,000 team members in our HVI, and we strive to collaborate and not compete. Clinical and operational leaders work together and focus on strategic growth in multiple clinical areas (coronary, structural heart, electrophysiology, aortic, limb salvage, wound care, etc.). Growing the pie becomes more important than fighting over the pie.
An HVI can provide a home for all cardiovascular specialists. Vascular surgeons have more in common with other specialists in aortic disease, peripheral arterial disease (PAD), complex venous care, prevention, etc. What are the other options for vascular? Historically, we have been sections/divisions in a general surgery department—has that gotten us very far? Alternatively, we can lobby for a separate vascular surgery department. In most institutions, this would be a small area with limited clinical and fiscal impact. In 2024, the Frederik Meijer Heart and Vascular Institute performed more than 4,000 surgical procedures, 10,000 catheterizations and 95,000 cardiovascular imaging studies, leading to over $1 billion in gross revenue. This fiscal impact allows us to provide resources that otherwise would not be available. For instance, we opened our fourth hybrid operating room (OR) last year. We have started or completed 61 heart and vascular clinical trials in the last five years, coupled with significant coordinator and statistical support. We have six training programs, including both a vascular surgery residency and fellowship. Recently, we lobbied and were approved to expand the residency to two spots per year. Many of these developments would not have occurred without the fiscal heft of an HVI. In my experience, a department of surgery may not support many of these priorities and a small independent department of vascular surgery would not be able to accomplish these initiatives.
Dr. Sheahan states that the real reason for an HVI (or service lines) is to capture downstream revenue, especially from ordering tests. In fact, we are piloting different value-based care models that will decrease the cost of care, increase appropriateness of care and ensure seamless quality. We are working with our payors to formalize this for patients with certain conditions, including heart failure, atrial fibrillation and claudication.
An HVI provides fiscal stability and additional options for our surgeons. We offer competitive salaries and can mitigate the downward reimbursement pressure due to our size. We are opening an ambulatory surgery center (ASC) as a joint venture between Corewell Health and our physicians. This will lead to performing endovascular procedures in an efficient, less costly venue, while also providing additional revenue for vascular surgeons who are investors.
I do agree with Dr. Sheahan on some of his suggestions. Most importantly, we need to continue to track outcomes across specialties and ensure seamless quality. Vascular surgeons specializing in an area allows focus on clinical improvement, standardized protocols, and leading multidisciplinary conferences, whether it be in PAD, cerebrovascular disease, aortic disease or other areas. Of course, if you have seen one HVI, you have only seen one HVI. Local circumstances (and local leaders) may impact the landscape—for better or worse—for vascular surgeons. Still, I believe an HVI provides the best structure for both patients and their doctors. Vascular surgeons should actively participate in an HVI and should lead or co-lead the entity. This will be the best way to ensure high-quality care for our patients and our long-term professional growth.
Reference
- Mansour MA, Kashyap VS. The business of healthcare vascular care in a heart and vascular institute. Journal of Vascular Surgery-Vascular Insights 2025; 3:100242
Vikram S. Kashyap, MD, is the endowed chair at the Frederik Meijer Heart and Vascular Institute, vice president of Cardiovascular Health at Corewell Health and professor of surgery at Michigan State University College of Human Medicine in Grand Rapids, Michigan.
