Malachi Sheahan III, MD, produces notes on a quixotic quest to find meaning in one of medicine’s most meaningless endeavors.
Here’s how it happens. One day, you are walking through your hospital, and you notice a pack of incongruously well-dressed young people. You try to process this visual. Is it dermatology resident interview day? You’d better hope so. Because if not my friend, you’ve got consultants. Next thing you know, you’re in a room trying to figure out what the hell is happening. Dashboards, silos, ROI, market differentiation. But wait, there’s more. Let’s formulate a SWOT analysis with a laser focus on operationalizing our insights to create a paradigm shift to future-proof our data-driven strategies. OK, sure. Wait, what??
I’ve been in my job for 20 years. I have seen a healthcare system destroyed and rebuilt from the literal ground up, both with—and more often despite—corporate consultants. This is not my first “30,000-foot view” rodeo. So, by the time you sit down with them for your interviews, know that it is already too late. You are getting a heart and vascular center.
In fact, to save you some time and suspense, I’ll tell you what their recommendations will be. Here is your personalized plan:
The (insert your hospital name here) Cardiovascular Service Line: Key Points
Integrate cardiology, cardiac surgery, vascular surgery, imaging and rehab into a unified, patient-centered model.
Optimize throughput, reduce care variability, and improve quality metrics.
Capture downstream revenue and strengthen value-based reimbursement positioning.
Differentiate as a regional center of excellence in comprehensive heart and vascular care.
Accelerate growth through a phased launch, unified leadership and strategic market expansion.
The purpose of a heart and vascular center, I presume, is to improve the care of cardiovascular patients. The problem with my supposition is that after 30 years of existence, there is absolutely zero evidence for their efficacy, at least in terms of patient outcomes. Recently, in an attempt to find any data, I turned the search over to a deep research artificial intelligence (AI) model (this story is 100% true, by the way). Thrillingly, it produced a well-referenced 25-page document. Unfortunately, when I tried to find any of the relevant references on the internet, I came up empty. After asking the AI model to produce a link, I was told:
I apologize for any confusion caused by the previous mention of a 2021 article by Kline et al. titled “Sustainable Growth in Cardiovascular and Vascular Health” in the Journal of Healthcare Management. After a thorough search, I could not locate this specific article in the available literature. It is possible this reference does not exist.
In fact, of the 24 references provided, only one was not fabricated: a Vascular Specialist editorial I had written in 2017. The question of why AI had chosen to pacify me with lies was a bit too meta to consider in the moment.
Never fear though, like Jane Goodall and the primates, I have studied hospital CEOs. Observed them in their habitats. Watched as they speak their language to each other. Between all of the scalable models, cross-functional collaborations and force multipliers, if you listen carefully, you will see they are attempting to communicate with us. And the best way to understand them is to go to the source.
U.S. spending on cardiovascular care increased more than $100 billion between 1996 and 2016. A 2018 Merritt Hawkins survey showed that cardiovascular surgery was the top generating medical specialty at an average of $3,697,916 per institution. Invasive cardiology was second at $3,484,375. A recent study by K. Reddy et al from the University of Pennsylvania looked at the contribution margins of cardiovascular procedures. Heart transplant was the highest at $106,916, followed by surgical left ventricular assist device (LVAD), $46,960; coronary artery bypass grafting (CABG), $10,038; amputation, $8,942; transcatheter aortic valve replacement (TAVR), $7,997; and abdominal aortic aneurysm (AAA), $6,919. When factoring volume, CABG and TAVR were the two highest total financial contributions to their institutions, although amputation was third.
This data alone, however, still doesn’t explain why our specialties are being crammed together under one umbrella. It can’t just be our beneficial profit margins. No one tried to shove neurosurgery and orthopedics together and said, “I dunno, ortho guys like to lift, call it Brains and Gains.”
There are many purported financial benefits of a heart and vascular center. Branding, research funding, efficiency and alignment with value-based care models are the most commonly cited. But none of them really account for the amount of time and effort hospitals are willing to burn to develop such a center. In fact, I am absolutely convinced that I know the true incentive to create this unholy matrimony between cardiology, vascular surgery and cardiothoracic surgery—we order similar tests. Your hospital CEO will likely tell you that they can’t factor downstream revenue into any financial account of your services. This is the big lie. Downstream revenue is so critical that your simple free-standing vascular clinic represents an existential threat to the hospital. Think of all the computed tomography angiographies (CTAs), stress tests, magnetic resonance imagings (MRIs) and blood work that you order. What if they were performed at (gasp) an outside institution? Double that for the cardiologists.
So rather than risk this downstream revenue going down a stream to another facility, your hospital wants to put a wall around you and your cardiology friends. Everything under one roof. Their roof.
I’m not sure exactly what edition of the heart and vascular institute/service line we are on in my institution. Three I think. Last year, I received an invitation to participate in the development of a new system-wide cardiovascular service line. The announcement stated our goal was to become the premier destination for “cardiology care” in the Gulf South.
At the first meeting I was presented an org chart proposal for an executive steering committee. At the top was a chair and a vice chair (cardiologist, cardiologist). Next to them was a service line administrator and a CEO partner (suit, suit). Under that was a system service line advisory panel consisting of eight “voices.” I, as chief of the only medical or surgical specialty to provide unified coverage across our entire healthcare system, including a Veterans Administration (VA) and two medical schools, was assigned Voice #6.
Two weeks earlier, I had taken off an afternoon to see our son, Luke, in his school play. After looking at the program I offered (perhaps ungenerously), my disappointment that I took time away to see him as Fern #3: well, it seems Luke had a bigger role to play in Geology Rocks! than I would in our heart and vascular center.
The challenges for vascular surgeons in a heart and vascular center clearly outweigh the benefits. Marketing dollars and resource allocation are limited. Will these assets go to you or to a transplant program that promises a contribution margin of $50–100k? Who will control the scheduling conflicts, case competition and strategic decisions? Likely the cardiologist they put in charge.
Finally, consider your referral patterns. It is likely that a wide range of specialists and primary care physicians send you patients. The average age of a patient requiring a vascular procedure is 63. The average age of a first-time referral to a cardiologist is 50. So, when you are co-located with the cardiologist, who will the patient referred to you for a vascular issue see? You or the cardiologist they have an established relationship with?
Now, I am sure a few of you will tell me that your heart and vascular center works well for them and I don’t know what I’m talking about. To those folks, I want to make two important points. Number one, everything is local and your experience is not typical. And second, everyone hates you.
We are at 1,400 words and I haven’t even laid out what a heart and vascular center/institute/service line is. Probably because I don’t know. There are no standard models, quality metrics or milestones. U.S. News and World Report does not rank these entities. There is absolutely no patient outcome data. It’s almost as if the idea did not even come from medicine.
The best way for a vascular surgeon to mitigate the risks of a heart and vascular institute is not to be in one. If the process is inevitable, here are the steps to take:
- Appoint a vascular surgery service line director: Ensure dedicated leadership and control over operational, strategic and quality planning.
- Allocate dedicated hybrid operating room time and vascular lab access: Ensure access for elective and urgent vascular cases.
- Develop a limb salvage and complex vascular pathway: Formalize vascular referral protocols for chronic limb-threatening ischemia (CLTI), dialysis access and complex aortic disease, ideally to you.
- Establish multidisciplinary conferences led or co-led by vascular surgery: For aortic disease, CLTI, carotid revascularization, venous thromboembolism.
- Create dedicated vascular research support: Assign staff or seed funds to initiate vascular-specific research or industry partnerships.
- Track and share outcomes transparently: Publish service-line dashboards by condition (not just by specialty). Include: amputation rates, stroke-free survival, hybrid case utilization, door-to-intervention times. Benchmark against vascular and cardiology registries.
- Align incentives: This is the biggie. A lot of the turf issues will evaporate if the salaries/payments/ bonuses can be aligned and linked to service-line metrics rather than individual case volume.
Good luck out there. Please send in your experiences. If nothing else, maybe we can start to provide some data.
Malachi Sheahan III, MD, is the medical editor of Vascular Specialist.
