WV HEALTH CARE AUTHORITY – 137202

CARDIAC SERVICES

CON STANDARDS MEETING

11/19/08 – 1:00 P.M. EASTERN STANDARD TIME

 

 

SONIA CHAMBERS:  All right.  It's about five after, why don't we go ahead and get started.  My name is Sonia Chambers and I'm Chair of the West Virginia Health Care Authority.  I have with me Marilyn White, who's also a board member.  We are--this is the second to last perhaps of our--in our series of meetings, getting input on whether certain services ought to remain reviewable under Certificate of Need.  And this one is about cardiac services.  And we are going to, why don't we go around the room, see who's on the phone and then we will have Tim briefly, briefly go over the standards and then we'll open it up for comments.  So again, it's Sonia Chambers and Marilyn White.

 

BILL ADAMS:  My name is Bill Adams.  I'm the administrator at CAMC Memorial here in Charleston.

 

DAVE JARRETT:  I'm Dave Jarrett [phonetic].  I'm with CAMC's Planning Department.

 

PHIL WRIGHT:  Phil Wright, CEO of The Health Plan there for Ohio Valley.

 

SHEILA KELLEY:  Sheila Kelley [phonetic], Certificate of Need Division.

 

TIM ADKINS:  Tim Adkins with the Certificate of Need Division.

 

MARIANNE KAPINOS:  Marianne Kapinos, General Counsel, Health Care Authority.

 

CINDY DELLINGER:  Cindy Dellinger, Assistant General Counsel, Health Care Authority.

 

MARTHA MORRIS:  Martha Morris [phonetic], Consumer Advocate's Office.

 

JESSE CLINE:  Jesse Cline [phonetic], Consumer Advocate's Office.

 

TONY GREGORY:  Tony Gregory [phonetic], The Hospital Association.

 

JIM THOMAS:  Jim Thomas [phonetic], Attorney, Jackson Kelly [phonetic].

 

KAY MYERS:  Kay Myers [phonetic], Health Care Authority.

 

SONIA CHAMBERS:  Okay, and on the phone?

 

RAYMONA KINNEBERG:  Raymona Kinneberg [phonetic], - - and Associates.

 

BRAD SCHNARR:  Yes, Brad Schnarr from Ohio Valley Medical Center.

 

ANGELA SWAGGER:  Angela Swagger [phonetic] from WVU Hospitals.

 

JILL PARSONS:  Jill Parsons, St. Joseph's Hospital.

 

ED HAMILTON:  Ed Hamilton, Mountain State Blue Cross/Blue Shield.

 

SONIA CHAMBERS:  I didn't think we could have one without you, Ed.  Anybody else?  All right, Tim?

 

 

TIM ADKINS:  Okay.  We'll look at Cardiac Cath Standards first.  The need methodology for diagnostic cardiac catheterization include all applicants must demonstrate an unmet need.  New providers must project a volume of 300 cases annually by the end of the third year of operation.  The need methodology for therapeutic catheterization services is as follows, hospitals that provide open heart surgery do not need a CON to provide cardiac cath services.  All applicants without cardiac surgery backup must demonstrate the need, the following, must have--must have provided diagnostic caths for at least one year and reported data to the ACC and CDR during that time.  Rigorous case selection for the performance of primary angioplasty must be in place.  For those that will be providing primary therapeutic cardiac cath, applicants must project a minimum of 36 PCI cases will be performed in the third 12 months of operation after initiation of service and annually thereafter.  For those providing elective therapeutic cardiac caths, applicants who participated in the demonstration pilot project must have performed a minimum of 36 primary PCIs or 200 therapeutic cardiac caths in each of the last two years.  Applicants who did not participate in the pilot project, they must provide PCI for two years and perform at least 36 primary PCI cases in each of the last two years.  Those applicants in geographically remote areas, more than one hour medical transport time, may have the two-year period waived if they can project a minimum of 36 PCI cases for each of the first two years and a minimum of 200 therapeutic cardiac caths by the end of the third year of operation.  In addition to the need the CON review requires all applicants to meet certain quality criteria, demonstrate financial feasibility and must provide charity care.  For cardiac open heart surgery the need is the applicant must have performed 1,000 diagnostic cardiac catheterization cases within the last 12 months.  Applicant must project 250 cardiac surgeries annually by 36 months after initiation of the service.  Applicant must demonstrate an unmet need, and here again they must address the quality, financial feasibility and to provide charity care.

 

SONIA CHAMBERS:  Okay.  We have a couple handouts I guess, and these will or are available on our website.  One is a Excel spreadsheet that lists all of the open heart and cath providers, their--the number of rooms and then the number of surgeries or caths.  Broken down by--caths being broken down by inpatient and outpatient and that's off our 2007 Uniform Financial Report worksheet 4A.  Then we also have a map that shows the cath hospitals, both diagnostic only and diagnostic therapeutic on it.  All right.  So I guess we'll just open it up for comments.

 

FEMALE VOICE 1:  Yes, may I ask, why does Wheeling not have any open heart?

 

SONIA CHAMBERS:  Phil, what are those numbers?  Phil noticed that we didn't have the numbers on the worksheet …

 

FEMALE VOICE 1:  And Phil has them?

 

SONIA CHAMBERS:  And Phil called to get them.

 

PHIL WRIGHT:  Three thirty two.

 

SONIA CHAMBERS:  Three thirty two?

 

PHIL WRIGHT:  Open heart surgeries, yes.

 

SONIA CHAMBERS:  Okay.

 

PHIL WRIGHT:  Through 9/30/07.

 

FEMALE VOICE 1:  Thank you, Phil.

 

SONIA CHAMBERS:  Through 9/30 is that …

 

PHIL WRIGHT:  I used the 9/30 on the left, the year ended?  I don't know if that's calendar year ended.

 

SONIA CHAMBERS:  That's their fiscal year end so you asked them--what did you ask them for?  An annualized amount?

 

PHIL WRIGHT:  I asked for 9/30--through 9/30.  I can check real quick.  Go ahead; I'll check.

 

SONIA CHAMBERS:  Okay.  Whether that's a--I'm curious to know whether that's a 12-month number or a nine-month number.  Okay. 

 

FEMALE VOICE 2:  What was the number, Phil?

 

PHIL WRIGHT:  Three thirty two.

 

FEMALE VOICE 2:  Three thirty two which …

 

SONIA CHAMBERS:  The total number of surgeries.

 

FEMALE VOICE 2:  What do you - -?

 

SONIA CHAMBERS:  I don't know.  Okay.  All right, comments?  Bill or Dave, you guys want to start?  Since you're over here, the only ones over here on this side of the table?

 

BILL ADAMS:  We're in favor of the continuation of - - Group, cardiac catheterization and cardiac surgery and remaining reviewable services and on the list of reviewable services.

 

SONIA CHAMBERS:  Okay.  All right.  I thought he was going to come back in and ask a question.

 

PHIL WRIGHT:  It's through 9/30.

 

SONIA CHAMBERS:  And is that--that's then a nine-month number?

 

PHIL WRIGHT:  Six--three months in '06, nine months in '07.  He's getting the full calendar year if you want it and he'll call me back in a bit.  - - .

 

SONIA CHAMBERS:  So it's going to be close…

 

FEMALE VOICE 2:  Yes.

 

SONIA CHAMBERS:  …to 332 for a 12-month number.  Okay.  Phil?

 

PHIL WRIGHT:  How many emergency transfers are required to cardiac hospitals when you don't have it performed in the open heart setting, in an open heart hospital?  These cardiac caths sometimes they have problems.  Do you record how many emergencies are required to be transferred to the hospital?

 

SONIA CHAMBERS:  In the data we get from the ACC it does, we do measure complication and I believe one of the specified complications is transfer.  It is very small.

 

PHIL WRIGHT:  One percent?  Less than?

 

SONIA CHAMBERS:  It's less than 1% I'm pretty sure.  And I can step out and find out the answer to that and come back.  Carol [phonetic], who is most familiar with that, is not in this meeting.  But while we go around the room maybe I'll see.  Kay [phonetic], you want to go ask Carol [phonetic] if she knows the answer to that, based on the WVMI data we get?  How many of the cases, what percentage of the cases are--cath cases are transferred to open heart facilities for open heart intervention?

 

PHIL WRIGHT:  Well you talk about 3,045 cases of open heart surgeries and it just doesn't seem like there's enough procedures being done to keep--it's keeping, you know, West Virginia's the 50th worst in this area.  What is causing that?  I mean I don't understand that.  Are people not getting, going in for the treatment?  I mean you look at the number of cases compared to the 1.8 million population it just appears that there's an inordinately small number driving this whole thing.

 

FEMALE VOICE 3:  I wonder how many are going out of state.

 

SONIA CHAMBERS:  Now wait a minute.  What you're saying is you think there should be--

 

PHIL WRIGHT:  [Interposing] A much higher number.

 

SONIA CHAMBERS:  There should be more open heart surgeries?

 

FEMALE VOICE 3:  Yes, or more caths.

 

SONIA CHAMBERS:  Or more caths?

 

FEMALE VOICE 3:  Or both?  Both probably for the number of population and as he said, the national stats that say we're the sickest in the country.

 

PHIL WRIGHT:  In this area.

 

FEMALE VOICE 3:  Yes.

 

PHIL WRIGHT:  We're 48th or 50th.

 

FEMALE VOICE 3:  For heart.

 

SONIA CHAMBERS:  Yes, should be the answer.  Okay.  So all right, so your question is you're somewhat puzzled that the numbers of procedures, be they surgeries or caths, are low for the disease prevalence.

 

PHIL WRIGHT:  Yes.

 

SONIA CHAMBERS:  Of 1.8 million people?

 

PHIL WRIGHT:  It just appears that there's a lot of people going out of the area or we don't have enough facilities to really take care of the problem.

 

FEMALE VOICE 3:  Do we have any physicians--we don't have any physicians on this meeting, do we?  Cardiac--that committee?

 

BILL ADAMS:  I've got a comment from CAMC's perspective.  The number of open heart surgeries is going down.  It's been that way for several years and it's attributed to several things.  One of them is that the number of PCIs, percutaneous coronary interventions that are being done, the stents, at CAMC we've seen an increase.  From '06 to '07 we had about a--we were going down like everybody else and we saw an increase so the - - was coming out.  The bases said, you know, those stents don't work as well as a lot of people thought they did.  You've got a certain kind of stent.  You've got to be on these drugs, PLAVIX is one of them, for a long, long time.  If you get off, you know, you've got problems and so we're seeing an increase, again, but so far as--

 

PHIL WRIGHT:  [Interposing] For the calendar year?  Okay.  Thank you.

 

BILL ADAMS:  --unmet need I can only speak to this area.  We occasionally get a transfer out for a certain kind of stent.  It's usually to the Cleveland Clinic, but we've got a set of rooms standing by.  We can do the cases that are referred to us and quite a few are referred to us.

 

SONIA CHAMBERS:  Okay.  Phil, the answer for--

 

PHIL WRIGHT:  Wheeling was 320 for the calendar year of '07 or through their fiscal year from October 1, '06 to 9/30/07 was 332.

 

SONIA CHAMBERS:  Okay.  All right.  So Phil, do you have an opinion about whether this should be a reviewable service--these should be reviewable services or not?

 

PHIL WRIGHT:  Thinking.

 

SONIA CHAMBERS:  Would you like us to come back to you?

 

PHIL WRIGHT:  Yeah.

 

SONIA CHAMBERS:  Okay, Jim Thomas [phonetic], comments today?

 

JIM THOMAS:  No, I don't believe--I mean, maybe to help further elucidate the comment from the health plan, I know they have had some recruitment issues with surgeons in various parts of the state.  In fact if it's distributed maybe somewhat to the decline; Morgantown and Parkersburg I think are two examples.  That's all I have.

 

SONIA CHAMBERS:  Okay.  Tony, Hospital Association?

 

TONY GREGORY:  We support CON reviewability for cardiac surgeries.

 

SONIA CHAMBERS:  Okay.  Mr. Gray [phonetic]?

 

BOB GRAY:  Sounds good.

 

SONIA CHAMBERS:  Caths?  Okay.  Consumer Advocate you're just happy to be here, right?  Okay.  All right.  Raymona?

 

RAYMONA KINNEBERG:  Support continued CON review for cardiac services.  We might have some comments on--might have some interest in changing the standard, but in terms of whether it should be reviewable or not, it should be reviewable.

 

SONIA CHAMBERS:  Okay.  Brad?

BRAD SCHNARR:  No comment at this point.

 

SONIA CHAMBERS:  Okay.  Angela?

 

ANGELA SWAGGER:  No comment but I would--I don't want to assume but I would think that we would be in support of CON review.

 

SONIA CHAMBERS:  I would think.

 

ANGELA SWAGGER:  Yes.

 

SONIA CHAMBERS:  Jill?

 

JILL PARSONS:  St. Joseph's Hospital supports continued reviewability of CON for cardiac services.

 

SONIA CHAMBERS:  And Ed?

 

ED HAMILTON:  Mountain State Blue Cross/Blue Shield supports the Certificate of Need process as it relates to cardiac services.  I might also add that we would probably support the, you know, the--whatever you need to do on the Health Care Authority side to enforce those standards on an ongoing basis.  And the reason I say that is if you look at the cardiac cath portion of the spreadsheet, you've got a couple of providers, at least, that are of low, you know, they're low volume providers.  And the question then comes up how long do you let that go before you say, you know, you're not up to snuff as far as volume?  Do you go in?  Do you look at quality concerns at some point?  Do you start, you know, looking at quality as it relates to a low volume provider?  You know, what is the enforcement process once it appears that perhaps things aren't working out with a particular facility?

 

SONIA CHAMBERS:  Interesting that you ask that question.  We were having discussions about that just today.  Just, there are, as you can see on these numbers, there are some providers who are below the number they are required to meet.  As you know, the Health Care Authority really has the ability for up to--we condition our Certificates of Need on attaining the number they put in their application by reaching the minimum threshold number by the end of the third year and we have had discussions with a number of those low volume facilities.  We have entered into some agreements or people have re-filed applications.  We have issued a couple show cause orders, looking at some of these numbers and we are continuing to do that with others as they come up on that three-year anniversary.  So--and in terms of quality we have engaged--we engaged WVMI as part of our angioplasty demonstration project to look at quality.  We require all those, anybody who comes in for cardiac CON basically now is required as a condition to report their data to the ACC NCDR database and they are all doing that.  Then WVMI looks at that information.  They keep it.  It is pure protected, so they do not release the specific information to us but they release aggregate information to us.  We have, however, had some discussions with them.  They won't tell us which facilities, you know, they might potentially have a question about, whether it's a reporting issue or an actual quality issue, but we have asked them to go back to those facilities and do some, have some discussion with them about that.  So we are looking at quality; we're just having to do it a little bit, in a little bit of a one-step removed way.

 

ED HAMILTON:  I have another question.  This is Ed Hamilton, Mountain State Blue Cross/Blue Shield.  There was an application and hearing earlier this year as it relates to Logan Medical Center and I was privileged to be able to sit through half the hearing.  And I didn't understand what happened the second half because I wasn't there, but I haven't seen any more activity on that $3.7 million application for cardiac cath and I'm wondering if I missed something or if it's still under deliberation?  What's the status on that now?

 

SONIA CHAMBERS:  It's still under review.

 

ED HAMILTON:  Okay.  One more question.  Once again, this is Ed Hamilton, Mountain State Blue Cross/Blue Shield.  There is a very nice set of reports available on your website that illustrate the utilization data for cardiac catheterization; the various codes, the various facilities, patient origination, but I think it only goes through 2006.  When can we expect that to pop back out for 2007?

 

SONIA CHAMBERS:  I don't--I'm not immediately familiar with what--the report you're talking about.  Do you guys know?  We don't have all of our report people in here, but Ed, if you would send me an email about that, specifically what report you're looking at that has data through '06, then I can maybe provide you with an answer unless, have you asked me that question?

 

ED HAMILTON:  I think the earlier question was regarding data in general as it pertains to the query vehicle that's available on your website that allows you to run queries for different diagnoses and procedures and so on and so forth.  That data is only available up to, or through 2006.

 

SONIA CHAMBERS:  That's our YODA, right?

 

ED HAMILTON:  Yes, no it's actually, I forget which tab it's on.  I'm not in front of my PC so I can't tell you, but it's under public use data.  There's a query vehicle and then below that there's a couple of other reports and then there's a large set of reports that have to do with cardiac catheterization.

 

SONIA CHAMBERS:  Okay.  I will--if you would send that to me on an email I will try to get an answer for you.

 

ED HAMILTON:  Okay.  Thank you.

SONIA CHAMBERS:  Mm-hmm.  Phil, do you have an opinion yet?

 

PHIL WRIGHT:  Yeah, I think it needs to be reviewed, but I'm back to the quality Ed was talking about.  There's a lot of facilities that are in locations where there are just not a lot of these but they do a very good job quality-wise.  And then there's other facilities that have larger volumes and you really don't know the quality.  Do we publish anything for the consumer?

 

SONIA CHAMBERS:  We, not at--no.  Presently we do not.  Again, we have been getting data from, as I said, from WVMI who gets it from the ACC.  I think it would be the intention of the Authority in the future to start reporting some quality measures; however, I think we would have to engage in a process with everybody as to exactly what quality measures we use and how we measure them.  It, you know, I think it is our intention to do that but I think we'd have to go through a process to get there.

 

PHIL WRIGHT:  I wouldn't think you'd need it for the facilities that have open heart surgery, but certainly the cath labs that are independent, I mean, it's absolutely.

 

SONIA CHAMBERS:  I would--I'm not sure we wouldn't want to do it for everybody.

 

PHIL WRIGHT:  If you're trusting them enough to do open heart, that's all.

 

SONIA CHAMBERS:  Well there certainly are a lot of national or federal entities that do do some of those quality measurements for specific services and those are available.  There are links on our compare care website to those, but I think it would be, I think it's our intention in the future to try to make those a little more readily available and user friendly.  All right.  Anybody else?  I though our other one was going to be the shortest; maybe this one will be.  All right.  Well, I appreciate everybody's time and attention and we'll have our last one tomorrow, which is on the private practice of medicine.

 

TIM ADKINS:  Written comments?

 

SONIA CHAMBERS:  Oh, written comments.  I would encourage anybody who would like to, to submit written comments to us.  Please do that within 30 days so we can pass this along to the legislature and other policy makers.  Thank you very much.

[END]