Author + information
- Spencer B. King III, MD, MACC∗ ()
- ↵∗Address for correspondence:
Dr. Spencer B. King III, Saint Joseph’s Heart and Vascular Institute, 5665 Peachtree Dunwoody Road NE, Atlanta, Georgia 30342.
Where will interventional cardiology fit in a health care system, if we ever get one? All the discussion about “health care,” of course, has not really been about health care or even health care costs, but about insurance. The promises of cheaper health insurance for some, if we get rid of the sick people, does not address the costs or delivery of health care. I do not know where we are going with health insurance, but despite the collapse of the “repeal and replace” Obamacare, I am sure this fight is not over. There must be improvements to health insurance, whether supplied by private enterprise or by government or by both, so that health care is provided for all. It seems to me that what is missing is the discussion of how to make health care affordable, not just to make health insurance affordable. The fee for service incentive drives much of the costs, but that is still the system that most of us still live with. Where do all the dollars go? Hospitals are expensive. Too expensive? Drugs in the United States and Japan are sold at prices that account for most of the drug companies’ margins. Insurance companies and other middle men account for a lot of the expense. But what about us? Are we too expensive? I do not think so, but I do think doctors are making less than they used to. At least in some fields, and I believe that interventional cardiology is one of them. I remember the day when interventional cardiology was the cash cow for practices and academic centers. With the fall in reimbursement combined with fewer procedures per operator, the squeeze is on for those who do interventions exclusively. Many of my colleagues in private practice and in academia tell me that the way to boost their relative value units is not in the catheterization lab but rather in the clinic seeing a large volume of patients. Elective percutaneous coronary intervention (PCI) has decreased in absolute numbers, whereas the number of interventional cardiologists has increased. The excitement about structural heart interventions is interesting but the consensus, that I believe is correct, is that this experience should be concentrated among those who achieve expertise and maintain an adequate volume to ensure continued competence. The volume of structural interventions cannot replace the large coronary patient volume that we used to have. ST-segment elevation myocardial infarction care has become the standard for all modern hospitals with cath labs, but the volume of these procedures are also beginning to wane. The dramatic clinical outcomes for the most vulnerable patients promised by PCSK9 therapy may further erode the work of interventional cardiologists.
So how does the interventional cardiologist of the next 10 years plan to pay for her student debt? Maybe by seeing more patients in the clinic or by affiliating with an academic center and applying for grants? Everyone agrees that the advances of science and research are what drives the future. But how will that future work out? The federal budget now on the table calls for a $6,000,000,000 decrease in funding for the National Institutes of Health. Funding for cardiovascular research has already taken a significant decline over the past few years. Will the industry come to the rescue? With declining margins, will the device companies be heavily investing in research? Sure, some will, but remember that Johnson & Johnson got out of the stent business as pricing and volume declined. This is clearly not the time to be reducing public support for research in cardiovascular medicine, and there is no other funding source that will pick up the slack. At least, not in the United States.
So what needs to be done to ensure that we are attracting the best and brightest into interventional cardiology and away from plastic surgery, dermatology, orthopedics, radiation oncology, ophthalmology, etc.—all of which are worthy endeavors but not as great as interventional cardiology. Perhaps we have been too aggressive in training too many. The demand remains but is largely driven by the need to have practitioners able to take the ST-segment elevation myocardial infarction call. Hospitals are also to blame for the decreased volume for PCI operators by supporting the overturn of the certificate of need laws in many states leading to unnecessary duplication of services and decreased volume for all. Elective PCI could be done by fewer operators if the figures we have seen for mean and median volumes per operator are correct. Is there an active investigation of the manpower (person power) needs for interventional cardiology? Will formal requirements for training and credentialing in subunits of interventional cardiology, such as structural and peripheral vascular interventions, be proposed by the American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American Board of Medical Specialties, or whomever? In this rapidly shifting period, it seems to me that such a study should be undertaken if it has not been already.
Some cardiologists have returned to the roots of cardiovascular interventions, to the periphery. Peripheral vascular interventions, however, also require specialized training. The direction here has also been toward concentrating the experience among experts who can maintain an adequate volume and competence. The competition from vascular surgery in some locales also poses a limitation. Some vascular and cardiothoracic surgeons have discovered the venous system. Yes, that is part of cardiovascular medicine, but I have not yet seen cardiologists opening vein clinics.
Until now, the health care debate has been about insurance, but it must turn to health care costs and delivery in the near future. As it does, all the players, including those of us who deliver health care, must become engaged. Interventional cardiologists have made some of the most important contributions to medicine since the introduction of this subspecialty more than 40 years ago. That progress will continue but it is now time to reflect on the interventional cardiologists and how to keep our specialty the most attractive one for young physicians to pursue.
- 2017 American College of Cardiology Foundation