Technology and Value Based Care in Cardiology w/ Daniel Blumenthal MD MBA

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Erik Sunset: All right. Hello and welcome back. I’m Erik, your host of the DocBuddy journal. And today we’re joined by Dr. Dan Blumenthal, who’s a practicing board certified non invasive cardiologist. president of the Novo cardio division and also an instructor at Harvard medical school. Thanks for joining us, Dr. Blumenthal.

Dr. Blumenthal: Thank you for having me.

Erik Sunset: Absolutely our pleasure, and that’s a, that’s a pretty short and concise intro. What, what else should our audience, what else should our listeners know about you?

Dr. Blumenthal: Yeah, so I, I am the president of the Novacardia Division of Cardiovascular Associates of America, which is a large cardiology focused practice management platform. We partnered with over 360 cardiologists across eight states and about 200 advanced practice providers as well who work in The 19 practices that are part of CPA [00:01:00] USA and Novocardia is the value based care division of Cardiovascular Associates of America.

Dr. Blumenthal: So we are focused and I spend all my time day in day out thinking about how we can improve the care model in these practices. So meaning improve the quality of care that are our physicians deliver for patients with heart and vascular disease and how we. Ultimately, try to help transition how they’re paid our our physician partners are paid for care from traditional fee for service mechanisms to more value oriented or risk oriented payment models, which reward the delivery of higher quality, more efficient.

Dr. Blumenthal: So that’s, that’s what I do on a, on a daily basis when I’m not practicing cardiology, which I, I still do several, several days a month, and then I, I also do some inpatient work at a, at a hospital here in, in Boston,[00:02:00]

Erik Sunset: Well, it’s quite a privilege to have you on our podcast because you are, you sound like an incredibly busy person with a very full calendar. So thank you once again for joining us.

Dr. Blumenthal: of course, my pleasure. Thank you for having me. Yeah, it’s you know, I, it’s. It’s a it’s been a, we’ve, we’ve been building a really interesting, exciting set of care model innovations at, at CBI USA and Novocardia, which are, you know, again, really geared towards helping to deliver better care for patients with heart and vascular disease who are receiving care from community based cardiologists and Happy to tell you more about about a lot of that work.

Dr. Blumenthal: I’m excited to kind of to delve into some of the details there and and also kind of talk about some of the levers that we pull to drive to drive improvements in quality and and reduce costs.

Erik Sunset: Me saying this is not meant [00:03:00] to be tongue in cheek, but when you talk about improving outcomes and value based care, the cardiologic system strikes me as a very high priority for a high quality outcome, not that the rest of the

Dr. Blumenthal: Yes. Yeah. Yeah.

Erik Sunset: speaking cardiologically, that seems mission critical.

Erik Sunset: So what are some of the things that are front of mind for you to ensure that that happens either through the use of technology, through the use of care protocols? You’re the physician here, I’m certainly not, and I don’t want to pretend to

Dr. Blumenthal: Yeah. So I mean, so you’re, you’re exactly right. So, I mean you know, cardiovascular illness is ubiquitous, particularly in older adults. Right. We have and it’s, and it it’s very expensive. So if you look at, you know, recent projections, depending upon whether you’re looking at data from the American Heart Association or The American College of Cardiology or from other published projections, anywhere from 40 to 50 percent of [00:04:00] older adults in this country will develop one or more cardiovascular illnesses.

Dr. Blumenthal: And and the cost of caring for those diseases is It’s extremely high already projected, you know, or an estimated 320 or so billion dollars a year is what we spend in this country on cardiovascular disease care and is projected to more than double by 2035 to something like 750. Billion dollars per year.

Dr. Blumenthal: So, you know, those costs can be measured as a percentage of GDP, which is, which is pretty astounding, right? Somewhere in the range of 2 percent of GDP spent on cardiovascular disease care. So it’s common, it’s costly, and there are lots of opportunities to help care for it more proactively, prevent it from developing in the first place.

Dr. Blumenthal: If it develops, prevent it from progressing or progressing as [00:05:00] quickly as it otherwise might. Thank you. And a lot of that work relates back to thinking about how we help ensure that our Physicians have access to supports to help them deliver evidence based cardiovascular disease care. And one of the things that I love about the field of cardiology is that there’s so much data and evidence to guide how we practice.

Dr. Blumenthal: We, in many cases, really do. There’s certainly a lot of room for clinical nuance and decision making. But in many cases we do know what works and what doesn’t work. And and so we can, we can really help patients. And a lot of that development of knowledge is, is a result of, of a lot of hard work that has been done by cardiologists, by academic researchers, by, You know, the N I H [00:06:00] by funders from pharma and biotech and device manufacturers to build the evidence base about what doesn’t doesn’t work.

Dr. Blumenthal: And and so we can use a lot of that information to help ensure that patients are receiving the right care in the right place at the right time. And then when it comes to thinking, go ahead. Yeah.

Erik Sunset: was going to say, I hope I’m not jumping tracks on your train of thought here, but one of the things I’d be curious about your perspective on is you, you listed all the great sources of research for the the empirical evidence of what works and what doesn’t work. Now we’re 15 years into the big electronic health record experiment in the U.

Erik Sunset: S. and it’s here to stay, here to stay. It’s not so much an experiment, but something new, something mandated. I would imagine that despite the fact physicians on average don’t care to be their own scribe, don’t care to be spending all their time in their EHRs, there’s got to be some good that’s come from that amount of [00:07:00] data collection that we weren’t, that didn’t happen before the Meaningful Use Act.

Dr. Blumenthal: Yeah. No, there’s a ton. I mean, so we and we are so I think there are a number of areas of, of where that data has started to has become really valuable. One is, and we’re, we are, you know, we have access to all of the EHRs that our physicians use, and they use a number of different EHR systems. And we’ve tapped into the, all of those systems and we’re aggregating information.

Dr. Blumenthal: We can start to understand variations across practices in care patterns. Right. How many, what percentage of patients follow up and see their cardiologist after being discharged from the hospital? You know, where care is being delivered how much of it is being delivered in the clinic versus in the hospital versus in a different location.

Dr. Blumenthal: And that becomes very relevant when you’re thinking about procedural care in particular in cardiology, because procedure, many procedures can be [00:08:00] done. either in a hospital or hospital outpatient setting, or they can be done in an ambulatory surgery center or an office based. catheterization lab, which is like an ambulatory surgery center, but has has been licensed for an hour set of, of procedures that can be done typically that can be done in an office based cath lab.

Dr. Blumenthal: So we can start to look at, at where procedures are being done and whether they’re being done what types are being done. more commonly in the hospital versus in an ASC or vice versa. So just two examples, we can also look at medication prescribing, whether patients with heart failure are receiving evidence based guideline directed medical therapy, which is again has has a lot of evidence behind it from randomized trials and observational studies.

Dr. Blumenthal: And we’ve started to look at those data to help understand whether whether our patients with heart failure are receiving the right kinds of treatments. Not that every patient. With heart failure [00:09:00] should receive every single one of those medicines, but, you know, at a population level, you can start to understand how how commonly they are being used or not used.

Dr. Blumenthal: And that helps us to then think through how we help support our physicians. To to understand what they’re doing and to, and to make improvements in, in what they’re doing or to continue to do the right things. If they’re, if they’re doing them already at a, at a level that is, you know, that, that many of them are, but some still at times need some additional guidance on so just, just a few examples of, of how that those EHR data are being used.

Dr. Blumenthal: You know, on a on a daily basis, and in some cases, you know that work is ongoing to build the right, the right data feeds or the right analytics once we have the data feeds to, to understand different types of care patterns and variations in care.[00:10:00]

Erik Sunset: That’s EHR data for good, and I know that is like the number one self reported cause of frustration with

Dr. Blumenthal: Yeah.

Erik Sunset: viewing a physician as a career. I’m going to go back to, Oh,

Dr. Blumenthal: Yeah. No,

Erik Sunset: I was jumping tracks on

Dr. Blumenthal: no, no. All good. Keep, keep going.

Erik Sunset: The, you mentioned a stat. It was a percentage of folks that were going to end up with a cardiovascular disease going forward. And it was a big number, 40%. I think you said

Dr. Blumenthal: Yeah, I think it’s, I mean, the, the, the projections vary depending upon, you know, what age you’re, what ages of, of people you’re talking about and whether you’re including conditions like hypertension and hyperlipidemia or high cholesterol, which are, you know, very, which are more prevalent and, and, you know, affect Affect a substantial percentage of of of adults but something between the, you know, something between 40 and 50 percent of of [00:11:00] middle age adults and older will develop some form of heart disease.

Dr. Blumenthal: Yeah,

Erik Sunset: kind of two, kind of a two part question there, I guess maybe a three part question, but how could that possibly be? That seems like a staggering proportion of a general population. How does that stack up over time?

Dr. Blumenthal: well, how much how much time do you have the, the the, you know, we, we, when I say heart and vascular disease, I’m, I’m talking very broadly about. not just coronary artery disease or blockages in the heart arteries, but also heart arrhythmias, atrial fibrillation being the most common, congestive heart failure, which, you know, we just talked a little bit about, peripheral artery disease and that includes, you know, ischemic ischemic, cerebral ischemic disease or, or cerebrovascular disease.

Dr. Blumenthal: So again, I think the definitions [00:12:00] You know, Dick kind of will impact the percentages, but if you include all of those, meaning people who have had strokes or will have a stroke, people who will develop heart failure, people who will, who will develop blockages in their heart arteries, people who will develop abnormal heart rhythms, like atrial fibrillation, people who will develop peripheral artery disease.

Dr. Blumenthal: You’re talking about a very large number of, of the American population over lives. Yeah.

Erik Sunset: I know I’m just kind of firing questions at you, but that is truly staggering the statistics there.

Dr. Blumenthal: Yeah, so it, it is getting, it has improved. And I’m, I’m, you know, over the last 50 years has the rates of, of heart and vascular disease have declined. And. and rates of death from those illnesses have declined. And in large part, the decline in [00:13:00] the rates of, of heart and vascular disease and, and poor outcomes in particular from heart and vascular disease are a result of Reductions in rates of smoking in this country, better treatment of high blood pressure, better treatment of high cholesterol which are all three of which are major, major risk factors for the development of heart and vascular disease.

Dr. Blumenthal: I would say, you know, the rates of diabetes have increased and, and, and so that has been a countervailing trend and force in driving sustained rates of. Heart and vascular disease because diabetes is an important risk factor as well. But I think the work that we’ve done to, and, you know, in public health experts deserve a ton of the credit here.

Dr. Blumenthal: As do you know, as do as do physicians, both from primary care and cardiology and other fields. You know, the, the overall we have done a lot of a, a, a [00:14:00] lot of good in, in terms of reducing. the the severity of and the rates of a lot of those risk factors for heart and vascular disease. Yeah,

Erik Sunset: are improving despite some of the countervailing measures, because at first blush,

Dr. Blumenthal: there’s a but in recent years, they have stagnant that those declines have stagnated, right? So we’ve kind of plateaued. And in some cases, and particularly for certain populations, rates of heart and vascular disease have started to increase again. So we cannot give up. And we can’t, we can’t lose focus.

Dr. Blumenthal: And I think our specialty societies and, you know, have continued to remind us that, that we, we can’t lose focus in terms of our ongoing efforts to drive improvements in not just outcomes, but also rates of development of these illnesses.

Erik Sunset: You’re, you’re reading my mind there, Dr. [00:15:00] Blumenthal, because you, is an arena where it sounds to me, as a non physician, non provider, that an ounce of prevention isn’t worth just a pound of cure, it’s worth maybe a ton of cure. I mean, I would imagine a lot of these conditions are tough to reverse once they’ve sort of taken hold. You said something a little bit ago that, you know, the state of the art is to be able to deliver the right care. In the right setting at the right time, and I would imagine that’s

Dr. Blumenthal: Yep.

Erik Sunset: tough to do whether you’re talking about an intervention or whether you’re talking about preventative guidance to a patient, I would imagine that’s tough to do without the right technology in play.

Dr. Blumenthal: Yeah. Yeah, it is. And and that technology, I think there are a number of ways in which we think about the use of technology in in our organization to help drive better outcomes. We think about and I’ll talk about two of them. I think we think about expanding the bounds of the clinic into a patient’s home [00:16:00] through remote monitoring through virtual care, telehealth to try to ensure that we are managing patients in between their in person visits more closely and more efficiently and and, and that remote monitoring can take the form of a number of different.

Dr. Blumenthal: interventions. It can be anything from remote blood pressure monitoring to, you know more frequent downloads of data from implantable devices that are, that are gathering data. They’re already in a patient’s body, like a defibrillator or a pacemaker. Our, our pacemaker and defibrillator technologies have advanced to the point where You really don’t have to actually go into the office to have your pacemaker information recorded and given to your clinician.

Dr. Blumenthal: You can actually connect your pacemaker or your defibrillator via Wi Fi or even via Wi Fi to to a device which can [00:17:00] then read all that information, upload it into the cloud. Send it to your provider, your clinician, and then your clinician can review it and identify things that may be off or wrong that that need to be followed up or or give you a call and say, Hey, everything’s looking good, you know, connect again in 3 months and, and and, and I’ll receive that information back at that time and then do another review.

Dr. Blumenthal: So you know, we also have, yeah. Home based electrocardiograms or, or telemetry that we can, that we can use to monitor patients who have abnormal heart rhythms. We, we have and we have a set of, of interventions that we are, you know, that we deploy. For patients who are we, we actually have a partner organization named Duxlink, which we recently brought in to the CVA USA network of practices.

Dr. Blumenthal: And that Duxlink organization is [00:18:00] solely dedicated to managing patients in their homes through largely through virtual or remote. monitoring technologies and telehealth based interactions. They do send they can send people into the home to and in some for some higher risk patients, they do that, but they have the ability to gather a ton of information about how a patient is doing through a variety of monitoring techniques, including blood pressures, weights, the electrocardiogram that I mentioned.

Dr. Blumenthal: Oxygen saturation monitoring. They use Alexa to to interact with patients and and gather information from patients about how they’re doing. And then, you know, use all that information to to help manage very a patient very closely in their home and help them to remain in their home unless they’re really, really, really, really sick.

Dr. Blumenthal: And and they’ve demonstrated the ability to reduce [00:19:00] hospitalizations, reduce costs of care. for patients with multiple chronic conditions, cardiovascular conditions, including heart failure, atrial fibrillation, coronary artery disease, and, and, you know, multiple conditions within that group. So we have a heart failure program as well, which man, which is largely virtual, which delivers.

Dr. Blumenthal: evidence based counseling and education to patients in the comfort of their home via a remotely located clinician and a health coach, and uses remote patient monitoring, the blood pressures and weights and oxygen saturations that I mentioned, to help manage and monitor those patients vitals and their weights, look for early signs of decompensation in between those visits and between those visits with their clinicians.

Dr. Blumenthal: So just two examples of, [00:20:00] of services and, you know care model innovations that we’re deploying at scale across across parts of our network to help better manage patients.

Erik Sunset: One of the things I’m curious about, because with the right patient adherence, I would imagine it makes your job a little bit easier. So people are hooking EKG and it’s connected to the internet. You know, they don’t have to haul it into your office or to the practice to get the data off of it. Once again, and not meaning to be tongue in cheek, but an issue with your heart or your lungs or, you know, these mission critical systems for your body.

Erik Sunset: Do you find that patients are pretty adherent? I mean, I think about, God forbid, if I end up in that 40 percent or so with an issue that we’re expecting to see. I’m going to be on top of it because I don’t want to die because I didn’t do something that was as simple as hooking up to a monitor. What’s, what’s patient

Dr. Blumenthal: Yeah. For these interventions, you mean, or for, or for, or more generally just [00:21:00] with medications

Erik Sunset: think

Dr. Blumenthal: or both.

Erik Sunset: if you have the, if you have a thought, you know, medication adherence is

Dr. Blumenthal: Yeah.

Erik Sunset: but even the remote patient monitoring aspect of it.

Dr. Blumenthal: Yeah. I, I think so what, what I think what we’ve started to learn is that There are, there are certain barriers to adherence that that exist across, across our healthcare system, right? Those are a lack of understanding of the intervention or what a patient, a patient lacks understanding of what it is that they should be doing.

Dr. Blumenthal: Often when people are not taking their medicines, it’s because they don’t really understand, A, that they were supposed to take the medicine, B, when they were supposed to take it. or see why they were supposed to take it. And so that’s a oftentimes a failure of our failure, right? In terms of our ability or or to how well we educated the patient about about the medicine or addressed questions that they have about about the intervention, the medicine the other relate to [00:22:00] cost.

Dr. Blumenthal: So we know that particularly for medicines, which are, you know, on patent, for example, and are more expensive, have higher co pays or cost shares, those those co pays or cost shares, Really do impact the likelihood that a patient will take the medicine and so asking them before you prescribe the medicine whether or not they have concerns about their ability to pay for it can help identify circumstances in which a patient is less likely to be able to adhere to the medicine.

Dr. Blumenthal: You have issues of access. So even if you, you know, even if you address all of those questions, you address their concerns, you help them to understand why it is that they’re supposed to be using a medication or adhering to an intervention. You’ve, you’ve asked them about whether or not they have the ability to pay for it.

Dr. Blumenthal: They may not be able to access the intervention, meaning. They may not, they may have mobility challenges which prevent them from going to [00:23:00] the drugstore to pick up a medicine, or they may have difficulty standing up and walking to the door or walking to wherever they need to sit in order to connect to Wi Fi and have the information from their mobile intervention downloaded via, via the Internet to their provider to to to be used to help care for them.

Dr. Blumenthal: So there are a whole host of challenges and barriers to adherence that that have been well documented through research and and, you know, clinical experience over decades but which in practice do impede. The ability of patients to, to use the things that we know work and and it’s our job as, as health care professionals, as clinicians and, and parts of the broader care team to help identify those barriers in, in the day to day.

Dr. Blumenthal: work that we do caring for patients [00:24:00] and do our best to address them. And that’s hard work. It often is not reimbursed. And so and, and, and I, and I should say, you know, Medicare has. And other payers have have started to put in place ways to actually get reimbursed for some of some of that care coordination, care management, education time.

Dr. Blumenthal: And and that has, I think, helped to kind of unlock the ability to to address some of those barriers in in the course of delivering care. But those are those are fundamental issues that we have to address as a society, and I haven’t even talked about kind of. You know, I’ve skirted around social determinants, but a lot of what I’ve described relate to, you know, relate to social determinants, right access, affordability, et cetera.

Dr. Blumenthal: You have language barriers, you have many other, other barriers to adherence, which I think really really do impact our ability to, to implement interventions at scale and in practice.

Erik Sunset: Well, [00:25:00] and that’s, that’s the whole point of, of value based care, what you’re talking about too. You know, I don’t have to tell you, if you can, if

Dr. Blumenthal: No, that’s right.

Erik Sunset: If you’re reimbursed and compensated for an over and above, what is today an over and above intervention on behalf of a patient, you’re hopefully keeping them out of the hospital as opposed to watching a tragedy in slow motion unfold.

Erik Sunset: I can’t get their data. I know they’re

Dr. Blumenthal: That’s right.

Erik Sunset: taking their medication. at

Dr. Blumenthal: And so,

Erik Sunset: I’m

Dr. Blumenthal: yes.

Erik Sunset: business and not a charity. Which is a tough way to look at

Dr. Blumenthal: Yeah.

Erik Sunset: it’s the hard

Dr. Blumenthal: That’s right. It is absolutely the hard truth. And part of the part of the vision and part of what I think is so exciting about you know, value based care is that is that when it works right, works correctly, it gives you the resources that you need as a, as a, you know, as a clinician to address a lot of those barriers, right?

Dr. Blumenthal: You have the ability to hire the care manager. You have the ability to hire it. [00:26:00] Those other members of the care team, but beyond you as the, as the, as the physician or you as the nurse practitioner to help extend, extend yourself, address those factors, which are so critical to address to drive better outcomes.

Dr. Blumenthal: And and, you know, the fee for service incentives that we have right now are not consistent with. That kind of that that vision for how care should be delivered. And and so, you know, what I spend a lot of my time doing is thinking through how we can design not just the care model, but also design the contracting approaches for cardiologists and for patients with heart and vascular disease to enable some of those resources to exist in and around.

Dr. Blumenthal: The cardiovascular care specialist because cardiovascular care specialist for a subset of patients with heart and vascular disease [00:27:00] is, is a really critical member is really at the center, I would say, of, of the care team for a subset of patients with heart and vascular disease and plays a really integral role in, you know, in the delivery of, of of care for, for patients with heart and vascular disease more broadly, whether it’s in the, you know, in the hospital or in concert with the primary care physician as a partner.

Dr. Blumenthal: And we do view PCPs as as very important, critical partners who we work very closely with and who we coordinate with. So I think there’s a there’s a, we view it, we view a a, a value based care risk based contracting payment structure as actually not as actually being very much in line with how we think cardiovascular care should be delivered and paid for in the future.

Dr. Blumenthal: And [00:28:00] and that it will incent the delivery of better care at lower cost.

Erik Sunset: Hard to argue with you, Dr. Blumenthal, I mean that in my opinion, my non expert opinion here, the first step to fixing healthcare, right? Everybody can see the big numbers that we spend on it. You talked about percent of GDP for cardiovascular care. It’s even worse when you look at healthcare as a whole.

Erik Sunset: And when you look at 25 percent of the healthcare spend that’s wasted is on administrivia, like administrative tasks,

Dr. Blumenthal: Yep.

Erik Sunset: burden that just makes me sick to my stomach. So that

Dr. Blumenthal: Yeah.

Erik Sunset: based care helps to get that value chain in alignment. The delivery of care fee for service by chain, not necessarily aligned between the three main parties, the provider, the patient of the payer, obviously, and I’m hoping I could put you in your soapbox just just a little bit. That if we do get

Dr. Blumenthal: Okay.

Erik Sunset: chain in alignment with value based care, we want people to [00:29:00] remain, remain healthy. What

Dr. Blumenthal: Yeah.

Erik Sunset: see as most critical to avoiding those unforced errors as a patient? And this is a silly example, but maybe not eating McDonald’s three times a day, driving your blood pressure through the roof and giving yourself hypertension. I mean, that’s

Dr. Blumenthal: Yeah.

Erik Sunset: but what something has to give, because there are a lot of self inflicted errors and when people talk about people’s health,

Dr. Blumenthal: Yeah. Yeah. Yeah. There are a lot of self inflicted errors. I, I, I think man

Dr. Blumenthal: you know, I, I think that, so, so the, I, it’s hard, it’s hard to argue with the McDonald’s example. You shouldn’t be eating McDonald’s three times a day. There was a movie about that.

Erik Sunset: good now.

Dr. Blumenthal: Yeah, there were, I think there was a movie, right? There was a, there, the documentary showed that it. You know, I I’m blanking on the name of the documentary, but the, the

Erik Sunset: me. Supersize me.

Dr. Blumenthal: supersize me.

Dr. Blumenthal: Thank you. I’m thinking of the book fast food nation. But yes, there, [00:30:00] there was a I think we know that that’s not good for you. There are a few other things. So, so you know, I mentioned diabetes early earlier in this. In this show and, and, you know, we also have a the, the diabetes epidemic that we face is related to the obesity epidemic that we face and, and, and I think a lot of that there’s several reasons why we are as a nation getting bigger you know, from a, from, from an eating standpoint, I think we drink a ton of, of sugared soda in this country and and And that to me is just a waste, right?

Dr. Blumenthal: So this is one very small example, but it’s it’s a bit of a pet peeve of mine. And so I thought I would highlight it. The second kind of zooming back out is I think that patients need to, in many [00:31:00] cases, in a system which I wish would always look out for people, but which doesn’t always look out for people Patients, I think, need to really focus on being their own advocates and and if they can be their own advocates and push for what they think they need, what evaluation they think they need push to be educated about what, what’s wrong with them, what their clinician is thinking.

Dr. Blumenthal: I think that that can do a lot of good. I have seen circumstances as a clinician where. Patients have advocated for themselves and gotten treatment that has been critically important for them. I have friends, Physicians who, who have had to advocate for themselves to get needed care and and have, as a consequence, had really important diagnoses identified that wouldn’t have otherwise been identified.

Dr. Blumenthal: So it happens to everyone across this [00:32:00] country. And I think the more that individuals can advocate for themselves. The more likely it is that we will that we will make sure that we hold the health care system accountable for, for doing the right things. So just one, you know, one other example that popped into my head that I thought I would, I thought I would highlight.

Erik Sunset: What does that look like? You go into an office, not right. And

Dr. Blumenthal: Yeah,

Erik Sunset: well,

Dr. Blumenthal: I think.

Erik Sunset: test, but something’s, hey, something’s not right. And I need to know exactly what it is.

Dr. Blumenthal: Yeah, I think you have to say, I think you have to say, listen, like, I’m not, I, you know, I’m, and I’m not, I don’t mean to say by any stretch that that we as clinicians are not trying our absolute best to figure out what’s going on. Right. But, but there and, and to do right by patients. I fundamentally believe that doctors are doing as well as they are in general.

Dr. Blumenthal: You know, trying, trying every day to do their and nurse practitioners and physicians assistants are trying to do [00:33:00] their best in a system, which is which is really broken and and doesn’t support them in the ways that that we should be supported. But, but I think that I think that looks, I think that that, you know, looks like asking questions about what’s going on, asking questions about why certain treatments are necessary or why they aren’t necessary.

Dr. Blumenthal: Asking. Whether there are alternatives, asking whether, you know, whether whether you know, what they’re feeling could be related to X or Y instead of just asking, you know, kind of asking the physician what they think is going on. If you have thoughts or you have questions you, you know, you should ask them or, or make them known.

Erik Sunset: It’s, it’s as easy as that voice, your opinion, voice, your concern.

Dr. Blumenthal: What’s your opinion? Right. I, I, I, yeah, I, it’s, it’s I mean, I,[00:34:00]

Erik Sunset: Well, those are, those are wise words. Let’s pivot a little bit to one of the hotter topics you read about closing out 2023. It’s died off a little bit in 2024. I think everybody’s really excited about AI in medicine, but going into 24, there was a lot of buzz around certain cardio procedures coming off that inpatient only list and being reimbursable. In the surgery center. We talked

Dr. Blumenthal: mm-Hmm.

Erik Sunset: chain. It’s really

Dr. Blumenthal: yep.

Erik Sunset: to beat at the surgery center for great outcomes, affordable for the patients, A place physicians wanna do procedures and we even give a nod to our friends at the payers that they get to pay less. So that makes them happy as well. What are your thoughts on that?

Dr. Blumenthal: Yeah, I am. So you’re exactly right. There are a number of procedures. Well, so first of all, in cardiology, we’ve been able to do procedures in A. S. C. S. For, you know, for a deck almost more than a [00:35:00] decade. We’ve been able to implant pacemakers and defibrillators. to do diagnostic procedures, you know, heart caths to do interventions, necessary interventions in the leg arteries, the arm arteries and more recently, you know, Medicare has approved and doing stents for stable, severe blockages in the heart in ASCs.

Dr. Blumenthal: And, and I think that I think I think we’re going to see over time, and we saw this in the pandemic, right? By necessity, because there were certain procedures that were done in ASCs that hadn’t typically or previously been done before, and payers relaxed some of of their some of their location based requirements to allow certain procedures to be done in A.

Dr. Blumenthal: S. C. S. And as a consequence, we were able to gather some information about about those procedures, in particular, right sided ablations of arrhythmias, super [00:36:00] ventricular arrhythmias, which you know, have been shown to to be performed at a high level of safety and efficacy in ambulatory surgery centers based on several published case studies and case series, a lot of which came from the pandemic.

Dr. Blumenthal: So I think we’re going to see a lot of additional procedural care continue to move into ASCs over the next five to 10 years from cardiology. And And, you know, we need to continue to gather data on efficacy and safety, but every almost everything that we’ve seen to date suggests that, you know, rates of, of efficacy remains remains equivalent to when procedures are done in hospital settings and and they, those procedures can be done safely and patients are really satisfied and have a great experience.

Dr. Blumenthal: So, you know, it, it’s a really and I should also mention costs are anywhere from 30 to 50 percent [00:37:00] lower when you have the same procedure done in an ASC is when you have it done in a hospital or an HOPD setting whether inpatient or HOPD rather. So we, we we have really a win, win, win situation here for.

Dr. Blumenthal: patients, most importantly for providers and for payers and you know, both public and private. And I think I think for that, you know, for that reason, we’re going to see continued movement of procedural care, cardiovascular procedural care into ASCs.

Erik Sunset: That that cost savings or the, the lesser cost that the a

Dr. Blumenthal: Yeah, it’s good.

Erik Sunset: should be staggering to people and if you’re not plugged in it end, it ends up being staggering. So this is a little bit of

Dr. Blumenthal: It is huge.

Erik Sunset: Long walk for a short

Dr. Blumenthal: Yeah.

Erik Sunset: Prentice, who’s the CEO and president of ASCA, the Ambulatory Surgery Center Association on the show last year, and one of the [00:38:00] things that he shared was one of the largest hurdles that ASCA, as the advocacy group for ASCs, is hoping to overcome is simply awareness. So if you’re a patient and you hear percent of the cost or as much as 50 percent less expensive than going to the hospital, I have to do it there. There’s no choice. I’m going to the hospital because that’s a mortgage payment. That’s a car payment, whatever the case is. So the question to you, doctor, is what would be your words to the wise for your fellow cardiologists to help spread the good word and to help ensure that If you can do a procedure at

Dr. Blumenthal: Yeah.

Erik Sunset: ASD that you can, if you feel that’s the right thing in your clinical decision making.

Dr. Blumenthal: Yeah, well, I, there was one other thing. I think there was one point that I wanted to make about the, the, the payment, right? The payment differential is, is that, you know, is that those savings do get passed on as you, as you noted to patients, because patients typically bear a percentage of the cost [00:39:00] of the procedure in the form of a cost share.

Dr. Blumenthal: And so if you have a 20 percent cost share. For, for a procedure which costs thousands of dollars, you have to pay 20 percent whether it’s in the HOPD, often depending upon your, your insurance arrangement you know, but in many cases, you, you know, the cost share doesn’t change depending upon the location.

Dr. Blumenthal: So you have to pay 20 percent of that procedure cost, whether it’s in the HOPD setting or the, or the ASC setting. And so if you can reduce the total cost of the procedure, you reduce your total cost share. By a proportional amount. So that’s a big deal as you noted. I think that the the, the message that I would deliver to cardiologists, my, my colleagues is that I think, you know, we are in many, in many ways, I think, probably where orthopedics was.

Dr. Blumenthal: eight to 10 years ago in terms [00:40:00] of in terms of, you know, the use of A. S. C. S. The growth of A. S. C. S. And and that we should be thinking about how we can deliver the best quality care at the lowest possible cost and find away. To ensure that we are doing so in a safe, effective way and not shy away from using ASCs.

Dr. Blumenthal: In fact, embrace them. If we think that ASCs are as the data suggests they are the right place to do many of our procedures, particularly those which are, you know, not in super high risk patients you know, are, are relatively routine. Right. That, that part of the way that we, that we improve the efficiency and the value of care that we’re delivering in this country is by making important decisions about, about how to find a way to deliver care in the lowest cost setting.

Dr. Blumenthal: And and ASCs are a great opportunity to [00:41:00] do

Erik Sunset: Yeah,

Dr. Blumenthal: that. That was a little yeah, go ahead.

Erik Sunset: I was going to say, really, the only opportunity to lower cost and deliver the same standard of care as things sit today is at the ASC. And I don’t mean to sound like too much of an advocate. I’m not on a pack for the ASCs in any way, shape, or form, but a big fan of the venue and it’s important for patients to have that option.

Dr. Blumenthal: Yeah, yeah. And I, I agree. And I, and I think I think it’s a, I think we’ll you know, we’re going to continue to see them be more broadly used. And we do need to gather data on outcomes and track, you know, track quality and safety outcomes. And and there’s several efforts afoot to do that.

Dr. Blumenthal: That’s just part of ensuring that that what we’re doing is right, right? That we’re and we’re continuing to improve. So I do think that’s very important. And I wanted to mention that

Erik Sunset: And you can see if I, if I can, you can see that that data collection effort start to really begin [00:42:00] in earnest. I mean, those of our listeners who are really policy wonks will know the ASC as a setting wasn’t subject to the same meaningful use

Dr. Blumenthal: yeah,

Erik Sunset: as hospitals and practices were. Hard to really blame them after some of the early days of meaningful use, but for the most part, ASCs are not really all that digital.

Erik Sunset: There’s a big technology adoption lag across all of healthcare and ASCs are even 10 years behind that. But we’re seeing that change and leaders in the space have acknowledged that saying, Hey, it’s in our best interest to capture this data. We need to be looking at outcomes. We need to be looking at hospital admissions after procedures done here. How do we do it if we’re not electronic? Because your staff

Dr. Blumenthal: of complications, rates of complications rates, rates of, as you mentioned, rates of post procedural ER visits and hospitalizations. Those are, those are in my mind and their registries, which are being set up to do this, which I think will help [00:43:00] us ensure that we, you know, that the policy community and that outcomes researchers have access to.

Dr. Blumenthal: To the right information to do that work,

Erik Sunset: That’s a place where that it’s a common theme for me today. That value chain is in alignment and the particular ASC data value chain gets to learn from the lessons of the last 15 years and hopefully not make any of the mistakes that we’ve already seen. Dr. Blumenthal, as we kind of wrap up our chat here, is there anything else that we need to share with the audience? We, I think we’ve given technology. At the point of care and talking through some of the the grander population health issues, I think we’ve given them a fair shake, but what else do you want to add? anything,

Dr. Blumenthal: I actually don’t have, I think we’ve, I think we’ve covered I think we’ve covered a tremendous amount of ground in the last 45 minutes. I mean, I just wanted to thank you for your, for your time and for having me on,

Erik Sunset: it was, it really was my pleasure. I [00:44:00] love getting to have this type of conversation with experts in their field. And our listeners will want to be able to find you online. If you’re, if you’re up for it, are you big on any social medias? Where, where would you point people?

Dr. Blumenthal: You know, they can find me via linkedin. On X, my handle is at Blumenthal DM one. And and then if, yeah. You know, via the CVUSA and Novocardia website. So it’s www. cvausa. com, www. novocardiahealth. com.

Erik Sunset: We’ll be

Dr. Blumenthal: any of those.

Erik Sunset: Get those links in the into the show notes. So they’re easily accessible for you on behalf of the entire DocBuddy team. Dr. Blumenthal. Thanks again for joining us to our audience. Thanks for listening. Be sure you’re subscribed on Apple podcasts, Spotify, and YouTube. So Joe has got the newest episodes in the DocBuddy journal and until next time, I’m your host, Erik.

Erik Sunset: Talk [00:45:00] soon.