Trends in cardiac care: contractions, concentration, collaboration.

Cardiovascular services is entering an age of contraction and concentration. The number of programs and the growth in inpatient procedures have topped out and the presence of significant excess capacity has become apparent. During the next five years, there will be heightened pressures to simultaneously decrease the overall number of cardiac procedures performed and, on the part of individual providers, increase procedure volume in order to achieve economies of scale and high levels of quality. It is likely that the number of health care organizations with OHS programs and PTCA may be cut to 500 by the year 2000, significantly influencing the redistribution of cardiac services along regional lines. The public, government, and private payers have embarked on a quest for value; and in the future they will only purchase services from providers demonstrating high-quality outcomes and average, or below average, charges. HCFA's Cooperative Cardiovascular Project is typical of the direct continuous quality improvement and management initiatives that will be implemented to monitor appropriateness, outcome quality, and resource utilization through the application of clinical practice guidelines (CPGs) and data on the treatment of AMI, PTCA, and CABG surgery. A more indirect, managed care approach by purchasers to obtaining higher value can be seen in the Medicare Participating Heart Bypass Center Demonstration project, the federal government's first big step into selective specialty care contracting for clinical service on a package price basis. Several different types of private initiatives have been used to achieve wider distribution of service while maintaining high program volumes and high-quality care through collaboration and the formation of interhospital linkages. Although some of these have included collaborative programs to encourage voluntary community-based planning and discourage the duplication of services, the payers demand for value (cost/quality) and the organizational leverage of the regional health alliances will accelerate the process and spur the formation of a smaller number of high-volume invasive programs. Large invasive programs will continue to formalize interhospital linkages to provide an integrated set of services in a layered system of cardiac care.(ABSTRACT TRUNCATED AT 400 WORDS)