LANSING — A draft proposal before the Michigan Certificate of Need Commission leaves little room for new open-heart surgical programs in Michigan and would establish new quality measures for heart hospitals to meet.
In updating certificate-of-need standards for open-heart surgery, a state committee proposes using quality measures developed the Michigan Society of Thorasic & Cardiovascular Surgeons to judge the performance of open-heart programs. If a hospital fails to achieve an adequate score in a rating system developed by the society, the Michigan Department of Community Health could then force improvements.
The draft proposal represents a significant change in thinking about how to judge open-heart programs at a time when the number of procedures performed statewide continues to decline.
The idea for years has been that hospitals that performed the most heart procedures tended to have the highest quality. The draft proposal to the Michigan Certificate of Need Commission alters that long-held view.
“(Open-heart surgery) programs should be judged based on quality metrics rather than volume,” states a summary that an open-heart standards advisory committee presented to the CON Commission in December.
Under the draft proposal, the view is that even hospitals that fail to meet volume standards for performing a minimum number of heart procedures each year can do open-heart surgery “as long as they provide outstanding results,” said Dennis McCafferty, vice president for health policy at the Economic Alliance for Michigan, a management-labor coalition that follows CON issues.
“We like a lot of the elements of the draft proposal,” McCafferty said.
That includes not changing language to make it easier for more programs to launch in Michigan, which could affect Metro Health in Grand Rapids should it again seek approval to perform heart surgery.
“We already have enough open-heart programs in the state,” McCafferty argues.
The CON Commission will review the standards advisory committee’s draft proposal and final language submitted from Department of Community Health staff when it meets March 28. The commission can accept or alter the proposal and send a final version out for a 90-day public comment period, or reject it and opt to maintain the status quo.
While not taking a formal position on the draft proposal, the Michigan Health & Hospitals Association likes changes that create a new method for determining the quality of each hospital’s open-heart program.
“The (standards advisory committee) presented some compelling data to the CON Commission in its careful review of the open-heart surgery standards, which showed quality outcomes and cost were not necessarily correlated to volume in the case of the programs they reviewed,” said Tracey Burtch, public affairs manager at the MHA. “In general, the MHA is supportive of seeking the best data available to create meaningful quality standards and accurately measure performance. Volume can be an important consideration, but if more accurate measures are available, then MHA supports looking beyond volume. This is a positive direction for the assessment of programs and for the CON process.”
One change the Economic Alliance for Michigan would like to see in a final version is allowing the Department of Community Health to revoke the CON of any program approved in the future that fails to meet the 300-case requirement within three years.
In 2011, 11 of the 33 hospitals in Michigan that perform open-heart surgery did not meet the standard for performing 300 cases annually for programs approved since 1993 and 200 cases for programs approved between 1979 and 1993. Under state law, hospitals only must meet the standard in effect at the time their program earned approval.
Acceptance of the draft proposal would end an ongoing debate on whether the state should continue to license heart programs that fall below minimum volume requirements. The Department of Community Health has never revoked a CON in those instances. A CON revocation for an open-heart program also means a hospital would no longer have the authority to do elective cardiac catheterization procedures.
McCafferty said the new quality measures and the need to maintain the existing volumes standards represent a balance between allowing low-volume programs to continue without readily accommodating new programs.
“They (hospitals) made their capital investments. It’s too late to pull them back, but we don’t want to see any more,” McCafferty said.
The draft proposal before the Certificate of Need Commission would essentially maintain the status quo for the number of hospitals performing the procedure. The standards advisory committee decided not to change requirements for starting a new open-heart program.
Metro Health tried unsuccessfully in 2010 to obtain state approval to launch an open-heart program in Grand Rapids that would compete with Spectrum Health, which in 2011 performed the most surgeries in the state with 1,045 adult cases.
The Department of Community Health rejected Metro’s open-heart application in December 2010, citing the health system’s inability to meet volume standards. Metro was hoping the standards advisory committee would change the methodology used to compile volume data for a new program, but the panel chose to maintain the status quo.
“It’s not impossible to achieve that goal (of 300 cases), but it certainly makes our application more difficult,” said Dr. John Key, chairman of cardiology at Metro Health’s Metro Heart and Vascular practice in Grand Rapids.
The health system has not given up on the idea and wants to eventually re-apply to the Department of Community Health and break what it views as Spectrum Health’s monopoly over the procedure in the Grand Rapids area. The nearest open-heart programs are in Muskegon, Kalamazoo and Lansing.
“The community and patients are clamoring for a choice in the market, and we’d like to be that choice,” Key said.
Spectrum Health deferred comment on the draft proposal until after the March 28 CON Commission meeting.
McCafferty of the Economic Alliance, however, cites Department of Community Health data that shows open-heart surgeries declined 30 percent between 2000 and 2011 as the number of hospitals performing the procedure grew from 27 to 33, diluting market share for many.
“We don’t need to make it easier to get into the game. The game is shrinking,” McCafferty said.