 to give this ground round, I think it's a true privilege and it's an unearned privilege, I have to say, to which I'm very grateful. So I was asked to give this talk and I don't know if I'm gonna do this by sharing my screen first. Very good. I was asked by Dr. Coulter and Dr. Plana to present to you and I was asking myself what would be a good presentation to this elite group of cardiology fellows and this outstanding group of faculties and an institution like Texas Heart. And so I decided to just think around the work that I do which I think I'm fairly good at, but I'm new at. I've been doing this for about 12 months and that was a suggestion by my colleagues, Dr. Plana and Dr. Coulter. And the initial thought was to talk about the cardiovascular service line and I was thinking what it is that we do in the cardiovascular service line and that got me to thinking about the talks I have on regular basis now around quality and around stewardship and that got me to think from point number three to move my way up to point number one on the brief overview of the objective of this talk. It is through the physicians and the physician dyads that we achieve quality and stewardship. And we do that because of point number one that the world has changed since I was in training and now we are moving away from volume to value. So now I'm reversing the order and building up my case and I'm hoping at the end to give you a sales pitch for recruitment because I want to have the Texas Heart fellows working for our organization. So I'll run by our service line and the opportunities that we have and hopefully can entice you to work with us. I have this, I have no disclosures. I do have a disclaimer. I'm not known to follow lecture notes and follow slides so I'll be talking and I have put a timer so that I stay on time. So forgive me again and table that under an inexperienced lecturer. So clearly the healthcare system is changing. There is a significant struggle with the cost of care. There's staffing shortages. The technology is very expensive, especially in some of these highly technical fields like cardiovascular care. And that there is an ongoing demand from the payers and there's a lot of pressure to reduce cost and deliver effective and rational care in the management of patients. And the system is broken at many different levels. So unfortunately our approach has been over the last 20 years or so. So early in the 2000s, there was a shift towards value or a focus on value. And I'm not so certain that we understood or that the people that pursued that understood the implications of their initiatives and or strategies. The payment models are definitely not supportive of a value-based model of care delivery. There are significant redundancies in the way we deliver care. The many attempts to improve quality such as the enforcement of guidelines, the pressure towards the use of electronic records, attacking fraud and pursuing it. Yeah, it did cause some changes in behavior, but it's not necessarily meaningful impactful value for the patients and or the larger system. And I think this is a global problem. The COVID-19, if it showed the obscene lack of collaboration between health systems, countries, significant failures in the ability to integrate and collaborate and or support each other was a very selfish disintegrated approach at many different levels internationally and nationally and within states possibly and between health systems. It eventually brought us back to realize that we're influenced by what happens to each other and that this is a societal proposition and that we need to work together. It took some time to get there and now we're kind of back into that wavering position of how do you go about this and do we really need to do that? So I went back to see what value meant and the basic definition of value beyond healthcare is the best achievable outcome at the lowest cost. Some of you and especially maybe your faculties who are interested in the business side of medicine are familiar with the work of Professor Michael Porter who is a Harvard strategy professor. At one point in time in his encounter with some one of his relatives had a healthcare problem and he was in a hospital recognized he recognized that there are some major fundamental fractures in the way the healthcare industry approaches healthcare. And I say specifically industry because at the end of the day this is a business of some sort and how you approach it should be in a way similar to any other businesses or business ventures. So he has some seminal papers out there that has influenced a lot of these leaders in the healthcare system especially on the government side. But as you can see I've highlighted the points he speaks of a very siloed system. It is structured around supply of services. There is no particular continuum of care. There is no concept of population health and this is the last 20 years around that time is when he wrote his papers or got involved with healthcare as one of his academic ventures. And it's hard to argue against that logic. It didn't come from physicians. It came from strategy people and industry people because this is truly what was going on. We were building the case around supply of services what physicians can do as opposed to what the patient actually needed and the long-term implication of what we do to the patients and to their family and to the society at large. That was a very painful proposition though because shifting from volume and shifting from in a system that is based on fee for service was a shift from volume and profitability to value which is a reduction in volume because if you're thinking prevention of procedural medicine and prevention of surgeries and prevention of using the hospital for care you're talking about reduction in profit and that approach was complicated. And unfortunately, the decisions that will follow were based on very sound philosophical premises that we will all agree to but rather very poorly thought of strategies of deployment. So I think the value agenda was growing. The concept is let's pay for performance. Let's pay for quality. Let's focus the care around the entire continuum of care. Let's go beyond the acute episodes and let's go and focus on the patient and involve them in the decision around what we should do for them as opposed to approach them in an authoritative paternal pattern and say, hey, this is what you need to have and this is what should be done. And I have to say I had practice in that arena and trained in that arena or I'm sorry, era when we were basically telling the patient, you have to have this because this is what needs to be done, very limited conversation, very limited assessment of the other variables around the life of that patient and very little concern about the cost of what we do. Everybody was concerned mostly about the survival of the patient during a procedure and that remains a very important variable obviously but there wasn't a whole lot of agony with patients' recurrence of recurrent admissions or subsequent failures in other areas of the medical care that was missed such as their cholesterol or diabetes or smoking or what have you. So Dr. Porter spoke of aligning competition around value and basically stated that value in healthcare is the health outcomes per dollar of cost expended. And that's a very logical position to have. The problem is in the definition of what we mean in outcome and the way we think about how we should reward those who outperform and should rectify the works of those who don't. So as you see here, we will go through, I'm gonna try to go through these fairly quickly. What you see here is just a progression of some value based and alternative payment models that Medicare and other payers got interested in in the early 2000s and it escalated around March of 2010 around the Affordable Care Act. A lot of these programs are no longer in existence. It failed and it simply failed because it wasn't well thought of in my humble opinion and we will go through some of the reasons for that. But in 2004, hospital compare came about and it was about reporting the outcome of hospitals. The intent was to use peer pressure and allowed the consumer to pick based on who was performing better than the other and then choose the service or the providers based on that. And initially it was around process of care. So it was, did you give aspirin post myocardial infarction and then it moved eventually to clinical outcomes? Did you get readmitted with heart failure? Did you get readmitted with an MI? What was the mortality rate? And this was publicly reported. And yeah, on the premise, this makes perfect sense. And the way this was handled was still around fee for service. There were some penalties if you didn't perform well. This was followed shortly thereafter with the hospital readmission reduction program where 3% of the reimbursement of hospitals were actually at risk in case of heart failure and myocardial infarction specifically. And along the same path came the value-based purchasing which was deemed to be an effective program because it was basically budget neutral. So it was passed without any difficulties. The intent was to withhold money and move it around to the hospital that outperformed others and basically indirectly penalized the others with cuts and payment. To disrupt the fee for service, other alternative methodologies of payment were considered. Accountable care organizations are basically integrated networks of hospitals and physicians. They were to assume risk for quality and cost. And in return, they would get rewarded or penalized. And similarly, the bundle payment care improvement programs were intended to address specific episodes, usually say a myocardial infarction or an ammonia, follow the patient over a period of time and basically share back any profit that can come from a proper and effective care versus reduced the payment to the hospital because the hospital went basically beyond what it was supposed to do. The physician enterprise and physician practices were also affected by these programs. So there were physician quality reporting, value purchasing, two tracks for payment were established after under MACRA. One was the incentive payment program and the alternative payment programs. And this is basically, for us, it was around the time when the electronic medical records has come about. So it was working around the meaningful use, the effectiveness of communicating with the patients on the cost of care and the data was collected. And in a way, you were forced to do that because if you couldn't report, you would be penalized. So I chose this word carefully, but I do believe a lot of these initiatives were performative initiatives. And there is periodically some sort of a wave that comes in. I see now the American College of Cardiology and the American Heart Association and a lot of other societies pursuing now the social determinants of health and equity in healthcare. This has just become the new fad, I feel. And around that time, 10, 15 years ago, the big thing was quality and value. It seems that it's always derived by people who are interested in the ideas and the philosophies, resumes gets built, startups get started and get bought, new programs are initiated, and the people that were supposed to be served by these initiatives are exactly where they are 20 years later. And in most of the time, actually these programs, when we're reviewed, so we'll go back now to the value-based purchasing and quality improvement and alternative payment models. These programs had, based on the evidence, and I quoted here peer review journals. So these are not some fringe assessment or some political hacks, speaking about the government taking over control the healthcare, but rather these are scientific papers that looked and saw that none of these measures or interventions had worked. And in fact, what we see, for instance, in the hospital reduction program, an increase in the gaming of how you code, then I actually find myself repeatedly in this position. I do structural procedures and I'm always thinking, how do we code properly so that we're not penalized? And what that means, basically, we're lowering the bar. We're thinking beyond what we were supposed to think about. That's how I see it anyways. It's like saying politicians are known to lie. That's just a normal thing and we laugh it off. We don't hold them to higher standards and we don't expect politicians to perform as real leaders and representatives. Well, similarly, now we're thinking of value as a gaming thing and we just have to know how to report properly and how to get around it as opposed to how to fix it, because again, the measures and the initiatives weren't aligned properly. And I think the value of that was tremendous because millions and millions of dollars, if not billions, were spent to know avail and no success. In fact, some of these programs were associated with increase in the mortality and maybe that's not necessarily true, but at least this few papers are documented that patients were sent home early or were advised not to be admitted and pushed away from the hospital and end up dying more likely than... And so there was no value to the patient, which was supposedly the center of these initiatives. Furthermore, and it depends on how you approach this, some of these programs actually penalized the hospitals that were considered to be the safety net for patients because their patients were more complicated. And now today we talk about the social determinants of health and the implications of having no gas money to get to see your doctors or being unable to afford certain medications or having no access to specialists and these initial quality improvement initiatives did not take that into account. So the implications were your hospital is not performing well, your patients don't do well, your hemoglobin A1C is not on par so you're gonna get penalized. And what that did is basically destroyed actual smaller hospitals in rural areas, physicians who were actually fighting the good fight, attempting to improve the outcome of very complicated patients' population to no benefit to the patient or to the system eventually. So now I'll stop talking about the value-based and move now to point number two, which is the case that I'm trying to make, which is that we have to get involved now. The good news is a lot of these programs failed. The bad news is the logic behind these programs was actually sound and healthy and we were supposed to pursue to improve the way we deliver healthcare. And I could be wrong, but I feel that the voice of the, and I use this word carefully, the working physician, so you can have an MD and an MBA and provide some suggestions about how you deliver care. But if you're not connected to the intricacies of how you practice in your hospitals, the shortages of in staffing, the complexity of electronic medical records, how we're doing the meaningful use of these electronic medical, how are we achieving the continuum of approaching that patient from hospital till the days that follows in the outpatient setting? If you're not involved, your plans will come just like Dr. Porter's, very non-specific, philosophical, we will all agree to it, but it's not practical or tangible. The motivation was cost reduction. It had nothing to do with the patient's well-being and I'll make another important thing, the physicians and providers will be. All it did is cause more burnout. It pushed everybody to the brinks. It taught us how to use the electronic record by clicking in certain places to ensure that we talked about smoking and we did address the high blood pressure, even if we didn't, because it was performative at the end of the day. And what we did not understand, I guess at that time, or those who came up with these propositions, did not understand is that there are more complicated variables around care delivery that goes beyond a certain number of blood pressure, that is, or a certain medication as for post-myocardial infarction. There are limited resources. There's ongoing pressure and demands and the patient complexity continues to increase and the technology is not necessarily helping, it's just adding more, many more layers where we could do stuff, but I'm not so certain that it's impacting the long-term of the patient. Think of TAVR and this is a common question we always have, patient could be demented in a nursing facility, very limited quality of life and yet an argument is being made, let's just do TAVR. A patient come in a cardiogenic shock, crashing 50 pressers and somebody says, well, but the mitral valve is leaking, we can attempt a mitra clip and the patient dies five days later. So yeah, I mean, we're supposed to take care of patients but we have to be thoughtful and we have to approach this as a team and we have to take into account and this is not because the government wants us to do it or the payers, they clearly failed and their objectives were post-reduction, not patient care. So eventually the physicians have to say this is for the patient care specifically, for the better patient outcome specifically and it's driven by our stewardship of resources and our interest in providing a value to this patient. So with that in mind, I think I'll make a, and I hope in the ground rounds there might be non-cardiologists but I'm obviously biased. I feel that the cardiovascular specialist is uniquely positioned to demonstrate and to lead the value initiatives in any organization. We work in a very unusual dynamic, we're in hospitals and we're in offices, we're proceduralists and we collaborate with surgeons. We deal with patients in the very early stages, you have those who deal with genetic abnormalities and cardiomyopathies and we take the patient through that, continue from prevention to palliation. We're moving now from hospital to ambulatory to deliver services. We've led a significant amount of technological revolutions especially people like you guys coming out of one of these leading institutions in healthcare and in science. And these are opportunities because A, it increases the patient longevity and gives them value but it also has opportunities around supply chain around cost savings. And I think the key here is that the cardiovascular physician is should get involved and should be influential in the future ventures because the good news as I said some of these attempted, although some of them are still operational some of these quality interventions by government and payers went away just because they couldn't do it right and it failed but some of them are still operational and the reality of it is that this is something we have to contend with and deal with because the cost of healthcare and the implication of that to the national budget and to the survival of our systems healthcare system. So then from there I'll move to the I guess how we would approach it as cardiovascular specialist if we were working doctors. And I think the dyad model of leadership. So I've been in this post for 12 months now and I don't have a dyad leader. I've had to make this case repeatedly to my boss and I think sooner than later it will be approved. I do think that this joint venture between working physicians and administrative dyads to anchor them to reality. So I tend to think about things that are sometimes in my mind as a physician should happen right away or why can't we do this or that or why don't we pursue this or that but in most of the time the administrative side of the operation knows the complexity and she and he can tell you, well, you know, we need to work around this particular part of the organization or around this particular law. And I think that yin and yang in collaboration is the key to success in leadership because they are complement each other as leaders and they can speak to a specific common vision that can lead the organization in the right direction. And this was actually something I found in the American College Council for on clinical practice is always white paper arguing for the validity of this dyad leadership structure. I state that to you because I'm going to take you now to our common spirit cardiovascular service line and how we built this as an organization using some of the concepts that I've just discussed our belief that value is important to our patients and that leadership should be physician driven or providers driven and it should be in combination with our colleagues in the administrative side of medicine or care delivery. So I'm sure most of you know this but common spirit health came about two to three years ago and non-for-profit organizations and dignity health and Catholic health initiatives came together. They have one or two common goals that they're both non-for-profit and they both share the vision of service, they're faith-based and they are however completely different organizations they don't look alike in many different ways. So this has been a very interesting journey for the organization and for those of us who are involved with the periphery in setting the strategy it is the largest if not one of the largest probably the largest cardiovascular operation today in the US and the numbers are staggering. We do about 11,000 hearts something in the vicinity of 40,000 plus PCIs. This is a year obviously 50,000 CRM procedures, 3,000 TAVRs this year or earlier this year. 2,500 left atrial appendage procedures and these are booming programs so we're seeing an increase in the growth of these opportunities. And these growth opportunities within the system. We are scattered across a very wide and the large footprint of 22 states. We have very complicated data they're not necessarily united although we're working in that direction. Medical groups of academics and non-academics community-based independence, frenemies, people that work in our facilities and work elsewhere. So we have a very complicated medical group as well just to add to the difficulties that we have. That said, to put the service line together we needed an organizational commitment to a service line concept. We needed an organizational commitment to the dyad structure. So the understanding I had when I interviewed for this post is that yes the physician's voice will be heard. I maintain a very active clinical practice intentionally because I feel that this will remove any pressure on me to do something I feel would not be appropriate for us as physicians. And it gives me the ability to say if this is not going to happen I am not gonna be able to sell it to my colleagues and if I'm not gonna be able to sell it to my colleagues I think I'm gonna have to walk and go back to my practice. I think that's important in the structure of leadership and along the same path I think the only leadership model that works is a servant leadership. So it's built in that we have to work with accountability to our colleagues. Our job, my job as I see it is to mediate, to facilitate, to align around what we think is meaningful to us as physicians and providers within the CV space. And value is very important to us. I think we spend a lot of time talking and we kind of divided around metrics of quality in our metrics of financial stewardship. But in the grand scheme of things this is as we go back and look at the value definition and that is really what it is gonna come down to quality and reduction in cost. So the dyad model is the structure I spoke of. As I said, I tend to kind of drift off the slides but this is now seen at many different levels. So in Texas, I think of Dr. Juan Carlos Plana and Don Thompson as my counterpart dyads in the Texas division. I speak to them about their needs and challenges and I communicate with them our needs and challenges to learn from them. And if you see point number three, which I don't wanna miss, I think philosophically we all believe and I think that's logical that we rely on local successes and expertise to improve the national experience. We don't come from the top say and this is how it should be done. We come to Texas and say, how do you do it here? And why is it not similarly done in say in Nebraska? And we learn from that experience and go back and forth. That's how I see the service line should work working and I think it's been so far successful for our colleagues and for our organization. So we have that dyad model across the board. We encourage it in facilities as well, a physician and a counterpart administrative leader. This is the structure of the service line. We have a governing body called the executive team. It's representatives of, so Dr. Plana and Dawn are for instance out of our Texas division. There we have all the divisions represented there. That's the governing board that I put together last year. And I go there to ask for guidance and direction and to argue some of my ideas. So that we have a divisional representation and clarity that we can do whatever it is that we're trying to do. From there, you go down to the senior leadership team and this is basically every facility and it's representative dyads. And as you can see in the very bottom, we have various, we divided councils into basically a cardiac surgery council, electrophysiology, anesthesia, vascular, structural, cardiac intervention and heart failure. I'm hopeful to start a new one called cardiology because I think we need to have a general cardiology slash imaging council. Along the same path we put together a governing body to oversee all the structural programs that we have at Common Spirit and I'll speak to their role in a second. And my biggest hope is to develop a research institute to utilize the huge amount of data that we have coming from throughout the 22 states, coming from academic institutions, from small hospitals, rural hospitals. We have a unique cohort of patients and physicians. We have a unique experience that can be number one, the best U.S. experience for any new technology to validate any study or research that was done in an academic institution, say. And more importantly, actually to influence some of these metrics that we've talked about, the social determinants of health, the equity in healthcare, how do you improve quality and value? Well, if there is any place that we should do that, it should be coming out of an organization of this size. And that's a call for action for all of my colleagues, especially those with interest in research. We have to start utilizing this data. We have to weaponize it to improve the outcome of patients and to influence decisions across the board in other healthcare organization and in government and with payers. And to that end, I think the research institute is the next step in that direction. So now I'll speak a little bit and very briefly about how we improve quality and how we influence supply chain and a financial or rational utilization of resources. So we pursue, we use data and some of you may have been very involved with this. I know Dr. Perrin leads our cardiology clinical council. So he's very involved. Dr. Chung leads our vascular council and obviously Dr. Plana and Don Thompson are very involved with the executive team. But we use the data to influence behavior. This is not something that I've invented, it's actually something I've inherited from my colleagues and CHI, my predecessor was Dr. Jerry Guinato who had put this together. And I have taken the role after him and took it back to the larger group now with dignity being part of Common Spirit. Using the data has been very influential. The data is used as an opportunity to find ways to improve outcome, not to humiliate anybody or to pressure anybody but rather to say we do better than, we can do better than this. And if people can do it this way we probably could do as well what they've done. And then trying to understand what are the challenges and how do we go about it? We do it very bluntly, the data is shared. It's national benchmarks, it's coming out of registries that we all agree to. We understand pre-hand what are the limitations of these registries and we can argue that but most of the time this has been very effective in awarding those who outperform the others. And this recognition of top performers that come with some valid and useful gains I would say. For instance, our Centers of Excellence which is a designation we give to those who outperform others are the ones that test technology for us. We were the first to drop the Boston Scientific Taver valve before it was pulled off the market. This is how we've learned from the top performers and we've improved the outcome of others. And the designation is based on the work of physicians. So I don't sit down and write these things. I actually go to the leaders and say, Dr. Silva and say, hey, I need your input in this particular committee. We're trying to look at Taver Centers of Excellence. We have basic requirements to enter. At the very bottom you see these measures are necessary and it's related to one is volume which is based on the national coverage determination. There is a specific volume you have to meet. Then from there you go to in-hospital mortality a metric that the physicians have chosen. You need to at least meet the basic requirements to enter to be a top performer there. And then from there we decide what are the quality metrics that we look at? At one point in time it used to be ICU length of stay. We removed that because nobody goes to ICU now. We keep moving and pushing the dial on the quality metrics and the stewardship metric to improve the outcome. And in every year we refine this data and every year we're ambushed by how many people can meet the criteria and we have to tighten that and we keep pushing it to improve quality. The physicians play a major role here and they decide what metrics and how do we achieve it? So this is basically the structure of this. Since I've been mentioning Dr. Plano a lot you might think that he had bribed me to do so but actually Dr. Plano has been very influential in a lot of these activities. So I'm gonna mention him again. He was one of the founders of the Structural Heart Clinical Council that initially used to be called the TAVR Council and it oversaw just basically the TAVR programs and we moved it now to oversee all of our structural programs. Applications are usually also looked at for any new programs and every program irrespective whether they're top performers or average performers are reviewed. We review them based on again at the NCD for instance I'm choosing TAVR here as an example, TVT registry and the NCDR TVT registry and these metrics are refined as I said but in most of the time it's very basic expectations of performance and if someone falls behind we usually expect them to give us some sort of an action plan to go and understand the root causes of their failure be it an increase in mortality or stroke or what have you and come up with a reasonable proposition for us to say hey this is what we're doing this is our action plan and that would allow us to continue to pursue that program and follow them and see if their quality improves and a lot of these domains have been demonstrated repeatedly that we're actually able to influence behavior just by sharing the data with the physicians and by maintaining some mild peer pressure towards improving outcome. So you see here this is a composite endpoint to the right that combines a lot of the meaningful TAVR specific and again I'm using TAVR as just an example TAVR specific complications and or obviously mortality and you see that we've altered the course we've had some fluctuation but we're shifting in the right direction now this is for the larger cohort and we share with every program their data with everybody else so you can see everybody's data there in mortality and volume in moderate sedation and there is a definite impact from sharing that data the meetings are usually conducted right now in Zoom every physician is looking and seeing their program they go back and some of them will ask how did you guys get around this problem we seem to have an issue with stroke and this conversation usually leads to what we call the shared learning experience where people start teaching each other and occasionally would lead to some protocol development and we learn from other programs that they have institutionalized some sort of a process that they can use in other facilities and we can replicate the same experience. So I feel that the key point for our success and the CVS service line are on quality is that we've actually dependent completely on the physician's input. Our objective is to develop protocols and guidelines that sometimes have been very helpful when we share them in improving the quality in other programs we recognize excellence and we had moved this objective for the last five years and now we're looking at actually this year at an addition to TAVR isolated cabbage tier the appendage occluder procedure and mitral valve repair surgery and PCI now we're looking at the aortic valve surgery as well. So we continue to push this envelope and the hope would be in my mind that one day we will have centers of excellence of cardiovascular care. So if you met say out of six or seven procedures you met say five of those and as a top performers that we recognize you as the hub the center for our research for our technology evaluation for our leadership across the board for the national organization that would be the source for talent a center that is known for that. And obviously we advertise for that and this is a good marketing tool to some extent. So I think I made it towards the end successfully. This is my last slide. I ask myself every day what it is that we should do better. I do wanna move away from we still have a lot of work to do around operational efficiency but I do wanna move away from that towards what represents us as a brand what is our competitive advantage? I spoke about research. I think that's a unique I know it's not common for community-based hospitals and the majority of our hospitals are community-based to think of research as a tool but I do think that's something unique to us. We can, and I think you understand that piece more than others. This will be one of the potential pillars of our competitive advantage. The other piece being our involvement with the most vulnerable of patients being non-for-profit. So we have the advantage that has been recognized by a lot of the industries and other by government agencies that we would be the ones who should influence policies. And so I see advocacy as our next move as well and getting involved with population health. I'd like to move away from being a recruitment center. This is one thing I see. I'm not a researcher or a scientist but all I see in common-spirit research is we started the clinical trial under the leadership of so-and-so and we recruited 800 patients. I wanna see podium level research as I say. I wanna see my common-spirit colleagues doing what you guys do at Texas Heart and I wanna see the Texas Heart Group lead that and even have a larger audience by saying we don't just give you the Texas experience we give the US experience. We let this research and had other institution tag along. And obviously there are other areas that are related to our operational efficiency such as improving the way we deliver care and maybe moving from hospital to the ambulatory space. That's a complicated conversation obviously because we're a hospital system but I do think it's, as I said, the change is coming and we just have to get with it. That's the way the world is going to go. And I suspect we will be moving in that direction strategically in the CV service line and along the various disciplines of CV.