The cardiac wars among Connecticut hospitals are back.
Nearly a decade after the state’s larger acute care providers competed fiercely to block smaller competitors from offering emergency angioplasty services, a new wrinkle in the fight over the procedure that helps restore blood flow to the heart for patients with blocked or narrowed arteries has emerged.
In the past 14 months, four community hospitals have asked regulators for permission to begin offering elective angioplasty, which was once thought to be too risky to perform at smaller hospitals that lack in-house open heart surgery capabilities.
But new research that suggests those safety concerns were exaggerated — and technological advances that have made the procedure much simpler — have small Connecticut hospitals racing to get in on the elective angioplasty business.
And in some cases they are drawing fierce opposition from nearby competitors looking to protect their market share.
Recent bids by Greenwich and Norwalk hospitals to add elective angioplasty were fiercely opposed by Stamford Hospital and several neighboring New York hospitals. Farmington’s John Dempsey Hospital is raising red flags over The Hospital of Central Connecticut’s proposal to get in on the business.
With hospitals charging $10,000 to $12,000 per procedure, millions of dollars in revenue are at stake, heightening the competitive tension at a time when hospitals are already experiencing financial pressures from state and federal government funding cuts.
“The studies show doing elective angioplasty without surgical backup can be done safely with no different outcomes,” said Dr. Justin Lundbye, the chief of cardiology at The Hospital of Central Connecticut. “That stance has opened up a lot of opportunities for hospitals that want to offer it.”
Angioplasty has been around for decades, but new technology has made the procedure less intrusive than it used to be, Lundbye said. The procedure involves inserting a thin plastic tube through the groin or arm to deliver a stent — a thin mesh like tube — or balloon-tipped catheter into a blocked artery to help open narrowed passageways to the heart.
Many Connecticut hospitals offer the service in emergency situations, when the life of a heart attack patient is on the line. But only larger hospitals with in-house cardiac surgery services have traditionally been allowed to offer angioplasties on an elective basis, which is where the majority of the patient base exists.
The thinking was that patients needed access to open heart surgery in case there were complications with the procedure.
In the last few years, however, multiple studies, including one published by the American College of Cardiology, have indicated that non-emergency angioplasty is as safe at hospitals that don’t offer open heart surgery as it is at hospitals that do offer it.
The new findings have led Greenwich, Norwalk, and Lawrence + Memorial hospitals, along with The Hospital of Central Connecticut to each submit applications in recent months with the state Office of Health Care Access (OHCA) to add elective angioplasty.
Regulators have already rejected Greenwich Hospital’s bid, but Lawrence + Memorial Hospital in New London got the go-ahead and has already performed 11 successful procedures.
Officials from hospitals vying to add the nonemergency service say the expansion will allow patients to get access to care closer to home, prevent delays in treatment and reduce overall health care costs by cutting down on duplicative diagnostic testing.
Competing hospitals raising opposition say access to elective angioplasty services isn’t an issue and that allowing new players to enter the market will just dilute their patient bases and create financial hardships.
Dr. Mike Summerer, the CEO of John Dempsey Hospital in Farmington, said his hospital could lose up to 100 patient visits and $2 million in annual revenue if The Hospital of Central Connecticut in nearby New Britain is allowed to start offering elective angioplasty.
Fewer patients would also mean fewer education opportunities for cardiovascular fellows at the teaching hospital, he said.
“It would have a significant financial and educational impact,” Summerer said. “We find the whole trend troublesome because it will dilute the patient experience around the state.”
But Lundbye said The Hospital of Central Connecticut is already providing up to 100 angioplasties per year to patients in emergency situations and so it makes sense for the hospital to be allowed to extend the service on an elective basis, especially when the science now says it is safe to do so.
Lundbye said he also believes the impact on John Dempsey’s patient base would be much less severe.
Currently elective angioplasty patients at The Hospital of Central Connecticut are sent to either Hartford Hospital or John Dempsey Hospital for treatment, Lundbye said. Hartford Hospital, which is affiliated with The Hospital of Central Connecticut, is supporting the service expansion.
There are financial benefits as well.
If they get regulatory approval, The Hospital of Central Connecticut will likely double or triple its angioplasty patient base over the next few years, adding $2 million to $3 million in new revenue, according to financial documents filed with OHCA.
Since the hospital already has the full-time staff and equipment in place, there would be little to no capital costs as well, Lundbye said.
“If we are not allowed to offer this, we are doing a disservice to patients,” Lundbye said.
The decision to allow community hospitals to add elective angioplasty, however, isn’t just about safety and effectiveness. Financial considerations and access issues are also taken into account. Hospitals must prove to regulators that there are unmet needs for the service in their geographic footprint.
In the southwest corner of the state, fierce battles have been waged over that issue when Greenwich and Norwalk hospitals put in bids to add elective angioplasty last year.
Both hospitals drew rebukes from Stamford Hospital and neighboring New York hospitals. Greenwich Hospital saw its application get rejected by OHCA, while Norwalk is still awaiting a regulatory decision.
Scott Orstad, a spokesman for Stamford Hospital, said the hospital put up opposition because there is no shortage of suppliers in Fairfield County and that angioplasty volume has been declining both nationally and in Connecticut in recent years with no sign of the trend reversing itself.
Since 2003, the number of emergency and elective angioplasties performed in Connecticut has declined by 22 percent going from 8,169 procedures to 6,350 procedures in 2011, according to the Department of Public Health.
As the only provider in the area with surgical back-up, Orstad added, Stamford Hospital also has the clinical resources needed if a complication arises during an angioplasty procedure.
“With patients already having ample access to high quality full-service cardiac hospitals in our service area, Stamford Hospital believes there is no need at the present time for additional elective angioplasty programs in lower Fairfield County, especially ones that do not offer on-site surgical back-up,” he said.
Dr. Christopher Howes, Greenwich Hospital’s cardiology chief, said he was disappointed by OHCA’s decision and that opposition to his hospital’s bid to add elective angioplasty was mainly about turf wars.
Greenwich Hospital does about 40 emergency angioplasties per year, and projected the addition of 150 to 200 elective procedures over the next few years, which would have added around $756,080 to their bottom line.
“A lot of this has to do with market share,” Howes said. “We are not going out of bounds by saying we want to do this procedure.”
In its rejection letter, OHCA officials said Greenwich Hospital failed to prove there was a clear public need for the service because there were already enough providers in the region.
In February, New London’s Lawrence + Memorial Hospital became the first Connecticut acute care provider to offer elective angioplasty without having surgical backup.
Dr. Brian Cambi, a cardiologist at Lawrence + Memorial, said the hospital’s bid was successful because there are no existing programs in the service area.
Unlike the 10-to-15 angioplasty centers that exist along the Hartford to New Haven corridor, the eastern half of the state has only one outpost, forcing residents, in some cases, to travel 50 to 60 miles to seek treatment, Cambi said.
Cambi said New London hospital started the elective service in March and has already performed 11 successful procedures. Over the next few years, the hospital anticipates its elective angioplasty patient base will grow to around 135 patients adding up to $838,473 to their bottom line, regulatory filings show.
