New Drive for More Elective Angioplasty, Community Hospitals Say Long Overdue

Lilo H. Stainton | April 11, 2018 | Health Care
Legislative reform could ease regulations governing where cardiovascular procedure can be performed — and bring economic benefits to small hospitals and their patients

Interior of the catheterization lab at Hunterdon Medical Center
Community hospitals are hopeful that new legislation and fresh leadership in state government will translate into a more permissive policy when it comes to elective angioplasty, a lucrative and potentially life-saving cardiovascular procedure that is now tightly regulated in New Jersey.

Leaders of these facilities have embraced legislation introduced late last week that would require state officials to license several dozen additional hospitals to do this work, if they could meet specific quality and volume standards favored by national experts.

These officials — who have been pushing for a policy change for more than six years — said reform would improve patient outcomes, while saving them travel time and hassle, and benefit small hospitals and their communities economically. But the issue never gained traction under the administration of former Gov. Chris Christie, in part because it could translate to a revenue loss for some of the state’s largest healthcare systems.

Leaders of community hospitals are also encouraged by the appointment of state health commissioner Dr. Shereef Elnahal, a former federal health official who has committed to using good data and expert guidance in crafting policy; hospital officials believe he will also embrace the approach outlined in the new bill.

‘…fair and equal access’

Robert P. Wise, president and CEO of Hunterdon Healthcare, which operates Hunterdon Medical Center, a leader in the reform movement, said the legislative proposal would bring them “one step closer” to offering all aspects of the procedure in their facility, which invested $17 million a few years ago to create a state-of-the-art cardiac care lab, but is still not licensed to provide a full spectrum of treatments. “Our residents should have fair and equal access to critical preventative cardiovascular healthcare right in their community,” he said.

Angioplasty involves inserting a tiny tube, or catheter, into a patient’s artery; physicians can then inject a dye and study the flow of blood, in order to diagnose cardiovascular concerns. If they discover a problem, they can use a miniature balloon to enlarge the artery or a stent to prop it open, reducing the risk of heart attack, stroke or other cardiovascular problems. (Heart disease remains the number one cause of death in New Jersey and nationwide, and stroke is third.)

But not all hospitals are licensed to provide both the diagnosis and the treatment in all situations. Under current New Jersey rules, 29 facilities — generally members of larger healthcare systems, clustered in the most populous 14 counties — are permitted to perform the procedure to restore stronger blood flow for non-urgent patients, or “elective” cases.

Another 25 locations — primarily smaller, community hospitals, like Hunterdon Medical Center, in seven largely rural counties — have the capacity to handle all aspects of angioplasty but can only offer the fix in an emergency. If a diagnosis reveals a non-emergency concern, the patient is referred to the nearest full-service facility to undergo anesthesia again and receive the treatment itself. As a result, thousands of patients each year make this trek.

Current set-up ‘makes no sense’

“It makes no sense from an economic point of view. It makes no sense from a community point of view, or a patient-care point of view,” said Al Maghazehe, president and CEO of Capital Health, which runs community hospitals in the Trenton area that are restricted to non-emergency angioplasty. “But it makes a lot of sense politically because the big systems don’t want others to have this. Because once you move elective angioplasty to another hospital, guess what, they now own that patient,” he said.

The current regulations stem from a previous belief that angioplasty should only be handled by hospitals that have full cardiac-surgery capabilities and could perform open-heart surgery if the procedure went wrong. But cardiac care has improved with the development of microsurgery and other evolutions; in 2012, researchers at Johns Hopkins University published a landmark study on the matter, confirming that modern angioplasty has a low enough risk to be offered at hospitals that don’t have the cardiac-surgery backup.

While many states used this study as the basis for revising their licensing regulations, New Jersey’s Department of Health chose another route. It allowed the 11 community hospitals that participated in the Johns Hopkins research — offering full angioplasty options without a surgery suite onsite — to continue to provide all options as part of a “demonstration project.” The state also launched a larger review of its licensing procedure that was still ongoing in November; the DOH did not respond to a request for an update yesterday.

Lawmakers from both parties have pushed the state for years to update its policy, with those who represent rural areas that have community hospitals particularly eager to expand access to elective angioplasty. Sources said many of these facilities are also hopeful that new revenue from the procedure could help offset losses they expect in state Charity Care or other government funding lines.

The new bill (S-2427) — sponsored by Sens. Joseph Vitale (D-Middlesex), the health committee chairman, and Vin Gopal (D-Ocean) along with Assemblymen Andrew Zwicker and Roy Frieman, (both D-Somerset) — would amend the state’s 1992 law governing hospital licensure. The measure has yet to be posted for a hearing in either house.

‘…unnecessary delays in treatment’

The proposal would allow certain facilities to apply for a license to perform elective angioplasty, and require the DOH to approve these requests, if the hospital met certain requirements, including performing at least 200 procedures annually. It would also exempt these facilities from going through the lengthy Certificate of Need process, which is often required as part of state licensing. The goal is to allow any qualified hospital to seek approval, according to those involved.

“We wholeheartedly believe that all hospitals in the state that have the capabilities and trained physicians should be allowed to treat cardiac patients in a timely and safe manner, rather than delaying care by transferring patients to hospitals out of the area, causing unnecessary delays in treatment,” said John T. Gribbin, president and CEO of CentraState Healthcare System, which operates a hospital in Freehold that also faces this challenge. Gribbin praised Vitale for sponsoring a bill that he said will ultimately benefit all New Jerseyans seeking cardiac care.

Dr. Paul DeRenzi is the medical director for the cardiac catheterization lab at Saint Clare’s Hospital in Morris County, another site seeking to expand its current treatment options. Physicians have performed emergency interventions at the Denville facility for the past 12 years he said, with excellent results. “Clearly, the time has come for Saint Clare’s and other New Jersey hospitals to be allowed to perform the procedure on an elective basis,” DeRenzi said.

The new bill is not the only legislation proposed to address this issue. A proposal (S790) by Senate budget chairman Paul Sarlo (D-Bergen) and Assembly health committee chairman Herb Conaway (D-Burlington), a physician, calls for the state to provide elective angioplasty licenses to certain “mentee hospitals” that are part of a larger system, as long as a “mentor hospital” is already permitted to offer all aspects of the treatment. While the bill did not name any facilities, observers believe it would benefit Hackensack Meridian Health, a powerful system based in Sarlo’s district that has partnered with Seton Hall to open a new medical school.

This measure recalls legislation introduced last fall by Sarlo and former Assembly Speaker Vincent Prieto (D-Hudson), which drew sharp criticism from the community hospitals seeking to expand the practice when it passed the Assembly health committee last fall. Several hospital officials said that approach would only extend the current system of “haves” and “have-nots.” This bill also awaits a hearing in both houses.