Hospitals can struggle to make specialty programs safe and lucrative

Since 2022, Benefis Health System, the major nonprofit hospital in Great Falls, has sought to bring a specialty heart procedure to the vast region it serves in central Montana. The endeavor introduced an option for local patients, but it was also a competitive move to align the hospital’s services with similar programs in Missoula and Billings, according to interviews with top hospital administrators.

Along the way, doctors within Benefis recounted voicing concerns about how the health system tried to ramp up the specialty program. Three doctors who spoke with Montana Free Press said the hospital’s apparent disregard for their concerns contributed to their resignations.

Here are three takeaways from MTFP’s recent investigation.

Building a program in a rural setting is tough.

When Benefis committed to a specialty heart procedure called TAVR, it also signed on to a list of requirements set by Medicare, the federal health care insurer. TAVRs are almost exclusively performed in older patients, so Medicare is the payer in most cases.

To be eligible for Medicare reimbursement, the federal government requires a “heart team” approach that includes having an interventional cardiologist and two cardiac surgeons on staff. Experts told MTFP that TAVR cases also require specialized facilities, anesthesiologists and other support resources to build a successful program. All this requires a high level of staffing as a foundation, and those resources are called on for each operation.

Smaller hospitals may not have the resources or staffing for TAVR. In those that do, it’s a significant financial commitment.

Montana hospitals are competing for limited patients

One healthcare expert told MTFP that, in theory, health systems in Montana’s larger cities could agree to divide specialty care to reach the most patients. That’s because volume and frequency contribute to better outcomes.

This is important for TAVR because another Medicare requirement is that hospitals perform a certain number of procedures annually to qualify for reimbursement.

“The requirement is because quality of care is lower when services are done less frequently,” Gerard Anderson, a health policy and hospital finance researcher at Johns Hopkins University, told MTFP.

So while Montana hospitals are pursuing a certain number of patients and procedures to demonstrate proficiency to Medicare, they’re competing over a limited number of patients to meet those goals.

Competition for revenue often wins out.

Health systems aren’t typically rushing to collaborate with each other because there is a competitive aspect to specialty care. Hospitals want to be seen as proficient at procedures like TAVR because doing so can raise their profile as a destination for other aspects of heart care.

Benefis administrators told MTFP that, for someone living in Lewistown, for example, the commute to Billings or Great Falls is pretty similar. And once the patient decides where to receive services, they’re likely to remain with that health system for additional visits, labs and other procedures — all of which are tied to revenue.

“Once you’ve sent them away, you’ve lost that patient,” Dr. Greg Tierney, Benefis’ executive vice president of system clinical operations, told MTFP in a May interview. “So in order to maintain our heart program and our heart volumes, you have to have that full complement of services.”