Welcome to the Becker's Healthcare podcast.
I'm Elizabeth Gregerson, a reporter here at Becker's,
and I'm thrilled to interview today doctor Norma
Keller, chief of cardiology at NYC Health and
Hospitals Bellevue
and also the system wide cardiovascular lead for
NYC Health and Hospitals
on the podcast today. Doctor Keller, thank you
so much for joining me. I'm so grateful
you took the time out of your day
to share your insights with our podcast audience.
Thank you, Elizabeth. It's
a pleasure.
Before I dive into my questions, if I
could ask you to just kind of give
a brief introduction of yourself and your organization,
that would be great.
Yeah. Fantastic. So,
you already mentioned that I'm the chief of
cardiology
at Bellevue. And,
Bellevue is, the flagship hospital within the larger
New York City Health Plus hospital system, which
is the largest municipal hospital in in the
country.
So that has its challenges as as well
as,
its amazing features as well in terms of
what we can accomplish
for, not just our Bellevue patients, but the
entire system.
I've been here for for many years since
an intern. So,
Bellevue is and and public health care is
is really in my DNA,
and and love,
being part of this amazing mission that the
system has.
I'm also,
associate professor of clinical medicine at NYU, and
I do, teaching as well
and and direct,
one of the clerkships, the critical care clerkship
at at NYU School of of Medicine.
Perfect. Thank you so much. I'm grateful to
be able to kind of elevate your insights,
you know, not just in cardiology, but public
health as as well.
I think to kick us off, I'd love
to start
kind of with the topic with cardiovascular
prevention and screening and and how that is
a is a strategy in and of itself,
right, as part of cardiovascular
care.
How do you, from your position,
try to get
those goals
for screening prevention
to align with broader system level goals?
Yeah. In our system, it's it's pretty easy.
Our our main,
mission is to provide equitable care to, all
folks who come to our system or in
New York City,
regardless of their ability to pay or any
any social social or cultural,
barriers or characteristics they might have, which is
really liberating
as a provider.
And it includes emergent inpatient
care, which is a huge focus. And sometimes
we forget,
about preventive, but that's actually one of our
the core values
of our system is is to also promote
health.
And it's so important in cardiology given it's
the number one killer of,
both men and women.
And so it's not just a focus at
Bellevue, but throughout the system.
I think Bellevue plays a key role because
some advanced preventive care can be can be
delivered here, and all patients within the system
have access to Bellevue.
So when we think about Bellevue, we're we're
our patients are are not just those that
walk through our doors, but also that are
referred
here, and we we think about them in
in the same way.
So just for an example,
our prevention program has
advanced high blood pressure
evaluations
and support. So So for for folks that,
might be having a a difficult time or
have a complex diagnosis, they can be referred
here. And we could see them here, care
for them, and then we collaborate with their
clinicians
at their their home hospital pretty pretty seamlessly.
Perfect. Yeah. I love how that's kind of
it's already integrated into the system level goals.
So it's it's not as hard to balance.
How do you feel safety in the hospitals
or health systems, you know, on the flip
side of the coin so on the opposite
side from prevention and screening,
there can be, you know, these innovative cardiology
procedures and new technology.
How,
from your perspective, can safety net hospitals, health
systems
adopt those types of innovative
procedures or invest in that type of technology
while still balancing, you know, financial risk, reimbursement,
equity considerations?
How do you juggle all that?
Yeah. That's a huge challenge and a challenge
that that we faced,
in our system.
And, it could be very difficult, but I
think,
the best answer to that is,
I think you have to provide it with
a within a system just so that there's
equitable equitable care for for these patients.
And the best way to do that is
to just recognize that
every hospital doesn't have to do everything. In
fact, it's probably not in the best interest
of quality of care. You don't really wanna
have
10 different experts in a in a niche,
intervention or technology.
You the system can invest in,
that technology
in one facility
and have that,
expertise
at that one facility, but make sure
that patients at our sister hospitals have access
to that care pretty seamlessly.
And that creates,
and that really requires,
strong collaboration
between
the the, main hospital that has a technology,
which currently is is Bellevue,
with each of our our sister facilities and
having a bilateral
communication
and,
process for access for their patients.
I think that's probably
mitigates the financial
risk.
And and I think it also ensures
quality of care since
a lot of this technology and
innovative cardiology procedures really are, another skill set
that needs to be,
cultivated.
Right. Okay. Perfect. So, yeah, it's kind of
investing in, you know, those procedures and technologies,
but doing it mindfully, intentionally, and, like you
said, with NYC Health and Hospitals kind of
centering that at Bellevue, but providing access to
the whole system,
through collaboration and integration. Does that sound right?
Yeah. No. That's exactly right. Perfect.
So
in the same vein of, you know, cardiology
service lines and and the tensions that they
face,
when it comes to high margin interventional
growth and then upstream prevention strategy
strategies
that, you know, could have the potential to
reduce that procedural volume long term. Are there
competing incentives there? How do you reconcile or
navigate those within,
you know, one system?
Elizabeth, that's a great question and certainly a
challenge because,
preventive procedures
or you don't really see the financial,
reward for preventive cardiac
maintenance. So I think that that's a real
concern.
So I think in order to address that,
it there really needs to be a shift
in in philosophy,
with,
finance,
administrators, and and clinicians
as well as legislatively
as well. And I think it's important for,
us to advocate for legislate to ensure that,
preventive health care is is valued and and
reimbursed.
One example of of that is
cardiac rehab, which is really important, and it,
has really,
demonstrated positive
outcomes for for patients who have heart failure
and MIS and cardiac procedures.
But,
you don't really see the financial gain of
that. It's
it's resource intense and it's not highly reimbursed,
but,
it prevents readmissions,
improves,
quality of life tremendously,
and and and has even harder
endpoints.
And,
the American College of Cardiology and other organizations
pushed for legislation to just to make sure
that that could be reimbursed and it's now.
So I think it's,
it needs to be attacked at multiple levels
from, a finance perspective, a legislative perspective, insurance
perspective,
and then a a different philosophy
for for providers.
Got it. Yeah. And thank you for using,
you know, cardiac rehab as as an example
of of that. I can't tell you how
many times it comes up
in my coverage
of just seeing the benefits and the long,
you know, the long term downstream benefits of
it.
So I think it's a perfect example to
kind of model, you know, like we said,
those
competing incentives and and balancing it all. Mhmm.
For my final question and to kind of
wrap things up for us, you know, our
audience is hospital and health system leaders,
some from public health systems,
academic medical centers. You know, we've got the
whole audience there.
From your position at NYC Health and Hospitals,
what do you feel are some
of the most or maybe one of the
most commonly misunderstood
operational
or financial realities
of running a cardiology service line specifically
within a public health system?
Another
great question. Mhmm.
I think the biggest,
misconception is probably
there's a futility or feeling like it's impossible
to,
stand up programs that are very resource intense
yet
really beneficial for for cardiovascular
patients.
And I think a good example of that
is ECMO,
both,
BV as well as as VA ECMO. We
we have a a comprehensive
program here that's a little bit
unique,
and developed because we are in a a
public health system. But it took us a
long time working with finance and administration
and and our our cardiovascular,
team
to,
develop a program that was gonna be viable
and sustainable
just because the equipment is expensive.
The tech, the expertise,
needs to be, provided,
and multiple different disciplines need this expertise. So,
it it's quite intense in terms of of
resources.
But,
I think if you have the right people
at the table and you can articulate
the the benefit,
it can be done in a public health
system with and I think, again, you it
can't be done at every single hospital, so
you really have to have
a central hub
that other systems really,
can engage and access
quickly.
We stood up our ECMO program actually during
COVID
Wow. Or it was critically needed just the
the, veno venous portion of ECMO.
And thank god we we did that and
we're able to do that, because we were
almost at the point of of initiating it.
And that turned out to be just so
so valuable for our patients who are other
otherwise would have would have died during the
the pandemic.
So I think that's the probably the the
the,
clearest example that I can give as something
that is takes a tremendous effort to stand
up within a public hospital or a system,
but can be done with the right people
at the table,
and and a unified
vision.
Even something as simple as cardiac rehab is
is hard to stand up within a public
hospital system as well because it's not highly
reimbursed and because you need different disciplines for
it to be really comprehensive
and effective,
but that too,
can be done and be successful.
We have a a comprehensive program here that
we started a couple years ago that is
highly successful, and there are hundreds of patients
down the waiting list.
So we are working with our other sister
facilities to see how we can have satellites
or provide this access, broader
than, just at the at the our main
site.
I think it's also important for, cardiovascular
leaders to think about new technology that's coming
out and and knowing the landscape and devising
a plan to make sure that all our
patients have access to that. Another example of
that was our structural heart program led by
doctor Harari here, which we started,
several years ago. And now we can have,
our patients within our system
have a nonsurgical
replacement of the aortic valve TAVR, which is
a great
modality and growing indications.
And now that our patients have access to
that, I think that's really important as well
as other structural heart,
procedures.
So it'd be wonderful if more public hospitals
were able to provide that,
comprehensive,
vascular care to patients as well.
Absolutely. Thank you for giving those two, you
know, concrete examples. I think they perfectly
encapsulate, you know, what you were saying of
of kind of that misunderstood mindset of, oh,
it must be impossible
when it's not. So,
as always, I appreciate you, you know, taking
the time to share your perspective and your
insights, and and thank you so much for
joining me today. It's been a great discussion.
Thank you. It was a pleasure. Thank you,
Elizabeth.
Perfect. And I invite our listeners to tune
in to more podcasts from Becker's Health Care
by visiting our podcast page @beckershospitalreview.com.
Thank you again, doctor Keller. Hope everyone has
a wonderful rest of their day.