I frequently conduct small geography workshops with activities for kids in my neighborhood. We all enjoy it immensely.
In fact, the kids demand that I have a workshop every Sunday!
This map-reading activity was on 09 December 2012. Details are in the slide show.
Dr Chandra Shekhar Balachandran
The Indian Institute of Geographical Studies
http://tiigs.org
geo 'at' tiigs 'dot' org (replace 'at' with @ and 'dot' with . )
I frequently conduct small geography workshops with activities for kids in my neighborhood. We all enjoy it immensely.
In fact, the kids demand that I have a workshop every Sunday!
This map-reading activity was on 09 December 2012. Details are in the slide show.
Dr Chandra Shekhar Balachandran
The Indian Institute of Geographical Studies
http://tiigs.org
geo 'at' tiigs 'dot' org (replace 'at' with @ and 'dot' with . )
Um problema não resolvido tenderá sempre a aumentar e se multiplicar, criando outros problemas que irão agir como uma força de atrito, impedindo o livre desempenho do sistema e causando atrasos, prejuízos e perdas de qualidade.
O QualityIndex é um banco de dados que faz análises dinâmicas em tempo real, permitindo a investigação imediata de qualquer problema apontado nos gráficos, através de análises sequenciais instantâneas que irão lhe poupar tempo e gerar economias impressionantes!
www.datalink.inf.br
Overview presentation of Millennium HealthCare Inc., a company providing physician practices and healthcare facilities of all sizes with practice development & management services utilizing our expertise to identify medical practice opportunities.
NVTC Capital Health Tech Summit: Dr. Shannon KeynoteAlexa Magdalenski
The 2017 Capital Health Tech Summit took place on June 15, 2017 at the Inova Center for Personalized Health. Dr. Richard Shannon, Executive Vice President, Health Affairs, University of Virginia provided the Summit's second keynote.
Overview presentation of Millennium HealthCare Inc., a company providing physician practices and healthcare facilities of all sizes with practice development & management services utilizing our expertise to identify medical practice opportunities.
Um problema não resolvido tenderá sempre a aumentar e se multiplicar, criando outros problemas que irão agir como uma força de atrito, impedindo o livre desempenho do sistema e causando atrasos, prejuízos e perdas de qualidade.
O QualityIndex é um banco de dados que faz análises dinâmicas em tempo real, permitindo a investigação imediata de qualquer problema apontado nos gráficos, através de análises sequenciais instantâneas que irão lhe poupar tempo e gerar economias impressionantes!
www.datalink.inf.br
Overview presentation of Millennium HealthCare Inc., a company providing physician practices and healthcare facilities of all sizes with practice development & management services utilizing our expertise to identify medical practice opportunities.
NVTC Capital Health Tech Summit: Dr. Shannon KeynoteAlexa Magdalenski
The 2017 Capital Health Tech Summit took place on June 15, 2017 at the Inova Center for Personalized Health. Dr. Richard Shannon, Executive Vice President, Health Affairs, University of Virginia provided the Summit's second keynote.
Overview presentation of Millennium HealthCare Inc., a company providing physician practices and healthcare facilities of all sizes with practice development & management services utilizing our expertise to identify medical practice opportunities.
An overview of clinical healthcare data analytics from the perspective of an interventional cardiology registry. This was initially presented as part of a workshop at the University of Illinois College of Computer Science on April 20, 2017.
Cancer Diagnostics Reference Laboratory / NeoGenomics April 2014 investors company overview presentation. This presentation highlights the following:
--Fast growing cancer genetics lab servicing Oncologists, Pathologists and Hostpitals
--Strategic client partnerships created by "Tech-Only" model
--Dynamic, rapidly-growing and consolidating industry
Industry-leading revenue & test volume growth
--Strong productivity and operating leverage leading to accelerating cash flow and net income
--Strong Management Team with large cap lab experience
Presented by Mr David Fitzsimons, Clinical Specialist Speech Pathologist from the Children's Hospital at Westmead, at the CHA Conference on 24 October 2012
Opening Keynote"From Patient to Population: Providing Optimal Care - The Role for Technology"
Ronald Paulus, MD, MBA
President & CEO
Mission Health System
This presentation contains statements which constitute forward-looking statements within the meaning of Section 27A of the Securities Act, as amended; Section 21E of the Securities Exchange Act of 1934; and the Private Securities Litigation Reform Act of 1995. The words “may”, “would”, “could”, “will”, “expect”, “estimate”, “anticipate”, “believe”, “intend”, “plan”, “goal”, and similar expressions and variations thereof are intended to specifically identify forward-looking statements. All statements that are not statements of historical fact are forward-looking statements.
Investors and prospective investors are cautioned that any such forward-looking statements are not guarantees of future performance and involve risks and uncertainties, and that actual results may differ materially from those projected in the forward-looking statements as a result of various factors. The risks that might cause such differences are identified in our filings with the Securities and Exchange Commission. We undertake no obligation to publicly update or revise the forward looking statements made in this presentation to reflect events or circumstances after the date of this presentation or to reflect the occurrence of unanticipated events.
1. History and Current Status of
PCI Services in New Jersey
Charles Dennis, MD
Chairman, Cardiovascular Health Advisory Panel
Interventional Cardiologist, Virtua Health
2. Regulation of Medical Services
• Certificate of Need
– Designed to
• Restrain health care costs
• Coordinate services and construction
– Underlying assumption is that excess capacity
leads to health care cost inflation
– Exists in some form in 36 states
– Originated from the federally mandated “Health
Planning Resources Development Act” of 1974
– Repealed in 1987
– New Jersey remains a CON state
– Mechanism for approving new facilities/services
Charles Dennis, MD – November 2012
3. Certificate Of Need
Pros and Cons
Advocates Opponents
Healthcare is not a typical CON has not clearly lowered
economic product healthcare costs
Market forces do not follow By restricting services, CON
the same rules in healthcare reduces price competition
Patients do not “shop” for Prospective payment (DRG)
healthcare, making it price makes hospitals more
insensitive responsive to market pressures
CON limits healthcare costs CON programs may be subject
CON promotes appropriate to political influence or
competition institutional prestige rather
CON distributes healthcare to than community need
the economically
disadvantaged
Charles Dennis, MD – November 2012
4. Regulation of Existing Services
Hospital Licensing Standards
259 pages available at
http://www.state.nj.us/health/healthfacilities/rules.shtml
Subchapter 7 - Cardiac
Specific regulations for
Cardiac surgery
Cardiac catheterization and PCI
Electrophysiology
Charles Dennis, MD – November 2012
5. Hospital Licensing Standards
• Address
– Facilities and environment of care
– Staffing, equipment and supplies
– Quality assessment and improvement
– Scope of services
– Hospital and practitioner volume standards
– Mechanisms for review of performance
• Focus
• Volume (Facility and Provider)
• Quality (Difficult to measure)
• Do Not Address (Directly)
– Physician professional performance
Charles Dennis, MD – November 2012
6. Fundamental Concepts
DOH sets licensing standards for facilities
Facilities credential medical staff and are expected to
conform to regulatory requirements (both facility and
physician)
DOH collects performance data that assist in the
evaluation of conformance to regulations
The CHAP advises the Commissioner on licensing
standards and other issues
Charles Dennis, MD – November 2012
7. Cardiac Catheterization Services
Drivers of Expansion
There were insufficient cardiac catheterization
labs in the mid 1990’s
Demand accelerated after initial expansion of
laboratories
Primary PCI became the standard of care in the
early 2000’s
Success with Primary PCI led to demands for
expansion of Elective PCI
Charles Dennis, MD – November 2012
8. Cardiac Catheterization Program Growth Responds to Demand
12 Full Service laboratories in the mid 1990’s
Introduction of the Low Risk Catheterization Pilot Project
“Graduation” of Low Risk labs to Full Service status
Failure of a few low volume labs
Charles Dennis, MD – November 2012
9. Growth of Demand and Services
Catheterization demand grew 32% over seven years
Catheterization demand then declined, but remains 12% over base year
Market forces have rewarded successful labs and punished marginal facilities
8 labs are not meeting the 200 annual case minimum requirement
Charles Dennis, MD – November 2012
10. Primary PCI Program Growth Leads to Elective PCI Investigation
Primary PCI investigation begins in a single hospital in 1999
Efficacy of Primary PCI leads to program expansion
Question of safety and efficacy of Elective PCI without cardiac surgery on
site leads to CPORT-E
Charles Dennis, MD – November 2012
11. Growth of PCI Facilities Follows Demand
Following introduction of stents in 1995, PCI demand grew 52% to 2006
Demand for PCI fell in 2006 after introduction of drug eluting stents
Demand has been relatively stable for the past five years
Facility growth has been primarily in the Primary PCI arena, with a small
contribution of CPORT-E
Charles Dennis, MD – November 2012
12. Demand for Primary PCI Increases Slowly
Limited data for all Primary PCI
Demand has grown 10% over five years
Charles Dennis, MD – November 2012
13. Diagnostic Catheterization and PCI
Facility Requirements
Low Risk Catheterization Lab
Perform a minimum of 350 diagnostic cases by end
of second year of operation
Perform a minimum of 200 diagnostic cases
annually after the second year
Have a “normal rate” not to exceed 25%
Clinical Restrictions (recent MI, LV dysfunction)
No PCI
Charles Dennis, MD – November 2012
14. Diagnostic Catheterization and PCI
Facility Requirements
Full Service Catheterization Lab
Perform a minimum of 400 diagnostic cases
annually
No “normal rate” criteria
No clinical restrictions
Full Service Primary PCI Catheterization Lab
Meet Full Service Requirements for minimum of 6
months
Perform at least 36 Primary PCI procedures annually
Charles Dennis, MD – November 2012
15. Diagnostic Catheterization and PCI
Facility Requirements
CPORT-E Catheterization Laboratory
Meet Full Service and Primary PCI Requirements
Receive designation under competitive CON
Meet study training requirements
Perform a minimum of 200 PCI (Primary plus
Elective) annually
Charles Dennis, MD – November 2012
16. Diagnostic Catheterization
Physician Requirements
Low Risk Catheterization Lab
Director
150 procedures annually
100 procedures in the Low Risk Lab
All Catheterization Laboratories
Physicians
Minimum of 200 procedures as independent operator
Minimum of 50 procedures annually
Charles Dennis, MD – November 2012
17. PCI
Physician Requirements
Primary and Elective PCI
75 cases annually
Volume minimums are not enforced at cardiac
surgery facilities
Charles Dennis, MD – November 2012
20. Meeting Facility Requirements
2011 Volumes
Total Diagnostic Primary Elective
Surgery
Facilities Cath PCI PCI
Surgery 18 18 16 18 10
CPORT-E 11 11 10 11
Full
Service PCI 13 13 10
Full
Service 4 2
Low Risk 8 2
Charles Dennis, MD – November 2012
21. Cardiac Surgery As Metaphor
In 1994 there were 13 cardiac surgery programs
in New Jersey
In the face of rising demand, five additional
programs were approved between 1997 and
2001
Charles Dennis, MD – November 2012
22. Cardiac Surgery Program Growth Responds to Demand
Rising surgical volume in 1990’s
Additional programs approved
Declining surgical volumes since 2001
Charles Dennis, MD – November 2012
23. Program Growth and Case Decline
Average facility case volume 700 – 800 annually per program in 1990’s
Growth from 12 to 18 programs with concomitant case decline
Average facility case volume of 400 – 450 currently Charles Dennis, MD – November 2012
24. The Pain Is Not Shared Equally
2 programs have grown 5-32%
4 programs have shrunk 1-49%
4 programs have shrunk 52-62%
3 programs have shrunk 66-72%
Average decline is 50% Charles Dennis, MD – November 2012
25. BMS
Observations
•Predicting surgical case volume
decline should have been easy (stents)
•Predicting sub-prime mortgage crisis
should have been easy (Japan)
•8 of 18 cardiac surgery centers failed
to meet 350 case minimum in 2011
•Once open, clinical programs usually
do not close
Charles Dennis, MD – November 2012
26. Progressive decline in cardiac surgery volumes
Decline in PCI after DES introduction with stable volumes since
What is the expected effect of percutaneous valves?
What is the expected effect of new studies comparing CABG to
PCI with multi-vessel coronary disease?
Charles Dennis, MD – November 2012
27. The Three Legged Stool of Health Policy
Quality Access Cost
Mortality Geographic Patient
Morbidity Disadvantaged Payor
QOL Queuing Provider
Charles Dennis, MD – November 2012