The WSJ Health Blog had something on this yesterday.  From the Boston
Globe:

Heart congestion
For patients, the options can be overwhelming. Now, some doctors are
working together to reduce the confusion.

Cynthia Cooper's cardiac surgeon recommended surgery to treat her
blocked and narrowed heart arteries. But her cardiologist told her to
have a stent implanted instead.

"It can be extremely frustrating to have these different options
thrown at you," said the 72-year-old Walpole resident. "Why not meet
with all the doctors at one time? It would be much easier for the
patient."

Concerns like Cooper's are leading physicians at a growing number of
hospitals nationwide to sign cooperative agreements designed to cool
turf battles that can leave patients confused by differing treatment
recommendations and unsure about which specialist to see.

Competition for patients has become especially intense in recent years
among doctors who treat diseases of the circulatory system --
including cardiologists, vascular surgeons, cardiac surgeons,
neurosurgeons, interventional radiologists, and neurologists -- as
treatment options have increased and the lines between specialties
have blurred.

For instance, a patient with a blocked carotid artery in the neck can
choose treatments such as surgery, medication, or a stent -- which
doctors in numerous specialties now implant.

To reduce patients' confusion, increase revenue, and improve care, the
50 Beth Israel Deaconess Medical Center doctors who work in the
cardiology, cardiac surgery, and vascular surgery departments, along
with senior hospital executives, have formed an independent
corporation. For the first time, the doctors plan to share some of the
revenue they generate. They say the new Cardiovascular Institute will
increase cooperation, because they will be collectively responsible
for the institute's success.

Massachusetts General Hospital, which last year established a vascular
center in Boston and Waltham that includes seven specialties, has told
the departments involved to advertise for patients only as a group,
not individually. The center, not each department, decides which
doctors can perform procedures, based on strict criteria. Patients and
primary care doctors who do not already have a relationship with a
specialist and request referrals are assigned doctors on a rotating
basis.

At Brigham and Women's Hospital, which plans to open a cardiovascular
building next spring in Boston, doctors are negotiating cooperative
agreements among different specialties. They have agreed that, in most
cases, patients will see multiple specialists during one visit,
receive a group recommendation for treatment, and get a single bill.

"We're trying to find a way to bring doctors together, so turfs are
eliminated, and so they can pick the treatment that is really best for
the patient, as opposed to doing what they know how to do," said Dr.
Frank Pomposelli, chief of cardiovascular surgery at Beth Israel
Deaconess.

That kind of process wasn't available three years ago when a surgeon,
Dr. Ralph de la Torre, recommended a bypass for Cooper because he
believed it was the safest and most reliable option. But Cooper had
already undergone several abdominal surgeries and was reluctant to
have another operation. So she asked her cardiologist, Dr. Kenneth
Rice , for advice.

"I said to him, 'If I was your mother or your sister, what would you
tell me to do?' He looked at me and smiled and said, 'I would tell
you, you could do fine with a stent,' " Cooper recalled Rice saying.
She opted for an angioplasty, a procedure to clear the blockage from
her coronary artery. A stent was implanted to keep it open.

Several weeks later, surgeons and cardiologists discussed her case
during a meeting called Clinical Crossroads, a regular feature of the
Journal of the American Medical Association. It brings together
doctors at Beth Israel Deaconess to discuss patients who have to make
difficult decisions about treatment. Unbeknownst to them, Cooper sat
in the audience. The group overwhelmingly decided that her situation
warranted surgery. When Cooper told them she received a stent instead,
many of the doctors groaned, she said. The debate over her care was
published in JAMA in November 2004, and a follow-up article is
planned.

Cooper still believes she made the right choice: Her last checkup, two
months ago, showed the stent is working perfectly.

Beth Israel Deaconess doctors and executives are still working out
some details of the Cardiovascular Institute, which will be headed by
de la Torre. But doctors have agreed to establish standard treatment
protocols for patients to minimize the chances of conflicting advice.
For example, the institute will determine which doctors can implant
stents.

The three departments essentially will become one and will regularly
schedule group discussions before a patient decides on a treatment.

Chief executive Paul Levy said spinning off the specialties into a
separate business unit will help ensure that "patients see who's best
to see them, regardless of traditional jealousies," though doctors in
the three departments say they have been developing better
relationships over the past several years.

The most complicated aspect of the arrangement is how to share
revenue. Traditionally, insurers make separate payments to a doctor
and the hospital where a procedure is performed. Under the new setup ,
any growth in revenue paid to the hospital for cardiovascular
procedures and testing will be shared with the Cardiovascular
Institute. The institute also plans to use new formulas to share
payments made to doctors. Until now, individual departments and their
doctors have kept the fees they generate and decided how to distribute
them.

It's unclear whether such revenue sharing will spread to other
specialties.

Brigham and Women's and Mass. General have not agreed on widespread
revenue sharing among vascular and cardiac specialties. A major
stumbling block is pay disparity: Surgeons generally earn more money
than other physicians, so sharing revenue equally could reduce their
incomes. But the hospitals are testing the idea among smaller groups
of doctors. At Brigham and Women's, radiologists and cardiologists who
do cardiac imaging are pooling their professional fees, as are Mass.
General specialists who do noninvasive procedures, such as ultrasound
testing, in the vascular center.

"The best thing is to take the patient out of the middle and even the
playing field in some way," said Dr. Andy Whittemore, the Brigham's
chief medical officer.

Liz Kowalczyk can be reached at kowalczyk@globe.com.

© Copyright 2007 Globe Newspaper Company.