Heart congestion

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.