Brigham and Womens Hospital: Shapiro Cardiovascular Center

9-608-175
JUNE 17, 2008
________________________________________________________________________________________________________________
Professors Michael E. Porter and Robert S. Huckman and Jeremy L. Friese (MBA 2008) prepared this case. HBS cases are developed solely as the
basis for class discussion. Cases are not intended to serve as endorsements, sources of primary data, or illustrations of effective or ineffective
management.
Copyright 2008 President and Fellows of Harvard College. To order copies or request permission to reproduce materials, call 1-800-545-7685,
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MICHAEL E. PORTER
ROBERT S. HUCKMAN
JEREMY L. FRIESE
Brigham and Womens Hospital: Shapiro
Cardiovascular Center
In November 2007, Dr. Gary Gottlieb, president of Brigham and Womens Hospital (BWH), could
watch the steady progress of the new Carl J. and Ruth Shapiro Cardiovascular Center building each
day as he arrived at work. BWH cardiovascular leaders had talked about creating a free-standing,
integrated cardiovascular center as far back as 1984, and this vision was finally becoming a reality as
the July 2008 opening of the center drew closer. The hospitals Cardiovascular Council, created to
plan the new Center, was clear in its conviction that co-locating BWHs cardiology, cardiac surgery,
vascular surgery, and cardiovascular radiology practices in a dedicated facility would result in better
patient care and more efficient utilization of staff and facilities. The new Shapiro Center had
generated strong interest in Bostons highly competitive hospital community and among academic
medical centers nationally.
Nevertheless, the goal of integrated cardiovascular care at BWH remained a work in process. The
Center would create new relationships among BWHs departments and divisions and affect the work
of physicians and nurses. How the delivery of patient care would actually change, and the
implications for physicians and for the rest of the hospital, were being actively debated and certain to
evolve.
Brigham and Womens Hospital
Brigham & Womens Hospital (BWH) was established in 1980 through the combination of three
specialty hospitals in the Longwood Medical Area of Boston, Massachusetts: Robert Breck Brigham, a
hospital founded to serve patients with arthritis and other debilitating joint diseases, Boston Hospital
for Women, a womens and newborns hospital, and Peter Bent Brigham, which was founded to serve
sick persons in indigent circumstances. The merger reflected intense competition from a large crosstown rival, Massachusetts General Hospital, and declining reimbursement from private and
governmental payers. Over time, an intricate network of hallways and tunnels was built to connect
two of the three hospitals, and a new Tower Building was constructed in 1980 to serve as the hub for
medical and surgical inpatient care. While each hospital initially retained most of its operational
autonomy, BWH had evolved over time into a unified financial entity with a single management
structure.
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With 747 beds, BWH was among the nations elite hospitals, earning the number ten position in
the 2007 rankings by US News and World Report. BWH offered clinical services ranging from primary
care to virtually all medical and surgical sub-specialties with the exception of pediatric medicine.
While BWH had a broad range of service offerings, revenues were concentrated in five designated
centers of excellence: cancer, cardiovascular disease, neurosciences, orthopedics and arthritis, and
womens health. These five centers, which accounted for approximately 80% of BWH revenues, were
a key focus of marketing efforts and were supported in the capital allocation process. Unlike other
leading hospitals, such as Massachusetts General Hospital and Johns Hopkins, BWH had a limited
endowment and relied on debt for most of its financing. (See Exhibit 1 for financial statements.)
BWH was a teaching hospital of Harvard Medical School (HMS) together with Massachusetts
General Hospital (MGH), Beth Israel Deaconess Medical Center, Childrens Hospital of Boston, DanaFarber Cancer Institute, and several other local hospitals. Through its affiliation with HMS, BWH
played an active role in educating medical students and physicians-in-training (i.e., residents and
fellows). BWHs physician training programs were widely regarded as among the nations finest. As
in many academic medical centers, most BWH physicians participated in scientific research as well as
patient care. BWHs research budget consisted of over $400 million, and the hospital was one of the
leading recipients of government funding from the National Institutes of Health. BWH research had
resulted in breakthroughs in patient care including the first human organ transplant (1954) and proof
that cholesterol-lowering drugs lowered the risk for recurrent heart attack and death (1996).
In 2007, BWH had more than 12,000 employees, including 2,800 nurses, and 1,797 researchers.
BWH employed 1,604 attending physicians and 1,012 residents and fellows in training.
Geographically, BWHs campus was tightly constrained, surrounded by local neighborhoods, other
hospitals, and medical research facilities. In the past, BWH leaders had signed a pact with the city
agreeing not to encroach on the surrounding residential community whose residents were concerned
about traffic and loss of housing.
In response to growing pressure from third party payers, BWH had merged with MGH in 1994 to
create the Partners HealthCare System. To facilitate physician buy-in to the merger, each institution
was kept intact. Clinical and financial integration had proceeded slowly, although some
administrative structures had been centralized including information systems, human resources, and
finance. In 2007, both hospitals offered nearly identical clinical services, and the physician
organizations at the two hospitals remained completely autonomous. Some progress had been made
in integrating the electronic medical record systems of the two hospitals, so that physicians could
view test results and clinical notes from outpatient visits across institutions, and they shared a set of
quality and benchmarking programs. However, physician interaction across hospitals was limited.
In cancer care, BWH had a long relationship with the Dana-Farber Cancer Institute. Dana-Farber
was a national leader in comprehensive outpatient cancer care for children and adults. In 1996, BWH
and Dana-Farber agreed that they would remain separate corporate entities, but would work together
and provide coordinated cancer care by creating the Dana-Farber/Brigham and Womens Cancer
Center. All medical oncology outpatient care took place at Dana-Farber facilities, located less than a
block away from BWH. A bridge linked the two facilities. Outpatient surgical oncology was provided
within the surgery clinics at the BWH. Outpatient radiation oncology took place in the basement of
the Tower building. Some inpatient care was provided at the BWH on a dedicated floor of BWHs
Tower building that was renovated for inpatient cancer care in 1997 and licensed by Dana-Farber,
while the majority of inpatient cancer care was provided on various other floors of the inpatient
Tower in beds licensed by BWH. The Cancer Center offered multi-disciplinary care by specialist
physicians from both organizations. Medical oncologists were employed by Dana-Farber, but also
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were members of the BWH Department of Medicine, while surgical oncologists were members of the
BWH Department of Surgery.
As the Partners system evolved, BWH focused its network development activities on the southern
and western regions of the Boston metropolitan area. BWH offered outpatient services at several
locations in the Boston area. BWH owned two community health centers, which cared for the general
health needs of the local community. Two BWH cardiologists offered general cardiology services at
these sites. BWH operated a large ambulatory care center in Brookline, less than five miles away from
the BWH campus. The center was staffed by primary care and specialist physicians, including
cardiologists, all of whom were BWH employees. A new ambulatory center was being constructed in
Foxborough, MA (about 30 miles from BWH) in conjunction with MGH and would offer primary and
some specialty care, including cardiology services. Satellite locations had local site managers who
had reporting relationships to BWH senior management. Each of the clinical departments at the sites
reported up through their department chairs. All BWH sites and practices utilized the BWH
electronic medical record.
In 1998, BWH merged with Faulkner Hospital, a community hospital located three miles away in
Boston. Complex patients presenting at Faulkner were cared for on the main BWH campus, while
some less-acute services from BWH were relocated to Faulkner. This included several specialties,
among them cardiology, cancer, mental health, and gynecology. Faulkner also became the main
center for ambulatory orthopedic surgery.
Faulkner offered a wide range of cardiology services including nuclear cardiology, cardiac
rehabilitation, and general cardiology services. Attending physicians and physicians-in-training (i.e.,
residents) in some specialties, such as medicine and orthopedics, cared for patients at both hospitals.
Physicians could access patients outpatient medical records, diagnostic test results, and radiology
studies at either hospital through an integrated electronic medical record. The two hospitals used
separate electronic medical record systems for inpatient care. Three Faulkner cardiologists were BWH
employees, while the remainder was in private practice. BWH vascular surgeons also operated at
Faulkner. No cardiac surgery or interventional cardiology services were offered at Faulkner, and
patients needing these services were transferred to BWH. In 2007, BWH physicians performed over
5,100 surgeries at Faulkner Hospitalwith ambulatory orthopedic surgery accounting for 65% of the
total.
Finally, BWH had joint relationships with Milford Hospital (approximately 40 miles from BWH)
to provide cancer care through the Dana-Farber/Brigham and Womens Cancer Center, and with
South Shore Hospital (approximately 15 miles from BWH) to provide a variety of specialty services
including cancer care. While some physicians at the Milford and South Shore centers were BWH
employees, most were in private practice and did not have admitting privileges at BWH.
Organizational Structure
The BWH organizational structure mirrored that of most academic medical centers in the U.S.
Central administration consisted of physician and non-clinician personnel with responsibilities for
strategy, mergers and acquisitions, budgeting, capital allocation, space allocation, information
technology, marketing, and staffing and recruitment for non-physician staff. The hospital employed
nurses, pharmacists, technicians and other professional and service staff.
Billing for all inpatient services and outpatient services performed in a hospital setting included
two separate components: professional fees and technical fees. Professional fees were
reimbursements to physicians for services rendered. Technical fees went to the hospital to cover
facilities and non-physician services. Procedures and imaging services tended to be more highly
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compensated than cognitive-based activities, such as outpatient consultations. At BWH, professional
fees were billed and collected by the respective departments. For services performed in the BWH
department of surgery and reimbursed by government payers (i.e., Medicare and Medicaid), payers
were billed a single global fee covering both professional and technical services. The surgeon
captured this entire fee and paid BWH a monthly fee for use of BWH facilities and ancillary staff. For
government-reimbursed services performed in the BWH department of medicine, payers were billed
separately for professional and technical fees.
In 2000, a single Brigham and Womens Physician Organization (BWPO) was createddespite
significant political obstaclesthrough the merger of longstanding specialty physician groups that
had previously been autonomous non-profit organizations. BWPO was a subsidiary of BWH and
reported to Gottlieb. All BWH attending physicians were employed by BWPO. While BWH formally
contracted for physician services with BWPO, each department continued to maintain its own system
for administration and billing. Departments were beginning to streamline and combine
administrative services, but progress was slow.
Each physician belonged to a department such as medicine, surgery, or radiology (Exhibit 2
shows an abbreviated organizational chart). Most departments consisted of several divisions (e.g.,
cardiology was a division of medicine, while cardiac surgery and vascular surgery were divisions of
surgery). Cardiology was further divided into several sections, either based on medical condition
(e.g., heart failure) or treatment modality (e.g., interventional or electrophysiology). Each department
functioned as a stand-alone economic entity and had significant autonomy with respect to issues such
as patient care and physician compensation. Each department also oversaw academic activities
including research, teaching, and academic promotions. All physicians held an academic
appointment at Harvard Medical School. Academic promotions were based primarily on research
productivity, though the Medical School had also made several attempts to reward achievements as
clinicians and educators as important criteria promotion. Departmental leadership teams consisted of
a physician chair and non-clinical administrators who managed operations, personnel, and finances
for clinical, research, and educational activities.
BWH physicians were considered national leaders in their fields with many holding leadership
positions in their respective medical societies. According to Dr. Peter Libby, division chief of
cardiovascular medicine, academic physicians were motivated by a combination of pride, concern for
reputation, and desire for autonomy. While a management hierarchy was in place, change was more
a matter of persuasion than exercising formal authority.
Each department and division had a unique culture. The department of medicine and the division
of cardiovascular medicine were known for their emphasis on research and education. Most
cardiologists spent only a small percentage of their time on clinical activities, and concentrated on
research, education, and administration. BWHs department of medicine accounted for more than
half of BWHs federally-funded National Institutes of Health (NIH) research dollars, and the division
of cardiovascular medicine was a strong contributor. The divisions of cardiac surgery and vascular
surgery were also active in research, but a greater proportion of their activity was dedicated to
clinical care.
Each department and division had its own compensation structure. The department of medicine
collected a portion of clinical revenues from each division to support the departments infrastructure.
The department of medicine negotiated with each divisions leaders to determine the appropriate
percentage. Some divisions in medicine were not financially self-sustaining and were subsidized by
collections from other divisions. For example, approximately one quarter of BWH cardiologists,
primarily those involved in imaging or interventions, generated the majority of the divisions clinical
revenues. In terms of salary, the cardiology division paid physicians a salary irrespective of clinical
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output. Salaries were competitive based on the market rate of each sub-specialty and the divisions
overall financial status.
The divisions of cardiac surgery and vascular surgery compensated physicians on a fee-for-service
basis. Each surgeons compensation was equal to his or her collected revenues minus predetermined
overhead expenses for the use of office space and personnel. Radiologists were paid a base salary
with yearly bonuses based on pooled department revenues.
Partners outpatient electronic medical record (EMR) linked all primary care physiciansand
most specialiststhroughout the BWH network. The EMR included all outpatient physician notes
and some, though not all, inpatient notes. All inpatient and outpatient laboratory data and test results
could be accessed through this system. Physician orders were entered via a separate system, which
could also be used to retrieve laboratory and test results. A third Internet-enabled system allowed
radiology images and reports to be viewed by any BWH physician or nurse. All of these systems
could be accessed by physicians once inside the BWH firewall.
Cardiovascular Care
Cardiovascular disease included abnormalities of the heart, its blood vessels, and peripheral blood
vessels (arteries and veins). (See Appendix for a glossary of terms.) In 2007, the American Heart
Association estimated that cardiovascular disease cost Americans over $280 billion in direct costs for
a total of $430 billion including lost productivity. Heart diseases accounted for approximately 64% of
the total.1 Common heart diseases included high blood pressure, heart failure, coronary artery
disease, and cardiac rhythm problems. Electrophysiology was a growing cardiology subspecialty that
dealt with abnormal rhythms, such as atrial fibrillation. Improved care for heart attacks had led to
higher survival rates, which increased the subsequent incidence of heart failure and rhythm
problems.
Primary care physicians (PCPs), cardiologists, interventional cardiologists, cardiac surgeons,
vascular surgeons, diagnostic radiologists, and interventional radiologists all participated in the care
of cardiovascular patients (see Exhibit 3 for description of cardiovascular disease and specialization).
Primary care physicians (PCPs) participated in the diagnosis and care of cardiovascular patients
but referred most cases beyond easily controlled hypertension to specialists. PCPs would often
resume care for patients once a specialist had provided a diagnosis and defined a care plan. If issues
arose, the PCP would then refer the patient back to the specialist.
Cardiologists were physicians trained in internal medicine who obtained additional training to
diagnose and treat virtually all cardiovascular diseases. They cared for patients in both hospital and
outpatient clinic settings. Approximately 2% of U.S. cardiologists worked at an academic medical
center, 64% worked in private practice, and the balance worked at government centers or various
other types of group practices.2 Cardiologists maintained continuity of care for most of their patients
through routine outpatient appointments. Diagnoses combined clinical acumen and sophisticated
diagnostic tests, such as nuclear imaginga way to evaluate heart activity using radiotracers injected
into the vein. Some cardiologists interpreted imaging studies of the heart and blood vessels. Most
treatment by cardiologists involved pharmaceuticals.
Interventional cardiologists were specialized cardiologists who performed minimally-invasive
procedures using imaging equipment to diagnose and treat cardiovascular disease. Angiography (i.e.,
x-ray of blood vessels after the injection of contrast dye directly into the vessel), angioplasty (i.e.,
balloon dilatation of vessels) and the insertion of metal stents were techniques used by interventional
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cardiologists in the heart and extremities. The impact of rapidly improving imaging technologies
such as CT angiography on the volume of diagnostic angiograms was uncertain. Conventional
wisdom suggested the need for angiograms would decline.
Electrophysiologists were sub-specialized cardiologists who diagnosed and treated abnormal
heart rhythms (i.e., arrhythmias) caused by electrical problems of the heart. They performed a variety
of minimally-invasive procedures including pacemaker placement and ablation of abnormal heart
tissue.
Cardiac surgeons were surgeons who specialized in the heart, heart valves, and heart vessels.
They used traditional and minimally-invasive surgery to treat disease. Coronary artery bypass graft
(CABG) and heart valve replacements were the two most common surgeries they performed.
Vascular surgeons performed surgery on all blood vessels except heart vessels. Bypass surgeries and
carotid endarterectomies (i.e., surgery to clear blockages in carotid artery in the neck) were their two
most common surgeries. They also used angioplasty and metal stents to open narrowed arteries of
the extremities and performed minimally-invasive procedures to repair enlarged arteries (aneurysms)
by placing grafts within the artery. Improvements in angioplasty and stent technology had led to a
slight decline in cardiac bypass graft surgeries.
In radiology, diagnostic radiologists were involved in the diagnosis of cardiovascular disease
using advanced imaging techniques such as ultrasound, computed tomography (CT), magnetic
resonance imaging (MRI), and nuclear imaging. Some radiologists specialized only in cardiovascular
imaging, while others interpreted imaging studies of various body systems. Imaging the heart
required specialized techniques and technologies to correct for heart motion.
Interventional radiologists were radiologists sub-specialized in minimally-invasive procedures
using imaging equipment to diagnose and treat a wide range of diseases, including diseases of the
peripheral vessels, liver, and kidneys. They did not care for patients with coronary artery disease or
heart problems. They used angioplasty and metal stents to open narrowed arteries and veins and
performed minimally-invasive procedures to repair enlarged arteries (aneurysms) by placing grafts
from within the artery.
Other specialists involved in cardiovascular care included anesthesiologists, who provided
sedation or anesthesia during surgical and minimally-invasive procedures, and pathologists, who
evaluated heart and vessel specimens.
The 1980s marked the beginning of a significant evolution of cardiovascular care. The
proliferation of pharmaceutical treatment options made it difficult for surgeons to oversee the totality
of their patients care, as had been common practice. Instead, surgeons began to rely on cardiologists
to manage the medical issues while they focused on surgical intervention. This symbiotic relationship
created a natural union between the two specialties.
During the same period, interventional radiologists and cardiologists began to pioneer minimallyinvasive techniques (i.e., angiography and angioplasty) that could be used to treat the same diseases
of the heart historically handled by cardiac surgeons and diseases of the peripheral vessels handled
by vascular surgeons. Cardiologists then developed a new sub-specialty of interventional cardiology
and began performing angioplasty of heart vessels themselves. As research proved the effectiveness
of angioplastyand because patients preferred the shorter hospital stays and recovery times relative
to those for surgerythe volume of both cardiac and vascular surgeries declined. This prompted
vascular surgeons to begin performing angioplasty in the late 1990s. Simultaneously, interventional
cardiologists began expanding their treatment capabilities to include angioplasty of peripheral
vessels.
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In cardiovascular care, numerous studies had shown that increasing procedural volumes resulted
in reduced complications and costs for cardiovascular patients. A landmark New York study, for
example, showed that hospitals performing fewer than 600 annual heart angioplasties had
significantly higher rates of procedure-related deaths.3 Other studies also revealed volume-related
reductions in cost due to increased capacity utilization and decreased time per procedure.
Cardiovascular disease was typically a major source of revenue for medical centers, and BWH was
no exception. However, changes in reimbursement and new technology had resulted in flat to
slightly declining cardiovascular revenues. Recognizing that cardiovascular disease was its largest
cost area, the Centers for Medicare and Medicaid Services (CMS) began decreasing reimbursements
for cardiovascular care in the mid 2000s. Meanwhile, improved stent and pharmaceutical technology
had decreased the need for both open surgeries and repeat angioplasties. However, the number of
patients with heart failure or electrical problems was increasing, which compensated in part for the
above declines.
Cardiovascular Services at BWH
In 2007, BWH was considered a national leader in cardiovascular care, ranking third nationally in
the US News and World Report.
4 With over 25,000 outpatient visits, BWHs cardiovascular patient
volume was among the largest in the nation (Exhibit 4 provides the volume of cardiovascular
services at BWH from 2003 to 2006). Nearly 100 physicians cared for cardiovascular patients
including 56 cardiologists, 11 interventional cardiologists, 10 cardiac surgeons, eight vascular
surgeons, seven cardiovascular diagnostic radiologists, and seven interventional radiologists. Each
physicians clinical volume varied depending on his or her respective involvement in research,
education, and administration. For example, in 2006, the number of outpatients seen per vascular
surgeon at BWH ranged from 40 to 1,631.
Approximately 26% of new cardiology patients were referred by non-BWH physicians, 42% by
BWH primary care physicians or other specialists, and 32% were self-referred. Most patients that saw
a cardiac surgeon or vascular surgeon would have previously seen a BWH cardiologist, but this was
not always the case. Some patients were referred to a particular physician, while others were referred
to a division (e.g., cardiology) that selected a physician for the patient. Well-established physicians
with strong reputations typically operated at capacity based on direct referrals, while junior
physicians relied on referrals from their division.
Coordination of the initial physician consultation was handled differently by each specialty.
Cardiologists relied on a central cardiology office to phone the patient or referring physician to have
outside medical records faxed to the cardiology office. The central office would also coordinate
preliminary tests prior to the visit. Records were not typically reviewed by the cardiologist until the
patient visit. In cardiac surgery and vascular surgery, each surgeon had an administrative assistant
who performed these tasks. Surgeons preferred this method to deal with the many referrals directly
to their individual practices. Patients were referred to radiology for imaging of the heart or blood
vessels by their primary care physicians, cardiovascular specialists, or other specialists.
Outpatient clinic offices for cardiology and cardiac surgery were co-located on the second floor of
the (ASB), while those for vascular surgery were on the third floor (see
Exhibits 5 and 6 for locations of cardiovascular services prior to the opening of the Shapiro Center).
Outpatient offices for interventional radiology were in the basement of the Tower building. Private
offices for cardiologists were divided among the Tower and Peter Bent Brigham A and B buildings,
while those for cardiac and vascular surgeons were located in the Peter Bent Brigham building.
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Cardiologists and vascular surgeons set aside dedicated blocks of time for evaluating outpatients,
while cardiac surgeons often saw outpatients in between scheduled operations. Up to 50% of cardiac
surgeons outpatient visits occurred in their private offices and not in outpatient clinics.
Interventional radiologists mostly performed procedures and evaluated relatively few outpatients,
doing so in their clinic located in the basement of the Tower building.
Laboratory tests and additional diagnostic tests were routinely required following an initial
outpatient consultation. The waiting time for tests varied from the same day for blood tests to up to
two weeks for an echocardiogram. Echocardiograms, which were ultrasound images of the beating
heart, were obtained for most new cardiology patients and read by cardiologists on the third floor of
the Tower building. Stress-test nuclear imaging, a non-invasive evaluation of heart function using
radioisotopes, was jointly interpreted by radiologists and cardiologists and was located in the
basement of the Tower building.
Cardiovascular imaging performed by radiologists was located in the basement and second floor
of the ASB. BWH had dedicated an MRI scanner to cardiovascular imaging from 6 a.m. until 7 p.m.
During the overnight hours it was used by radiologists for emergency department patients. In
November 2007, BWH was one of two U.S. hospitals to begin offering cardiac imaging on a 320-slice
CT scanner, utilized 50% for cardiac imaging and the remainder for other anatomical areas such as
the chest and abdomen. Seven other CT scanners were used for cardiovascular imaging; each was
utilized approximately 15% for this purpose.
Within days to weeks of completing all necessary tests, a patient would return for an outpatient
visit to discuss the course of action with his or her physician. Depending on the complexity and
severity of disease, an additional referral to another specialisteither another cardiologist or a
surgeoncould be necessary. Waiting times to be seen as an outpatient by vascular surgery ranged
from one to two weeks for elective referrals to less than one day for emergencies. Cardiac surgery
waiting times averaged five days for elective referrals and less than one day for emergencies.
Following an outpatient consultation, surgery typically occurred within one to two weeks for elective
procedures and one to three days for urgent procedures.
Operating rooms for cardiac surgery and vascular surgery were located in the basement of the
Tower building. Interventional cardiology, electrophysiology, vascular surgery and interventional
radiology all performed minimally-invasive procedures in laboratories on the second floor basement
of the Tower building, which shared a common recovery room and family waiting room.
Approximately half of these minimally-invasive procedures were conducted on an outpatient basis.
All inpatient cardiovascular units at BWH were located in the Tower building, which consisted of
floors divided into four separate but connected pods. Nearly all surgical patients were admitted to
the hospital. Patients with advanced heart disease were admitted when acute care was necessary.
Cardiology patients were admitted to one of three dedicated pods on the 12th floor, with the fourth
pod on that floor being a coronary care unit (CCU) for cardiovascular and other patients. Inpatient
interventional cardiology patients shared a pod on the 10th floor with other medical patients. Cardiac
surgery patients filled the entire eighth floor, which included a cardiac surgical ICU. Vascular
surgery and interventional radiology inpatients were spread throughout the Tower building. When
these patients required imaging, procedures, or other diagnostic tests, they were transported to the
respective location within the BWH campus.
Nurses played a pivotal role in managing inpatient care. Although nurses were trained to deliver
care for a wide range of clinical conditions, they tended to be assigned to a specific unit in the Tower.
As a result, they concentrated either on general care or ICU care within a given clinical specialty.
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Following their inpatient stay, patients returned for outpatient visits to monitor progress with
BWH physicians or, in some cases, with their referring physicians in the community. The frequency
of follow-up visits varied from monthly to yearly, depending on the complexity and severity of
disease. For some cardiologists, return visits occupied their entire office schedule.
Communication among the various cardiovascular specialties generally occurred around the
needs of a specific patient. Most interaction occurred through email or phone conversations.
Physicians also interacted at weekly conferences for each specialty.
While each condition and patient required different care, the patient experience for nonemergency coronary artery bypass graft (CABG) surgery was fairly typical for cardiovascular
patients at BWH. A referring primary care physician would request a cardiology outpatient visit after
completing some preliminary blood work and an electrocardiogram (ECG). The cardiology office
staff would compile the outside medical records and schedule the patient for the next available
opening, typically with a wait of two weeks. After the cardiology consultation in the ASB, the patient
would return up to two weeks later for a stress test and echocardiogram. The cardiologist would
review the results with the patient during a second outpatient visit several days later. If these initial
tests suggested the possibility of coronary disease, the cardiologist would refer the patient for an
angiogram, a diagnostic imaging procedure that detected blockages in coronary vessels.
Angiograms were performed by an interventional cardiologist in the basement of the Tower
Building and would occur up to one week later. If the patient was a candidate for angioplasty, it
would be performed immediately. If not, the cardiologist would arrange for a cardiac surgery
consultation, on average five days later, either in the outpatient clinic in the ASB or the surgeons
private office in the Peter Bent Brigham building. The surgeons assistant would organize the
pertinent patient records for the surgeon to review. After the surgery consultation, the patient would
return to the Tower building within one to two days to be cleared for surgery by an anesthesiologist.
Clearance consisted of a medical evaluation and additional tests to ensure that the patient could
safely undergo surgery.
CABG surgery was performed in the basement of the Tower within one to five days following
clearance, depending on the patients condition. After surgery, the patient would be transferred to
the cardiac surgery ICU on the eighth floor of the Tower and eventually moved to a general care
room in a different pod on the same floor. Following discharge from the hospital, the patient would
generally return to the surgeon once or twice for post-operative care. The frequency and duration of
follow-up visits with a BWH cardiologist varied greatly. If the patients symptoms resolved and she
did well post operatively, the patient would receive future care from her primary physician,
returning to cardiology or cardiac surgery only if symptoms recurred or problems arose.
BWH had organized a disease management program for congestive heart failure (CHF) patients
that had resulted in a doubling of their survival rate. Patients were referred to a cardiologist
specialized in CHF who organized all of their outpatient cardiovascular care. Patients requiring
hospitalization were cared for by a dedicated CHF team consisting of an attending cardiologist and
resident physicians. Upon discharge, the patients primary cardiologist was responsible for care. The
heart failure section also worked together with cardiac transplant surgeons to coordinate care for
heart failure patients qualifying for transplant.
BWH had recently begun publishing outcomes data for cardiovascular care at the hospital on its
public website. It published data on select procedures and diagnoses, including coronary artery
bypass graft (CABG) surgery, heart failure, and coronary angioplasty and stenting. Published data
were those already collected and reported to various groups, including the State of Massachusetts
and the American College of Cardiology. Mortality and process data were reported for BWH and
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compared to national benchmarks when appropriate. Inpatient satisfaction surveys were also
published. On nearly all measures, BWH performed better than national averages.
Competition for Cardiovascular Care
BWH faced intense competition in the Boston region in cardiovascular care. Beth Israel Deaconess
Medical Center (BIDMC), located across the street from BWH, was a full-line, Harvard-affiliated
hospital with an excellent reputation for service. In the summer of 2007, BIDMC announced that fifty
of its cardiologists, vascular surgeons, and cardiac surgeons were forming an independent
corporation. The new entity was actively recruiting additional specialists from the community to join
them in working at a new BIDMC Cardiovascular Institute in the Longwood Medical Area.
Physicians would be compensated based on a new revenue sharing model for both technical and
professional fees. Affiliated community physicians would also share in this revenue pool. Details of
the revenue sharing model were not available.
Massachusetts General Hospital (MGH) was ranked fifth in cardiovascular care nationally by U.S.
News and World Report. MGH offered nearly identical cardiovascular services to BWH on its campus
less than four miles away. BWH and MGH offered combined cardiac transplant services. The MGH
organizational structure was very similar to that of BWH, with a physicians organization,
departmental chairs and an administrative structure. Boston Medical Center, affiliated with Boston
University, and New England Medical Center, affiliated with Tufts University, also offered a full
range of advanced cardiovascular care.
Among Massachusetts hospitals, BWH enjoyed the leading market share of cardiac surgery
patients with 19%. It ranked third, behind MGH and BIDMC, in vascular surgery, with 9%.
Southcoast Health System, a consortium of community hospitals in southern Massachusetts, cared for
the most cardiology patients (8%), followed by BWH (5%). MGH performed the most interventional
cardiology procedures (15%) with BWH second with 12%. (See Exhibit 7 for 2006 Massachusetts
market share data.) Lahey Clinic, a regional multi-specialty group practice, cared for the most
international patients seeking cardiovascular care in Massachusetts, followed by MGH and BWH.
Massachusetts hospitals had experienced steadily declining inpatient volumes for cardiology
services since 2002. Interventional cardiology and cardiac surgery had also seen slight declines.
Academic medical centers, including BWH, MGH, and BIDMC, all experienced declining
interventional cardiology and cardiac surgery volumes, while several community hospitals had
increased volumes and market share. Gottlieb expected yearly declines of 1%2% statewide in these
services through 2015, while electrophysiology procedures were expected to grow 1% yearly over the
same period. Heart failure was also expected to grow with an aging population and increased
survival from heart attacks and other cardiac events.
Several national competitors either already had some form of integrated cardiovascular care or
were launching new efforts to do so. The Cleveland Clinic, ranked first in cardiovascular care by U.S.
News & World Report, had operated a multidisciplinary Heart and Vascular Institute for many years in
dedicated facilities. In 2007, the Clinic admitted over 12,500 inpatients in its 333 cardiovascular
inpatient beds.5 In 2008, the Clinic was in the process of eliminating its specialty-based department
structure and replacing it with a structure of institutes based on organ systems. Physicians from all
cardiovascular specialties would report to the head of the Institute, who would be in charge of all
physicians and activitiesin the Institute, including compensation and academic promotion. A new,
larger Heart and Vascular Institute building was under construction and slated to open in 2008.6
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The University of Michigan Cardiovascular Center (UMCVC) opened in June 2007. At 350,000
square feet, UMCVC significantly increased the space allocated to cardiovascular care. In addition to
seeing patients, all physicians involved in cardiovascular care relocated their personal offices to the
new center. Four physician leaders divided managerial responsibilities for: clinical care, medical
education, research, and philanthropy. An executive committee, consisting of the five department
chairs whose specialties cared for cardiovascular patients, the dean of the medical school, the hospital
COO and CFO, and the chief of nursing, provided overall oversight, allocated capital, and hired
physician staff jointly with the representative departments. UMCVC housed nearly all cardiovascular
outpatient clinics, diagnostic facilities, operating and procedure rooms. It also included
cardiovascular research facilities and two floors of inpatient beds. The remainder of inpatient care
occurred in the main hospital building physically connected to the center. UMCVC was coordinating
some inpatient and outpatient services with providers in the local Ann Arbor community.
Financially, the center had an agreement with the hospital in which operating income above the
centers budgeted income would remain in the center.7
The Mayo Clinic, headquartered in Rochester, Minnesota, was the largest multi-specialty group
practice in the country. All outpatient cardiovascular care was located in the Gonda Building, a 1.5
million square foot outpatient center costing $441 million. One floor served as the Vascular Center, in
which virtually all physician appointments and diagnostic tests for diseases of blood vessels were
conducted. The Vascular Center had its own administrative structure, but physicians still belonged to
specialty-based departments that controlled compensation and the allocation of physician time across
clinical and research activities. All other outpatient cardiac care and testing, except angiograms of the
heart, was organized by specialty and took place at separate locations in the Gonda Building.
Inpatient care occurred in the Clinics hospital one mile away. Inpatients were primarily grouped by
specialty.8
The Johns Hopkins Hospital, located in Baltimore, Maryland, had created a Heart Institute in
2004. A new Cardiovascular and Critical Care Building was slated to open in 2008 and aimed to colocate high acuity patient care, including cardiovascular care. The Heart Institute would be located in
the new building and would include most outpatient cardiac care and testing, grouped by specialty.
Inpatient care and procedure rooms would be located elsewhere in the new building. The
departmental organizational structure of physicians would remain intact.
In addition to centers and institutes, there were several specialty cardiovascular hospitals in the
U.S. as of 2005. These had been formed by entrepreneurial physicians and were primarily located in
midwestern, western, and southern states. Growth in such privately-owned specialty hospitals was
increasing after what was effectively a federal ban on such facilities was lifted in 2006.9 No specialty
cardiovascular hospitals were present in Massachusetts in 2007.
Efforts at Integrated Care at BWH
The Shapiro Center was not the first effort to integrate care across specialties at BWH. In 1985, the
departments of radiology and obstetrics/gynecology ended a turf war by forming a partnership to
interpret high risk obstetrical ultrasounds. A new center was created and staffed equally from the
two departments, with professional fees collected by the interpreting physicians department.
Initially, the departments precisely reconciled revenues at the end of the year to ensure equality, but
this had evolved into a more informal understanding by 2007.
In 1984, cardiology, vascular surgery and interventional radiology decided to co-locate procedure
rooms and outpatient clinics in the Tower Building in an effort to improve coordination among
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specialists. Billing and professional fee revenues were handled separately by each department. Dr.
Andrew Whittemore, a vascular surgeon and now BWH chief medical officer, explained:
At the time, this arrangement was ground-breaking. Patient care was expedited because
physicians could easily communicate. This arrangement built trust and a sense of community
among specialists. Patients no longer had to coordinate their own care, and each received a
detailed care plan which was also communicated to their referring physician.
In 1986, a diagnostic vascular laboratory was established in which cardiologists, vascular surgeons
and radiologists jointly interpreted non-invasive diagnostic tests related to the peripheral vascular
system. Professional fees were allocated to the department with which the interpreting physician was
affiliated. This arrangement continued in 2007.
By the late 1990s, rapidly growing demand for minimally-invasive procedures such as angioplasty
required more space than available in the Tower building. The formerly co-located cardiology,
vascular surgery, and interventional radiology outpatient units were thus forced to relocate to
diverse sites in 1999. Despite efforts to maintain lines of communication, relationships among the
three specialties deteriorated and even became combative at times. Cardiology chair Libby noted:
Competition among cardiovascular specialists runs deep and is far from unique to BWH.
Interventional radiology had revolutionized cardiovascular care and drew patients away from
surgeons. Vascular surgeons and interventional cardiologists, who controlled the patients,
began to learn the skills perfected by the radiologists and took the business back. Over the
years, this dynamic resulted in a fend-for-yourself attitude.
Concerned about the turf wars and motivated by a desire to improve patient care, Libby and Dr.
Steven Seltzer, department chair of radiology, initiated informal discussions in 1998 to consider ways
to integrate cardiovascular care better at BWH. A preliminary business plan and organizational chart
was developed, but despite some initial momentum, little progress was made.
In 2002, Libby rekindled discussions about integration by offering to share interventional
cardiology procedure rooms with vascular surgery and interventional radiology, which performed
similar procedures in identical rooms elsewhere on the BWH campus. At the time, cardiologists and
vascular surgeons were beginning to perform angioplasty of peripheral vessels, which had
previously been the domain of interventional radiology. Vascular surgery accepted Libbys
invitation, but interventional radiology chose to remain separate. Under the agreement, cardiology
maintained control of day-to-day operations of the shared procedure rooms and cardiologists and
vascular surgeons maintained independent referral patterns and billed separately for procedures
they performed.
In 2002, BWH received a sizable donation from the Shapiro family to be used for infrastructure
improvements on the BWH campus. Plans began to take shape for a major new building, which was
initially planned as an ambulatory care building. Gottlieb, newly appointed as president, decided
that BWH should not expand less-acute care on the main campus. Instead, the space would go to one
of BWHs centers of excellence and help refocus the campus on patient-centered care. Because of
current and projected inpatient census and demand, the choice came down to cardiovascular care or
cancer. In the end, Gottlieb chose cardiovascular care because of the projected growth in high-acuity
treatment and its need for intensive care. Following completion of the cardiovascular center, Gottlieb
planned to renovate and redesign several floors in the Tower building. BWH agreed to minimize the
buildings impact on the community and relocate several residences that would be affected by the
construction.
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Simultaneously, BWH continued efforts to integrate cancer care within existing facilities. The
partnership with Dana-Farber Cancer Institute was solidified through further clinical integration,
joint reporting relationships, and the development of disease-specific centers involving clinical and
research staff at both the Dana-Farber and the BWH. Future plans included the renovation and
dedication of four floors in the Tower to inpatient oncology services.
The Shapiro Cardiovascular Center
To plan the new building, Gottlieb formed the Cardiovascular Council, which provided
leadership and advice as the project progressed but had no formal authority. The Council consisted
of Whittemore, Seltzer, Dr. Michael Belkin (division chief of vascular surgery), Dr. Morton Bolman
(division chief of cardiac surgery), Dr. Ken Baughman (section head of heart failure within
cardiology), (vice president), and other key staff including representatives from
nursing. Baughman had recently joined BWH from Johns Hopkins, where he helped lead a similar
but ultimately unsuccessful effort to integrate cardiovascular care. Whittemore and Baughman were
named co-chairs of the Council, which was charged with evaluating the current delivery of
cardiovascular care at BWH and designing a building that would allow integrated, patient-centered
care. Whittemore explained:
Our old system was designed by physicians for physicians who had a tendency to focus on
treating the disease and not the patient. When we designed Shapiro, we wanted the patient to
be the central focus. We wanted an inviting space where patients would feel comfortable and
attended to. The building needed to facilitate patient flow through the system and minimize
waiting times. We hoped to make it possible for patients to be able to schedule all of their visits
and tests through a single telephone number.
Baughman summarized the vision for the center:
Our goal was to provide one-stop shopping for comprehensive treatment of cardiovascular
disease. A high priority was placed on offering an outpatient visit and all pertinent testing
within one day of a patients initial referral to Shapiro.
The Council hoped that the extra space would reduce crowding and provide the necessary
capacity buffer to accommodate demand swings. Physicians from various specialties would occupy
outpatient clinics in close proximity to each other to facilitate communication. Council members
hoped this proximity would allow consulting physicians to evaluate their colleagues patients
without forcing those patients to change rooms or return at a later date.
The preliminary plans for the Shapiro building, a $352 million 10-story facility located across the
street from the main BWH campus, began to take shape starting in 2005 (see Exhibit 8). It would
house all outpatient, inpatient, laboratory, and testing facilities needed to manage cardiovascular
disease. At nearly 350,000 square feet, Shapiro was expected to be one of the largest cardiovascular
centers in the country and would represent the biggest capacity expansion in the history of BWH. All
cardiovascular services currently offered at BWH would be offered at Shapiroand selected services
including electrophysiology and imaging would be expandedwithout adding additional physician
or allied health personnel. BWHs total inpatient hospital beds would remain relatively unchanged,
as much of the Tower would be converted to private rooms.
The Center would contain 16 state-of-the-art operating suites, each able to accommodate nextgeneration minimally invasive technology, including robotic surgery and image-guided therapies. Six
rooms dedicated to cardiac and vascular surgery would form a pod. The remaining operating rooms
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608-175 Brigham and Womens Hospital: Shapiro Cardiovascular Center
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would be used by other surgical specialties. Current cardiovascular operating rooms at BWH would
be refitted for different uses. The new operating rooms would be on the first basement level and
would be contiguous with existing operating rooms under the Tower building.
Inpatient rooms, consisting of 136 ICU-adaptable beds, would span the top five floors and occupy
23% of the building. The Massachusetts Department of Public Health required hospitals to classify
their inpatient beds as ICU or general care. ICU-adaptable beds were not yet offered at any other
Massachusetts hospital. Initially, the Council chose to classify 32 rooms as ICU rooms and 104 as
private inpatient rooms, all designed to provide additional space for families including sleeping
accommodations for one member. Inpatient floors would be arranged by specialty with cardiac
surgery on the sixth (general care and ICU) and seventh (general care) floors, vascular surgery on the
eighth floor, and cardiology on the tenth floor. The ninth floor would be reserved for patients with
severe cardiac failure who required either general care or ICU care. While each floor had been
classified for a specific use, an inpatient coordinator had been appointed who would allocate
cardiovascular patients to unused rooms to maximize bed utilization.
Nurses at BWH were assigned to a specific hospital floor and concentrated either on general care
or ICU care. At Shapiro, the Council hoped nurses would eventually be cross-trained and care for
both general care and ICU patients. Changing the practice paradigm for inpatient nursing would
require additional staff training. Nursing leaders had been wary of these changes, and the issue was
expected to surface in upcoming labor negotiations in 2008.
Outpatient clinics for cardiology, cardiac surgery, vascular radiology and vascular surgery would
be located on the second and third floors, occupying 9% of the total square footage in the building.
Laboratory and some cardiovascular testing facilities would be located on second and third floors
and occupy 12% of the total space. Cardiovascular diagnostic radiology and nuclear imaging would
be on the second lower level.
Cardiovascular imaging was identified as an area with a high likelihood of successful integration.
Imaging was highly reimbursed relative to other cardiovascular services, and Libby and Seltzer
believed that economies of scale could be gained by joining forces between radiology and cardiology,
resulting in higher throughput and better utilization of scanners.
Under the new structure, cardiologists and radiologists would interpret studies independently in
a shared reading room. The plan was to alleviate competition by allocating studies equally between
radiology and cardiology and allocating professional fees based on the specialty of the physician
interpreting the study. Technical fees would go to BWH.
Patients would benefit from the combined expertise of both departments, while the departments
would benefit from better coordination and more efficient utilization of capacity. Libby and Seltzer
believed that radiology offered imaging and IT expertise while cardiology had relationships with
patients and understood cardiovascular pathophysiology. In 2006, an international search was
initiated to hire a director of cardiovascular imaging for the Shapiro Center, culminating in the hiring
of Dr. Marcelo DiCarli, who was then co-director of cardiovascular imaging in the BWH department
of radiology.
The Shapiro building was designed to improve patient flow and care integration. Outpatient
clinics would be co-located. All physicians would share a centralized physician only work space on
days when they saw patients at Shapiro. A few physicians academic offices would be located on the
fifth floor. These would be allocated to physicians in all cardiovascular services who were active in
patient care provided in Shapiro. Most physicians would maintain their private offices and
administrative staff in their original locations in the Ambulatory Services and Peter Bent Brigham
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Brigham and Womens Hospital: Shapiro Cardiovascular Center 608-175
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buildings. In Shapiro, and diagnostic testing facilities would all be located
within two floors of the outpatient clinics. Interventional procedure rooms and operating rooms
would be in close proximity to recovery rooms and family waiting areas. These would be shared by
all cardiovascular specialties. Scheduling for interventional cardiology, interventional radiology and
electrophysiology procedures would be handled by a single administrative staff.
Gottlieb anticipated strong demand for services at Shapiro. Initially, the center was to open in
phases. Based on projected demand, however, Gottlieb and the Cardiovascular Council decided to
open all floors in July 2008. Gottlieb and some members the Council differed regarding how to
respond if Shapiro capacity was not fully utilized. Gottlieb believed that inpatient beds should be
filled with overflow from the Tower buildings, while Council members believed the beds should be
protected for cardiovascular patients to provide capacity to allow BWH to accept cardiovascular
referrals on a timely basis.
Interventional cardiology would continue to perform angioplasty of the heart and peripheral
vessels; vascular surgery and interventional radiology would continue to perform angioplasty of the
peripheral vessels. Patients would be directed to a given specialty through the same channels that
existed prior to Shapiro and compensation structures would remain unchanged.
Given the growth anticipated in electrophysiology, an additional two electrophysiology
procedure rooms were included as part of the Shapiro construction. The electrophysiology lab would
continue to share its recovery room with interventional cardiology and interventional radiology. The
remaining space was allocated to ancillary services such as admitting, a patient/family center, and
other patient services. (See Exhibit 9 for the space allocation for the Shapiro Center and Exhibit 10 for
a schematic map of the building.)
Patients would enter the system by physician or self referral. Cardiology, cardiac surgery, and
vascular surgery would continue their current approaches to organizing patients medical records
and scheduling. After the initial cardiology consultation, however, the patient could obtain an
immediate echocardiogram performed on the same floor. If the patient needed a nuclear cardiology
test, he or she would likely need to return on another day. Council members hoped that a follow-up
outpatient visit with cardiology could be completed that same day.
Patients requiring an angiogram would return to Shapiro one to five days later to have an
interventional cardiologist perform the procedure. One to five days after that, they would visit the
cardiac surgeon. Clearance for surgery would be granted by an anesthesiologist in the Tower
building based on an additional visit.
Surgery, if needed, would be scheduled and performed at Shapiro within one to five days,
depending on the patients condition. Following surgery, the patient would be transferred upstairs to
the cardiac surgery ICU and then to a private general care room on the same floor. All subsequent
follow-up care with cardiology and surgery would be performed at Shapiro. Some patients admitted
to BWH with other health problems as their primary diagnosis also required cardiovascular care.
Libby and Baughman estimated that 70% of cardiovascular care provided by cardiologists would
take place at Shapiro and 30% elsewhere at BWH. They anticipated that the majority of circumstances
would require Shapiro physicians and technicians to travel to other parts of the campus, but some
services would require BWH patients to travel to Shapiro. Gottlieb commented:
Brigham and Womens and Shapiro are part of one hospital. We have the benefit that all
our campus facilities are interconnected. Our physicians can easily care for patients anywhere
on our campus. Today, for example, if a patient in our womens center develops an infection,
our infectious disease specialists can go to the center and care for her.
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608-175 Brigham and Womens Hospital: Shapiro Cardiovascular Center
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The measurement and publication of outcomes for cardiovascular patients at Shapiro was a topic
of intense discussion. The Council was actively involved in determining which additional clinical and
services measures would be monitored as a result of the new care structure. Administration was
working to develop an approach to gathering data given the lack of a comprehensive electronic
inpatient record and the presence of several different operating systems.
Discussions regarding the financial relationships between physician divisions had been
challenging. The objective was to develop a financial model that would support the integrated care
model that had been designed for the new building. How best to accomplish this was unclear given
that there were no specific assurances that divisions and their physician members would preserve
their revenues as the new practice model was put in place. An additional complicating factor was the
difference in market salaries. For example, while both cardiologists and radiologists interpreted
cardiovascular images, there was a significant difference in compensation between the specialties.
Federal anti-kickback laws prohibited or complicated the sharing of hospital technical fees with
physicians for Medicare and Medicaid patients, while the so-called Stark laws limited self-referral
the practice of physician referral to a medical facility in which he or she had a financial interest. These
regulations complicated the process of sharing of revenue across specialties or between the hospital
and physicians.
Each departments financial statements were treated as highly confidential. As of late 2007, the
financial structure at Shapiro would remain unchanged from the current BWH model. Departments
would remain autonomous and would collect revenues for their physicians services.
Dr. Joseph Loscalzo, department chair of medicine, explained:
Physicians are skeptical of financial integration. Departments fear losing revenue to
competing specialties. Surgeons fear losing patients to colleagues in their specialty. Physicians
will need to see that working together will not be detrimental financially before they are
willing to try.
Members of the Cardiovascular Council were taking the long view on financial integration. After
the first year of operation, they planned to prepare hypothetical financial statements as if Shapiro
were a stand-alone unit in an effort to help department leaders understand the potential of new
approaches to financial management. In the future, Baughman, in particular, hoped that the Shapiro
Center would serve as a stand-alone business unit where physicians would be paid by the Center and
would be solely accountable to its leadership.
Recent Challenges
During the summer of 2007, a proposal was made to relocate and expand a well-respected internal
medicine physician practice into the Shapiro building, supplanting the 12 echocardiography rooms.
Internal medicine leaders had questioned the demand assumptions for echocardiography and
advocated expanded primary care services to foster better coordination with the cardiovascular
services provided at the Center. Gottlieb had to resolve this issue. In addition, it was believed that
space for echocardiography testing could be accommodated in the existing floor plate of the clinics or
on the second basement level of the Shapiro building.
There were also concerns about the care of patients admitted to BWHs main campus with noncardiovascular primary diagnoses who required cardiovascular services outside the Shapiro building.
Finally, some physicians were unsure whether the new approach to cardiovascular care would
adversely affect the hospitals ability to attract, educate and develop young physicians.
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Gottlieb wondered if integration was occurring rapidly enough given BWHs aspirations. He
knew that, as a national leader in cardiovascular care, BWHs efforts would be watched closely.
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608-175 Brigham and Womens Hospital: Shapiro Cardiovascular Center
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Exhibit 1 Brigham & Womens/Faulkner Hospitals Financial Statements
Balance Sheet
(Fiscal years ending September 30, in thousands of dollars)
Assets 2006 2005 2004 2003 2002
Cash and investments 294,705 253,153 220,052 192,168 170,408
Current portion of investments limited as to use 157,146 119,362 137,968 154,404 114,010
Patient accounts receivable 209,229 176,840 175,812 173,186 169,562
Other current assets* 114,869 138,344 126,111 96,560 74,458
Total current assets 775,949 687,699 659,943 616,318 528,438
Investments limited as to use** 411,442 369,937 292,818 245,018 224,269
Long-term investments*** 143,021 121,030 100,280 87,192 71,065
Property and equipment, net 735,347 684,093 616,944 594,339 577,467
Other assets**** 67,125 55,112 43,100 48,759 40,927
Total assets 2,132,884 $ 1,917,871 $ 1,713,085 $ 1,591,626 $ 1,442,166 $
Liabilities and Net Assets
Accounts payable and accrued expenses 250,777 247,486 236,559 241,078 221,997
Current portion of accrual for settlements with 3rd party payers 1,304 23,213 26,608 26,280 18,281
Unexpended funds of research grants 52,091 49,689 42,639 33,140 32,004
Total current liabilities 304,172 320,388 305,806 300,498 272,282
Other long-term liabilities 89,734 117,434 140,844 146,432 149,825
Long-term debt 463,169 413,305 375,624 360,678 370,720
Net assets 1,275,809 1,066,744 890,811 784,018 649,339
Total liabilities and net assets 2,132,884 $ 1,917,871 $ 1,713,085 $ 1,591,626 $ 1,442,166 $
* Non-patient accounts receivables, current portion of pledges received, inventory, prepaid expenses
** Board designated funds, professional liability trust fund
*** Investments with Partners
**** Pension
Income Statement
Fiscal years ending September 30 (in thousands of dollars )
Revenues 2006 2005 2004 2003 2002
Net patient revenues 1,595,416 1,462,262 1,321,048 1,192,877 1,124,644
Other operating revenues* 515,589 463,108 435,407 421,125 371,899
Total revenues 2,111,005 1,925,370 1,756,455 1,614,002 1,496,543
Expenses
Employee compensation, benefits, supplies, and other 1,878,005 1,696,866 1,553,653 1,428,274 1,299,234
Depreciation and amortization 87,677 83,644 85,189 79,652 76,133
Provision for bad debt 39,381 38,773 51,522 30,495 43,740
Interest 20,827 18,342 16,362 15,796 17,285
Total operating expenses 2,025,890 1,837,625 1,706,726 1,554,217 1,436,392
Income/(loss) from operations $ 87,745 85,115 $ 49,729 $ 59,785 $ 60,151 $
* Indirect research revenue, trust/endowment income, cafeteria, parking, royalty income
Source: Brigham & Womens Hospital Annual Reports.
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608-175 -19-
Exhibit 2 Abbreviated BWH Organizational Structure
Vice President
Marketing and Planning
Vicki Amalfitano
Vice President
Public Affairs
Peter R. Brown
Vice President
Clinical Services
Elizabeth Glaser
Vice President
Support Services
Arthur Mombourquette
Vice President
Clinical Services
Sanjay Pathak
Vice President
Human Resources
Lisa Ponton, JD
Chief
Information Officer
Sue Schade
President
Faulkner Hospital
David Trull
Vice President
Clinical Services
Sharon Vitti
Chief Operating Officer
Executive Vice President
Kate Walsh
BWPO President & CEO
Allen Smith, MD
Exec. Dir.
Clinical Compliance
Janet Barnes, RN, JD
Assoc. CMO
Director Primary Care
Robert Goldser, MD
Vice President
Ctr for Clinical Excellence
Michael Gustafson, MD
Sr. Vice President
Chief Medical Officer
Anthony Whittemore, MD
Sr. V.P. Patient Care Services
Chief Nursing Officer
Mairead Hickey, PhD, RN, FAHA
Senior Vice President
Research
Barbara Bierer, MD
Senior Vice President
Finance
Roger Deshaies
Chief Development
Officer
Mark Kostegan
Exec. Director
Cmmty Health & Health Equity
Wanda McClain
Brigham and Women’s Hospital
President
Gary Gottlieb, MD, MBA
Cardiovascular Medicine
Peter Libby, MD
Angiography and
Interventional Radiology
Richard Baum, MD
Cardiac Surgery
Ralph Morton Bolman, III
MD
Vascular and
Endovascular Surgery
Michael Belkin, MD
Chief
Compliance Officer
James Bryant
Chief of
OB/GYN
Robert Barbieri, MD
Chief of
Radiation Oncology
Jay Harris, MD
Chief of
Psychiatry
Jonathan Borus, MD
Chief of
Neurosurgery
Arthur Day, MD
Chief of
Pathology
Michael Gimbrone, MD
Chief of
Dermatology
Thomas Kupper, MD
Chief of
Neurology
Martin Samuels, MD
Chief of
Radiology
Steven Seltzer, MD
Chief of
Orthopedic Surgery
Thomas Thornhill, MD
Chief of
Anesthesia
Charles Vacanti, MD
Chief of
Emergency Medicine
Ron Walls, MD
Chief of
Surgery
Michael Zinner, MD
Chief of
Medicine
Joseph Loscalzo, MD
Source: Brigham & Womens Hospital.
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608-175 Brigham and Women’s Hospital: Shapiro Cardiovascular Center
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Exhibit 3 Scope of Cardiovascular Care by Specialty
Medical Conditions Cardiology
Interventional
Cardiology
Cardiac
Surgery
Vascular
Surgery
Interventional
Radiology

Heart Failure X X
Valve Disease X X
Coronary Artery Disease X X X
Heart Transplant X X
Congenital Disorders X X X
Arrhythmia X X X
High Blood Pressure X
Peripheral Vascular Disease X X X X
Aneurysms X X X X
Carotid & Renal Artery Disease X X X X
Venous Disease X X X X

Source: Casewriter analysis.
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Brigham and Women’s Hospital: Shapiro Cardiovascular Center 608-175
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Exhibit 4 Overall and Cardiovascular Patient Activity at BWH
2006 2005 2004 2003

Hospital bed occupancy rate (%) 90 89 88 89
Total hospital admissions 45,068 44,784 43,105 42,187
Cardiac surgery admissions 1,470 1,377 1,380 1,446
Vascular surgery admissions 915 956 924 892
Cardiology admissions 4,584 4,722 4,558 4,592

Surgical procedures 30,736 30,059 30,015 30,700
Cardiac surgeries 1,648 1,497 1,518 1,650
Vascular surgeries 1,048 1,062 1,060 1,039
Interventional cardiology procedures 4,958 5,161 4,919 N/A
Electrophysiology procedures 1,969 2,022 N/A N/A
Interventional radiology procedures 6,584 5,534 4,615 2,840

Ambulatory activity
Total outpatient clinic visits 357,784 363,548 373,860 234,307
Cardiac surgery clinic visits 1,318 1,270 1,228 1,132
Vascular surgery clinic visits 4,762 4,372 4,238 4,332
Cardiology clinic visits 23,210 22,810 21,895 19,912
Total laboratory visits 1,618,685 1,555,396 1,537,894 1,473,390
Total imaging studies 285,493 277,025 259,947 234,307

Source: Brigham & Womens Hospital.
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608-175 -22-
Exhibit 5 Cardiovascular Service Locations in 2007
Lower Level 1
Lower Level 2
Floor 1
Cardiologists Offices;
Conference Room
Floor 2
Cardiac Surgeons Offices;
Conference Room
Floor 3
Vascular Surgeons Offices
Floor 4
TOWER
BUILDING
Lower Level 2
Interventional Radiology Lab &
Clinic; Electrophysiology Lab;
Interventional Cardiology Lab
Lower Level 1
Cardiac Surgery; Vascular
Surgery Operating Rooms
Floor 3
Floor 2
Floor 1
Echocardiography Lab; Electrocardiography Lab; Cardiologists Offices
Floor 8
Floor 7
Floor 6
Floor 5
Floor 4
Cardiac Surgery Inpatient Rooms;
Surgical ICU
Floor 10
Floor 9
Interventional Cardiology
Inpatient Rooms
Floor 12
Floor 11
Cardiology Inpatient Rooms;
Cardiac Care ICU
Floor 16
Floor 15
Floor 14
AMBULATORY SERVICES
Lower Level 1
Cardiac Surgery;
Lower Level 2
BUILDING
Vascular Surgery Operating Rooms
Floor 2
Floor 1
Cardiology Outpatient Clinic;
Cardiac Surgery Outpatient Clinic;
Noninvasive Vascular Lab
Floor 3
Vascular Surgery Outpatient Clinic;
Cardiologists Offices
PETER BENT BRIGHAM
BUILDING
Street Level
Source: Brigham & Womens Hospital.
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608-175 -23-
Exhibit 6 BWH Surface Map in 2007
Source: Brigham & Womens Hospital.
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608-175 Brigham and Women’s Hospital: Shapiro Cardiovascular Center
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Exhibit 7 Cardiovascular Inpatient Discharges for Eastern Massachusetts Hospitals in 2006
66.9%
48.2%
32.0%
5%
48.1%
8.7%
19.1%
11.5%
5.4% 7.4%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
General
Cardiology
Electrophysiology Interventional
Cardiology
Cardiac Surgery Vascular Surgery
All Other
South Shore
North Shore
Mt. Auburn
St. E
Southcoast
NEMC
Lahey Clinic
BMC
BIDMC
MGH
BWH
General
Cardiology Electrophysiology
Interventional
Cardiology
Cardiac
Surgery
Vascular
Surgery

Brigham & Women’s Hospital (BWH) 5.4% 7.4% 11.5% 19.1% 8.7%
Massachusetts General Hospital (MGH) 4.7% 8.3% 14.8% 18.3% 12.3%
Beth Israel Deaconess Medical Center (BIDMC) 3.6% 4.9% 11.1% 11.9% 10.6%
Boston Medical Center (BMC) 3.8% 3.1% a 9.6% 4.7%
Lahey Clinic a 4.9% 9.1% 8.6% 3.5%
New England Medical Center (NEMC) a 4.7% 5.4% 8.2% a
Southcoast Health System 8.4% 7.4% 6.0% 5.8% 5.2%
St. Elizabeth’s Hospital (St. E) a 3.5% 6.1% 5.3% 3.4%
Mt. Auburn Hospital a a 3.9% 4.3% a
North Shore Medical Center 3.6% 4.3% a 3.9% 3.5%
South Shore Hospital 3.6% 3.4% a a a
All Other Hospitals 66.9% 48.2% 32.0% 5.0% 48.1%

Source: Brigham & Womens Hospital.
Note: Data does not include outpatient procedures.
aNot in top 10 by market share.
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Laureate Education – Walden University, 2021.
Brigham and Women’s Hospital: Shapiro Cardiovascular Center 608-175
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Exhibit 8 Architects Rendering of Shapiro Cardiovascular Center
Shapiro Center
Source: Brigham & Womens Hospital.
Exhibit 9 Shapiro Cardiovascular Center Space Allocation
Mechanical
14%
Inpatient Rooms
23%
Support Services
11%
Cardiovascular
Imaging
6%
Patient Services
2%
Primary Care
Clinic
3%
Food Services
2%
Administration
7%
Surgery
17%
Cardiovascular
Outpatient Clinics
9%
Microbiology Lab
6%
Source: Brigham & Womens Hospital.
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608-175 Brigham and Women’s Hospital: Shapiro Cardiovascular Center
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Exhibit 10 Shapiro Center Schematic Map
SHAPIRO BUILDING
Lower Level 3
Support Services
Lower Level 2
Radiology; Nuclear Medicine;
Interventional Cardiology
Procedure Room; Recovery Rooms
Lower Level 1
Operating Rooms
Floor 1
Caf, Conference Center
and Staff Lounge
Floor 2
Outpatient Clinics;
Education Center
Floor 3
Outpatient Clinics;
Echocardiography
Floor 4
Mechanical Systems
Floor 5
Physician Offices and Lounge;
Pathology
Floor 6
Cardiac Surgery Inpatient
Rooms; ICU
Floor 7
Cardiac Surgery ;
Unassigned Inpatient Rooms
Floor 8
Vascular Surgery;
Interventional Cardiology
Inpatient Rooms
Floor 9
Advanced Cardiac Care
Inpatient Rooms; Cardiac Care ICU
Floor 10
Cardiology;
Cardiac Surgery Inpatient Rooms
Street Level
Source: Brigham & Womens Hospital.
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Appendix
Glossary
Angioplasty (i.e., Percutaneous Transarterial Angioplasty or PTA): a surgical procedure used to
enlarge the lumen of a partly occluded blood vessel (as one with atherosclerotic plaques on the walls) by
passing a balloon catheter through the skin, into the vessel, and through the vessel to the site of the lesion
where the tip of the catheter is inflated to expand the lumen of the vessel
Cardiomyopathy: any structural or functional disease of heart muscle that is marked especially by
hypertrophy of cardiac muscle, by enlargement of the heart, by rigidity and loss of flexibility of the heart
walls, or by narrowing of the ventricles but is not due to a congenital developmental defect, to coronary
atherosclerosis, to valve dysfunction, or to hypertension
Computed Tomography (CT): radiography in which a three-dimensional image of a body structure is
constructed by computer from a series of plane cross-sectional images made along an axis
Congenital Heart Disease (CHD): heart disease acquired during development in the uterus and not
through heredity
Congestive Heart Failure (CHF): heart failure in which the heart is unable to maintain adequate
circulation of blood in the tissues of the body or to pump out the venous blood returned to it by the venous
circulation
Coronary Artery Bypass Graft (CABG): a surgical bypass operation performed to shunt blood around
an obstruction in a coronary artery that usually involves grafting one end of a segment of vein (as of the
saphenous vein) removed from another part of the body into the aorta and the other end into the coronary
artery beyond the obstructed area to allow for increased blood flow
Dysrhythmia: a disordered rhythm exhibited in a record of electrical activity of the brain or heart
Echocardiography (Echo): the use of ultrasound to examine and measure the structure and functioning
of the heart and to diagnose abnormalities and disease
Electrophysiology: electrical phenomena associated with a physiological process (as the function of a
body or bodily part)
Hypertension: abnormally high arterial blood pressure
Magnetic Resonance Imaging (MRI): a noninvasive diagnostic technique that produces computerized
images of internal body tissues and is based on nuclear magnetic resonance of atoms within the body
induced by the application of radio waves
Nuclear cardiology: a branch of cardiology dealing with the use of radioactive materials in the
diagnosis and treatment of cardiac disease
PET: a sectional view of the body constructed by positron-emission tomography
Stroke: sudden diminution or loss of consciousness, sensation, and voluntary motion caused by
rupture or obstruction (as by a clot) of a blood vessel of the braincalled also apoplexy, brain attack, cerebral
accident, cerebrovascular accident
Source: Excerpted from Merriam-Websters Medical Dictionary 2003 (Springfield, MA: Merriam-Webster, 2003).
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Endnotes
1 Circulation, February 6, 2007.
2 American College of Cardiology, www.acc.org, accessed November 12, 2007.
3 Hannan, et al. Coronary angioplasty volume-outcome relationships for hospitals and cardiologists,
JAMA, March 19, 1997.
4 Americas Best Hospitals 2007, U.S. News & World Report.
5 http://www.clevelandclinic.org/heartcenter/, accessed December 28, 2007.
6 Teisberg and Porter, The Cleveland Clinic: Growth Strategy 2007, Harvard Business School Case, January
2008.
7 Interview with Kim Eagle, MD, University of Michigan Cardiovascular Center, April 21, 2008.
8 http://www.mayoclinic.org/news2001-rst/897.html, accessed December 28, 2007.
9 MedPAC testimony before U.S. Senate Committee on Finance, March 8, 2005.
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