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Duke phaseout seen natural part of Cleveland takeover


Long before the Cleveland Clinic offered to lend its aura of renown to Indian River Medical Center, there was another momentous, if much less extensive, affiliation with a prestigious institution: Duke University Health System, whose main campus is a nationally ranked, internationally recognized academic medical center.

It was 2005 when IRMC leadership decided to subscribe to the Duke Health affiliation for its planned Welsh Heart Center. It was a major stride for the community hospital and one that would shape its future in ways barely imaginable at the time.

A decade later, IRMC signed on with Duke for a second center of excellence, the Scully-Welsh Cancer Center. Together the heart and cancer centers brought the aging 37th Street hospital into the 21st century, with state-of-the-art treatment capabilities, excellent doctors and in the case of the cancer center, a physical extension of the hospital that would strikingly update its rear façade.

Now, it appears the Duke brand may be replaced by an even bigger name, and in a far more extensive integration. With a letter of intent due to be signed any day, the Cleveland Clinic will enter into exclusive negotiations with IRMC to take over the publicly-owned hospital.

Even absent a takeover, letting go of Duke may be a natural evolution for the Vero hospital. Already Duke doctors are on site less and less. And advisors in the possible Cleveland Clinic takeover who’ve already spoken with Duke Health say the university medical powerhouse is fine with the exit, if and when it occurs.

“By their nature and almost by design, affiliations all come to an end,” said Jamie Burgdorfer of Juniper Advisory, hired to guide IRMC through the current partnering process. “And that’s fine. It’s not a sign of failure. They all end because everybody’s circumstance changes. The two parties to the contract have individual circumstances and they don’t want to do it anymore.”

“We got to know the people at Duke and have nothing but a phenomenal opinion of them,” said Burgdorfer, who first heard of Vero Beach when Duke spoke of its affiliation here. “I probably couldn’t have found a better partner (for the cancer and heart centers).”

He says physician leaders at IRMC all spoke highly of the Duke affiliation.

“They helped develop very high-quality programs in cancer and cardiac care. They lent their expertise to develop clinical protocols and recruit physicians, and now it’s up and running. As a relationship it’s been quite successful. Even if Cleveland Clinic wasn’t coming in, it might not be around much longer anyway. Nobody’s upset about it. Duke completely understands. They have no problems with it at all.”

If the Duke-IRMC relationship is indeed entering its twilight, the benefit arising from it continues to shine. Patients continue to participate in important clinical trials and benefit from advances in genetics and other diagnostic tools under development at Duke. Programs begun under Duke’s watchful eye now stand on their own, monitored remotely for the most part. And staff recruited, vetted and trained by Duke seem more than willing to stay on to serve under new leadership.

“They basically gave us the playbook in how to set up a successful heart program. I think that helped us attract the kind of talented physicians we have,” said Janet Longenberger, IRMC’s associate vice-president of cardio-thoracic services. She was the first administrator of the Duke Heart Center when it opened in 2006.

Longenberger credits the Duke connection with attracting top talent to the heart program, including Dr. Cary Stowe, a highly respected cardiovascular surgeon who remains director of the program today.

With the Duke affiliation, the hospital also scored a top doctor to direct the Scully-Welsh Cancer Center. Dr. James Grichnik, a Harvard Medical School graduate with a Ph.D. in cell biology from Baylor College of Medicine in Houston, is a nationally recognized melanoma expert who previously directed the melanoma programs at the University of Miami and at Duke. He took over as director of the cancer center in January 2016, shortly after it opened. His wife Dr. Katherine Grichnik, a cardiovascular anesthesiologist, was named IRMC’s first Chief Quality Officer later that year.

“When somebody is looking at leaving a successful practice or leaving a major metropolitan area, it’s a scary proposition for them,” Longenberger said. “I think knowing that they were going to have a connection with an academic center helped. They knew they were going to have colleagues that they could bounce ideas off of.”

Dr. Joshua Kieval, an interventional cardiologist at IRMC, formerly practiced at West Palm’s JFK Medical Center, along with Dr. Jay Midwall. “Duke vetted us before we were even offered a contract [at IRMC]. My partner went up to Duke and was interviewed. They went through our CVs and our numbers. It wasn’t just a rubber stamp. They had to make sure that we were appropriate not only in what we do in our practice but to coordinate with what Duke’s policies are.”

Once they were on staff at the Vero hospital, Duke followed the physicians closely. “It’s changed a little bit over the years, but initially there was a lot of interest,” said Keival. “Duke monitored us. We had to report almost on a monthly basis – the stents, balloon and cath procedures. And, obviously, any problems with morbidity and any mortalities were immediately sent up to Duke for review.”

Today the association relies more on teleconferencing. But a decade ago, Duke physicians came to Vero twice a year, going over difficult cases and giving their opinions on approaches in care. Between visits, IRMC doctors felt free to consult with Duke. “They were always very receptive,” Keival says.

“Duke helped build a structure,” said Longenberger. “We report all of our data to national registries and have since the very beginning.”

Most significant to the hospital’s long-term outlook is the impression the cancer and heart programs made on prospective partners, not only for the advanced healthcare offerings already in place, but the anticipated support for future efforts, all but guaranteed to be buoyed by the town’s remarkable philanthropy.

“I thought the suitors were very impressed with those two centers,” said Burgdorfer. “You don’t find centers of excellence of that quality in towns of your size, and it’s because you have people who gave generously. That’s very helpful – and very unusual. It certainly had a positive impact on the impression that the finalists had when they visited Vero Beach.”

On those visits, there is little doubt that the hospital’s curb appeal was enhanced by the two centers. Having a Duke affiliation likely didn’t hurt either, and the marketability of the centers has proved especially important as both require a high volume of patients to be profitable.

Whether or to what degree profitability has been achieved isn’t known to the public; the hospital’s management company does not break out such centers in its public financial reports. But the cancer center’s director Lori McCormick says confidently that, in just two years, Scully-Welsh has attained patient volumes “above the business plan.” 

Profitable or not, the centers came up again and again as suitors laid out their reasons for wanting IRMC in their portfolios.

In the end, IRMC officials chose to negotiate exclusively with Cleveland Clinic, whose main campus boasts the highest-rated heart program in the country with a perfect score in the U.S. News and World Report rankings: 100 out of 100. Its cancer program ranks seventh, with a score of 75 out of 100.

Overall, Cleveland Clinic’s main campus is ranked No. 2 in the U.S. That is “rarified air,” as one former IRMC board member put it, though Duke University Hospital, the flagship of Duke Health, ranked a very respectable No. 17 on U.S. News’ Best Hospitals list. As for programs, Duke is ranked 11th in cardiology and heart surgery, and 38th nationally in cancer.

Cleveland’s focus on cancer care expanded last year, when on its main campus it opened the $276 million Taussig Cancer Center, a massive seven-story building centralizing outpatient care from surgery to social work.

It remains to be seen how much influence Cleveland Clinic – or any partner – could have on IRMC’s standing. Cleveland Clinic’s distal campuses, including in Broward County, don’t come up to the level of their mothership. Cleveland Weston is rated “high performing” in cancer care with a score of 52.1 out of 100, but it is not ranked in heart care with a score of only 40.8. In addition, it is ranked No. 42 in gastroenterology and No. 31 in orthopedics.

As for Vero, there is plenty of opportunity to up the excellent in its centers of excellence. Right now – not surprisingly considering its size – IRMC is not even ranked on the U.S. News list. Its heart program has a score of 26.5 out of 100. Though its patient services, including cardiac rehab and hospice, are ranked excellent, its 30-day survival rate is below average, with nurse staffing, advanced technologies, patient safety and patient volumes all ranked average.

Its overall cancer program wasn’t scored in the most recent U.S. News report, perhaps because it has existed only two years. Two treatments were graded, however: lung cancer surgery and colon cancer surgery each earned an “average.”

Cleveland Clinic, which is run by its foundation, poured close to half-a-billion dollars into a new cancer center, which dwarfs Vero’s investment.

It was IRMC’s own fundraising foundation that provided the money for the cancer center here. After it announced a $30 million fundraising campaign for the center, two island couples – Bill and Marlynn Scully, and Pat and Carol Welsh – stepped up, each donating $12 million. That philanthropy enabled the hospital to enlarge its plans for the center, which ultimately cost $49 million.

Pat Welsh is the former president of Citicorp Venture Capital who went on to co-found the investment firm WCAS in 1979; Bill Scully worked on Wall Street before joining the investment firm Twin Oaks Partners in Chatham, New Jersey.

The Scullys and the Welshes, who have given generously to other hospital expansions, have made clear their desire to make high-quality care available close to home for their Vero friends and neighbors, as well as county residents at large.

Indeed, compared to large hospitals in urban areas, Scully-Welsh Cancer Center feels like a neighborhood clinic, albeit a serene, spacious and elegant one. In design, it is very much in keeping with the Cleveland Clinic ethos that puts the word “empathy” in its architectural imperatives. 

Scully-Welsh adds a striking and modern rear façade to the main hospital building. Inside the cancer center, much as at Cleveland Clinic, the emotional aspects of good design become obvious. The calming, uncluttered interior with minimalist furnishings are in a neutral palette. Like Cleveland, streams of mood-lifting natural light pour through floor-to-ceiling windows, not only in the lobby waiting areas but in the spaces curtained off for chemotherapy.

There, the view of lushly landscaped gardens is uplifting even for a healthy visitor. Signs honoring donors’ losses – Andrew’s Garden, Sally’s Garden – further convey the momentous task the center daily takes on. 

The grasses and bromeliads outside are in counterpoint to the life-extending technologies within. Scully-Welsh’s outpatient center offers radiation therapy via a Varian Truebeam accelerator, remarkable for its high speed and accuracy while accommodating for movement as the patient breathes.

Other equipment for the center includes a DaVinci surgical robot, and a new tool for lung biopsy called electromagnetic navigation bronchoscopy. It uses a GPS-type sensor at the tip of a catheter that extends the reach of a bronchoscope, enabling the physician to gather tissue samples deep down in the lungs.

A spectrum of practitioners from surgeons to chemo nurses meet weekly to discuss challenging cases in advance of treatment. Occasionally, an expert from Duke Health is brought in via video-conferencing. At IRMC, the weekly meetings can be standing room only, their benefits extending beyond patient care to continuing education for medical professionals.

“This room is full” during the weekly sessions, says McCormick, opening the door to a well-appointed conference room, its U-shaped tables formed around monitors for remote participants.  “It’s very well-attended.”

“It’s an opportunity for collaboration that includes community doctors, even physicians who are not involved in a case, but they may have something like this. They can observe, hear the discussion, ask questions of their own,” says the hospital foundation’s newly named president, Liz Bruner, who gives frequent tours to donors.

“The last time I was here, a doctor from Duke was actually present and he made a presentation. We even have medical students from FSU who come because they want to learn.”

On the cancer center’s second floor are doctors’ offices and a spacious waiting room, empty on a Friday lunch hour last week but packed just the day before, officials said.

Where the new cancer center extension joins the existing hospital, patient rooms dedicated to cancer care were gutted and enlarged, allowing for a fold-out bed for a family member or friend. Existing operating rooms were refurbished to accommodate various cancer surgeries.

In contrast to its cancer counterpart, the Welsh Heart Center is more of a program than a structure, its components mostly clustered around the emergency room entrance. One facet still in development actually begins outside the ER – it is a program that allows emergency responders to transmit EKG results by cell phone to on-call heart doctors.

Among the most recent offerings of the heart center is TAVR, or transcatheter aortic valve replacement, a less invasive technique that uses a catheter to replace the valve without surgically opening the chest. Added only a year ago at IRMC, TAVR programs are expensive to start and require specialized training; they typically aren’t found in small community hospitals.

Two years ago, the center added an electrophysiology lab to treat arrhythmia, including atrial fibrillation.  Led by Dr. Brett Faulknier, the lab includes a new device called Mediguide, only the second in the state that allows Faulknier to track the procedure with minimal radiation exposure to both patient and provider.

“This assemblage of technology is state of the art,” said Jeff Passaretti, manager of six departments including cath labs, echo cardiology and electrophysiology. He says he sees 2,000 patients a year in the cath labs and electrophysiology lab combined.

Passaretti also takes pride in “door to balloon time,” the time it takes to get a heart attack patient from the ER to the point where the heart is accessed via catheter. “We’re at 52 minutes. That puts us in the top 15 percent in the country.”

Today, the two centers are collaborating in a cardio-oncology program, overseeing patients on chemotherapy whose regimen may damage their hearts. “It’s been so exciting to watch this spring up naturally out of the cancer center,” said Longenberger. “The guys started to pass each other in the halls and have conversations and next thing I know, they’re like, hey, we want to have a cardio-oncology program. And it just sort of took off.”

Two weeks ago, the cancer center called again, she says: this time, they want to create an oncology rehab to mirror the heart rehab program. “I thought, wow, that’s different. I don’t know anybody that’s doing that kind of care.”

“On the eve of all these changes, we’re looking at the heart program and kind of doing a gap analysis to see what it is we do and don’t have,” said Longenberger. “I’m always amazed that we really kind of already have everything.”