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Join John R. Mehall, a cardiothoracic surgeon and physician executive. We explore the lasting impact of the global pandemic on hospitals in the United States, uncover the underlying financial crisis often overlooked by headlines, and discuss innovative strategies to bolster hospital finances. In particular, we delve into the misconceptions surrounding extracorporeal membrane oxygenation (ECMO) and how its implementation can lead to positive margins while saving patient lives.

John R. Mehall is a cardiothoracic surgeon and physician executive.

He discusses his KevinMD article, “3 myths about ECMO that are costing hospitals and patients.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast and get CME for this episode by clicking on the CME link in the show notes. Today we welcome John Mehall. He’s a cardiothoracic surgeon and physician executive. His KevinMD article is titled “3 myths about ECMO that are costing hospitals and patients.” John, welcome to the show.

John R. Mehall: Oh, thank you, Kevin. I appreciate the opportunity to be here. I’m really excited about this, and thanks for all you do with your website and your podcast.

Kevin Pho: All right, thanks for coming on the show. We’ll talk about your article in a little bit. First off, briefly share your story and journey to where you are today.

John R. Mehall: Sure. I spent most of the last 25 years doing cardiac surgery and all that that entails, but I’ve also had a lot of other experiences. I’ve been really involved in education and training. I started a symposium for cardiac surgery fellows, and I also taught and proctored practicing surgeons on minimally invasive mitral valve techniques throughout my career. I led cardiothoracic surgery regionally for our health system for more than a decade and then helped co-lead a national cardiovascular service line for a Catholic nonprofit health system.

This really gave me a lot of insight into some of the areas where health systems had needs, and I started a series of health care-related service businesses, including a health care staffing business, which I later sold to Doximity, and also a perfusion and ECMO services business, which gave me greater insight into the ECMO space.

But it was really my clinical years, when I had some pivotal patient experiences with ECMO, that really drove my passion. There were obviously a lot of those patients, but a couple of them stand out. One was a young woman who, during the H1N1 pandemic, had not only respiratory symptoms but also a viral cardiomyopathy and near-constant ventricular fibrillation. We were able to put her on ECMO, and she ultimately got better and survived.

The other one was a young baby boy, which was probably more poignant because I had a young infant son at the time. We had done an arterial switch operation on the baby, whose aorta and pulmonary artery were in the wrong spots at birth, and we moved them to the right spots. But it was obviously a long and complicated operation, and at the end there was just too much tension on the coronary arteries to get good flow, and we couldn’t get the baby off bypass. So we put the baby on ECMO for just a couple of days while the edema got better, and he went on to survive and get discharged. Some of these things really showed me the amazing power and ability of ECMO to save lives and really change the course of patients who otherwise would have died.

Kevin Pho: So let’s talk about your article now. To get everyone on the same page, ECMO stands for extracorporeal membrane oxygenation.

John R. Mehall: Yes, extracorporeal membrane oxygenation, and you’re right, the acronym is ECMO. It’s really just taking the blood out of the body, treating it, where we oxygenate it and remove carbon dioxide, and then putting it back in. So in some ways, think of it as an artificial lung, kind of like dialysis is an artificial kidney. It can be done either to support the lungs or to support the heart and lungs.

Kevin Pho: Great. And you wrote this KevinMD article, “3 myths about ECMO that are costing hospitals and patients.” Now tell us, how did your article come together?

John R. Mehall: The article came together really out of my realization of the magnitude of the missed opportunity to save lives with ECMO. The ECMO outcomes are now very good, yet too few patients are being treated with ECMO. That really means that there are thousands of patients out there who could survive with ECMO, but they aren’t really being given the chance.

When I look at the total possible population we could be treating, I personally think it’s well over a million patients a year in the United States. That sounds like an awfully large number, but consider that we’re putting over 4 million patients a year on a ventilator in the United States, and that’s growing at over 20 percent a year, and roughly 20 percent of those patients on a ventilator are going to die. That doesn’t mean every single one of them is an ECMO candidate, but it’s certainly a large number no matter how you slice it.

There are over half a million patients a year who have cardiac arrest and show up in the emergency department, plus a bunch of patients who have cardiac arrest in the hospital, who all could be ECMO and ECPR candidates. There are patients with unstable pulmonary embolism and cardiogenic shock. There’s just a long list of growing indications. When you think about that number of patients and the good outcomes we have, we really should be treating a much, much larger number of patients. I think if we do that, we could be saving thousands of lives a year. So I’ve really gotten passionate about trying to increase awareness and patient access so we can start saving at least a thousand lives a day.

Kevin Pho: So give us a sense of the context. How often is ECMO used? Is it primarily used in academic medical centers and cities, or is it used in the community? Just give us a sense of the penetration so far.

John R. Mehall: Yes. We have a national database, and last year there were roughly 10,000 patients who got put into that database. So if you think of a possible treatment population of a million patients, that means we’re treating roughly 1 percent. So that’s gigantic room for expansion. We may never actually treat a million patients, but even if we were treating 250,000 or 500,000, 25 percent or 50 percent of the potential patients, it’s an exponential increase from where we are now.

The other part of your question, where is it? It really is predominantly in academic medical centers and/or large tertiary referral institutions. Of the thousands of hospitals in the United States, there are probably fewer than 100 that are doing this on a regular basis every day.

Kevin Pho: Tell us some of the indications for ECMO today.

John R. Mehall: Historically it came out of respiratory failure, but it’s really expanded beyond that. It’s still a great treatment for respiratory failure, and we’ve learned that the earlier we do it, and the less injury we inflict upon the lung with the ventilator, the better the outcomes are. But it’s also obviously for times when there’s both heart and lung failure. There are plenty of devices for heart failure alone but not many for heart and lung failure. And the expanding indications are really around cardiac arrest, shock, and resuscitation.

Kevin Pho: All right, so we talk about a few myths about ECMO today. Let’s go into that. What are some of the myths?

John R. Mehall: Well, when I started thinking about why we do not have greater penetration of this amazing technology, these are some of the things that really came out as common themes. One is that ECMO is a drain on financial resources, i.e. the hospitals lose money doing it. The second was that it’s too complex or too complicated. And the third is that the outcomes were poor. When we really peel the onion and look at these things, none of them are really true.

The first one is that ECMO is a drain on financial resources. In reality, ECMO is the third-highest reimbursed code from CMS; only heart transplant and CAR T-cell therapy are higher. It’s true that some hospitals are losing money on ECMO, but the reason for that is that they’re not coding and billing it correctly. And the reason they’re not coding and billing it correctly is that ECMO is an unbundled code. There are very few unbundled codes, and very few people know how to appropriately clinically document, code, and bill that correctly. But when it’s done correctly, the net contribution margin to the hospital should be well into the six figures, even for Medicaid and Medicare, and much higher for commercial insurance. So it’s really a myth that you would lose money doing ECMO.

The second is around complexity. As you alluded to a moment ago, ECMO is very much like dialysis and other treatments where we take the patient’s blood out of their body, apply some therapy or treatment to it, and then return it to their body. So if an ICU can do dialysis or plasmapheresis or veno-venous ultrafiltration, they can do ECMO. It’s really not fundamentally different.

The last myth centers around outcomes. Like all medical technologies, ECMO was developed many, many years ago, and when we first applied it, we applied it to patients who were moribund, on a compassionate-use basis. So obviously those patients were going to have a poor outcome. But as we’ve evolved our understanding over the ensuing several decades of whom to use it on, when to use it, how to use it, how to manage the circuit, how to manage the patient, etc., the outcomes are now very, very good. Over half of the patients, all comers, will survive when treated with ECMO. And if you take out the patients with underlying cardiac disease, over 70 percent of the patients are going to survive. So if you think of a cohort of patients who almost certainly would have died without any treatment, these kinds of numbers, two-thirds or 75 percent surviving, are really remarkable.

Kevin Pho: Now, what do you see as the biggest barrier that needs to be overcome in order to have that wider adoption of ECMO?

John R. Mehall: It’s a couple of things. One is the awareness issue. I think the myths that we just alluded to are pervasive. We have to debunk them, and we’re trying to do that. The other is going to be training and education and getting the knowledge out there on how to do this. Dialysis is a unique subset of skills. All these things are unique subsets of skills, and competent nursing staff and clinicians can manage any of these skills; they just have to be taught. So I think those are the two big barriers right there.

Kevin Pho: So from a physician standpoint, what kind of training needs to be involved to learn how to manage ECMO patients?

John R. Mehall: Fortunately, a lot of fellows who are being trained today are being trained on ECMO because of its presence in the academic centers, and they’re going out into community hospitals. A lot of community hospitals are actually realizing that they’re having trouble recruiting if they don’t have an ECMO program. So the barriers around physician training, I think, are in some ways being addressed by the training programs. As for the education of physicians who are already out in practice, I think that’s a very easy skill for them to master. They just need to be given the opportunity.

Then there’s also this: It really is a team sport. It takes more than the physician deciding they want to do it. They really have to get buy-in from the whole intensive care team, and the nurses and the other folks involved also have to be educated.

Kevin Pho: And then from a nursing standpoint or support staff standpoint, what kind of additional training is needed to manage ECMO?

John R. Mehall: Typically there is some nurse-specific education, but the nurses themselves are not managing the ECMO circuit. There’s usually an ECMO specialist, and those folks have either an RN, RT, or perfusion background, and then they are trained in the ECMO part of it. That particular training, for nurses, respiratory therapists, and perfusionists who have critical care experience, is not a large lift for them. They would then manage the ECMO circuit for anywhere from one up to several patients, depending on the acuity of those patients.

Kevin Pho: So are there any downsides to ECMO as compared to just the traditional ventilator?

John R. Mehall: That’s a great question. I think the downsides are very similar to a traditional ventilator, in that you really want to carefully select the patients that you apply the therapy to. Just like with the traditional ventilator, you can put somebody on a ventilator, or you can put somebody on ECMO, only to find out that there’s really no getting off of the ventilator or getting off of ECMO. So you want to carefully select patients who have recoverable conditions, who are neurologically intact, etc., so that you don’t end up in a scenario where you’re simply prolonging the inevitable. But other than that, this is a therapy that can be done by many, many hospitals and could really, truly save many lives that are not being treated.

Kevin Pho: So tell us, what do you see as the path forward in the foreseeable future?

John R. Mehall: Really, we’re working down that path, and the path is making people more aware. I think the awareness is growing. We saw during the COVID pandemic that there were literally hundreds of families who had loved ones who were dying on a ventilator at a hospital without ECMO, and they were calling ECMO centers and ECMO providers trying to get those patients transferred, and the centers didn’t have the capacity to treat them. But it reflected that there is awareness around that.

There are also organizations out there, such as Marie’s Miracle and others, that are really putting these success stories out and trying to grow awareness and access. As those stories get out into the mainstream media, it’s growing that core awareness. I think there’s a little bit of a lack of awareness on the provider side about the outcomes and the ease of doing it. I think those barriers are getting broken down, and it will expand the access.

Kevin Pho: We’re talking to John Mehall. He’s a cardiothoracic surgeon and physician executive. His KevinMD article is titled “3 myths about ECMO that are costing hospitals and patients.” John, tell us some of your take-home messages that you want to leave with the KevinMD audience.

John R. Mehall: Yes, thank you. I think the number one is that ECMO saves lives, period. Whenever you have a patient with respiratory failure, cardiac failure, or shock, think of ECMO as throwing them a lifeline, not as throwing in the towel. I think the paradigm has shifted on that. That’s the biggest one for the providers, for sure.

The other thing is that this is not too complex. If your nursing staff can do it, your ICUs can do it. In many ways, it is a recruitment and retention tool. It gives additional clinical ladder opportunities for your nursing staff. And lastly, there is no financial barrier to this. When done correctly, this should actually be a positive for the hospital in terms of its financial performance.

Kevin Pho: John, thank you so much for sharing your time and insight. Thanks again for being on the show.

John R. Mehall: It was my pleasure. Thanks for having me, Kevin.