CMS recently announced the final Outpatient Prospective Payment System rule for fiscal year 2019, invasive cardiac diagnostic procedures join the ranks of the newest procedures to be conducted in the ambulatory surgery centers. Increasingly, procedures that were the private domain of the acute care hospital will now be conducted and reimbursed by CMS in ASCs.
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As of the fourth quarter of 2017, there were more than 1.4 million invasive diagnostic procedures being performed annually1 in the U.S. These were the "bread and butter" procedures cath labs performed across the country.
The cardiac catheterization lab has long been one of the shining stars of any hospital. The cath lab was known for being the setting for many groundbreaking, minimally invasive, lifesaving procedures. It is the diagnostic cath and PCI procedure that has been the cornerstone of the CCL for over thirty years.
CMS seems determined, along with private payers, to continue to explore the boundaries of what is possible in lower cost sites of care. Much has been written about the ASC and the types of procedures now being performed with increasing regularity, and with invasive diagnostic cardiac procedures joining the ranks, one must ask how long until PCI will be reimbursed by the CMS in the ASC setting?
The answer to the above question and many others that hospital administrators must be pondering lies in the understanding of what it means to remove unwanted care variation. A hospital-based CCL has a very narrow window to get this right; and with this new OPPS rule, the window just got smaller. The implementation of CMS' Bundled Payments for Care improvement Initiative Advanced, which includes 8 cardiac procedures, adds to this and makes what this writer would characterize as the perfect storm for hospitals.
Hospitals are high cost sites for the delivery of care, especially for minimally invasive procedures. A majority of the procedures performed in a CCL are elective and qualify for less intensive nursing and reduced length of stay. Redesigning the care delivery model, or care pathway is about achieving operational and cost efficiencies without sacrificing procedural outcomes or quality, but at the same time providing an outstanding patient experience. Sound familiar? It's the quadruple aim.
In his recent paper, Amin, et.al outlined the costs in a graphic associated with PCI, specifically those costs tied to an overnight stay.2
If hospitals are to compete with the ASC, then administrators must understand their actual or true episodic cost. Hospitals must begin to think in terms of what the consumer wants, how to deliver that care in a consumer-driven manner and how to deliver that specific care in the most cost-effective manner possible.
Researchers have looked at whether shorter length of stay or same day discharge influences readmissions.3 In a study of the Nationwide Readmission Database published in the American Journal of Cardiology, there does not appear to be a correlation between shorter length of stay of elective PCI patients and unplanned readmissions.
In May 2018, the Society of Coronary Angiography and Interventions, published an expert consensus paper on LOS associated with PCI.4 The document provides an excellent overview of the considerations (clinical, social, programmatic and data) to support the safe and effective use of same day discharge for elective PCI patients.
This data and others published in very recent years strongly suggest hospitals must rethink their strategy and care pathway approaches for different patient populations. The elective PCI patient will increasingly request, and expect, to be treated as a consumer and have an expectation for recovering in their own home, thus requiring less intensive health care services.
Gary Clifton is Vice President of Terumo Business Edge. Mr. Clifton has spent decades working in various aspects of healthcare and industry all focused in and around delivery of cardiovascular procedures. In his current role, he guides a highly experienced team of healthcare professionals whose job it is to help hospital cath labs gain greater operational proficiency, efficiency and cost effectiveness.
References
1 2017Q4 NCDR Report from the CathPCI Registry
2 A Amin, et.al, Association of Same-Day Discharge After Elective Percutaneous Coronary Intervention in the United States With Costs and Outcomes, JAMA Cardiol. doi:10.1001/jamacardio.2018.3029, Published online September 26, 2018
3 Kwok, et.al, Relation of Length of Stay to Unplanned Readmissions For Patients Who Undergo Elective Percutaneous Coronary Intervention, American Journal of Cardiology, DOI: https://doi.org/10.1016/j.amjcard.2018.09.028
4 A Seto, et.al, Length of stay following percutaneous coronary intervention: An expert consensus document update from the society for cardiovascular angiography and interventions, Catheter Cardiovasc Interv. 2018;1–15.