Ups & downs of revascularization

The price for cardiac revascularization keeps rising while the need for procedures appears to be in decline. Go figure.

PCI and CABG often fall under scrutiny for several reasons. First, they cost the healthcare system a lot of money. A study published in the January issue of Health Affairs pointed out that in 2012, the cost for PCI and CABG in the U.S. exceeded $15 billion.

The procedures are also well tracked, thanks in part to resources such as the American College of Cardiology’s National Cardiovascular Data Registry and the Society of Thoracic Surgeons Adult Cardiac Surgery Database. A recent cost-effectiveness study based on those two databases found what has been reported before: CABG costs more than PCI but has better long-term outcomes.

Another study that focused on revascularization procedures in Massachusetts also confirmed a trend noted in other research. The team reported that revascularization rates fell by 39 percent over a decade, with elective PCI feeling the biggest drop. The authors credited better primary and secondary care and improvements in medical management for the reduction.

The Heath Affairs study forges new ground. The authors explored the impact of quality metrics— specifically CABG- and PCI-related mortality rates—on the prices insurers pay for the procedures. They used to the 2007 initiation for these metrics in Hospital Compare as the inflection point, proposing that injecting transparency into the marketplace would put competitive pressures on hospitals. Payers then might negotiate lower prices.

Six states, including Massachusetts, had public reporting systems in place for PCI and CABG before 2007. The researchers considered those six states their control and compared pricing before and after 2007 between the control states and states with no previous reporting.

Revascularization prices shot up between 2005 and 2010, but to a lesser degree between 2007 and 2010 in the states with no previous reporting mechanism. The authors suggested that Hospital Compare may have been a factor.

Of course, payers had transparency in the control states throughout the five-year study period. Did they continue to leverage competitive pressures to get more favorable prices? Was it just by comparison that their increase was steeper than the other states? Or does the ability to press hospitals on price plateau after a few years? If so, the states that had no previous reporting may be in for an uptick again.

Costs aside, clinical advancements that contribute to less need for revascularization deserve acknowledgment. This success means healthier patients. Fewer procedures, even if costs increase, should create a slimmer overall bill for the healthcare system, and that may help retain limited resources for the sickest patients.

Candace Stuart

Editor, Cardiovascular Business