CHICAGO—While transcatheter aortic valve replacement (TAVR) remains all the rage, Cathleen D. Biga, president and CEO of Cardiovascular Management of Illinois, delivered a sobering outlook based on the national coverage decision for the procedures at the 2nd annual MedAxiom's Cardiovascular Service Line Symposium.

“The last time I saw this much energy about a technology was CCTA [coronary CT angiography],” she said in a June 6 presentation.

There are three categories of codes, Category I, II and III. TAVR is a Category III code is what is referred to as an "emerging technology" and not yet approved by FDA, she said. Additionally, codes tapped Category III are not valued by the Relative Value Update Committee (RUC) but do have the potential to be covered by other payors. Currently, United Healthcare is the only private payor that has a specific payment policy for TAVR.

“The national coverage decisions [for TAVR] were much anticipated,” Biga said. Currently, the national coverage decision is out; however, this coverage won’t guarantee a hospital payment.

“We need to understand the different nuances that come along with this,” she said, adding that the majority of physicians performing this procedure are not getting paid for it and those who do are averaging a price of only $30,000. Physician payments are by a case by case basis. The proposed DRGs (diagnostic related group) for the procedures have payment levels in the $24,053 to $53,391 range.

What is necessary to start a TAVR program?
Starting a TAVR program has both facility and product requirements, said Biga. For example, on-site valve programs will require practices and hospitals to participate in registries.

“Proposals are very clear on highlighting who can participate,” said Biga. But the participation in these registries will come at a hefty price tag. Biga estimated that it would be $25,000 to start a registry followed by an additional cost of $10,000 per year to maintain it.

Additionally, it will be required for patients to have a work-up by two cardiac surgeons. Two specialists must evaluate the patient independently from each other. Additionally, she said the heart team should include specialists from echo, imaging and heart failure, among others. Biga said it has been difficult during RUC meetings to understand who exactly must be present during a procedure, a work-up and at post-op.

Along with these requirements, a non-experienced TAVR program is required to perform more than 50 total aortic valve restenosis procedures in the year prior to attempting TAVR, with 10 being high-risk. Additionally, the facility should have performed 1,000 catheterizations and 400 PCIs in order to get on board with TAVR.

Future payments
Biga noted that TAVR codes from the physician perspective lie somewhere around $2,000; however, she noted that the payments trend toward the facility side rather than to the physician.

“If we get CPT [current procedural terminology] codes we are hoping that the DRG fall somerwhere between $30,000 and $44,000 for the DRG payment."

She added that multiple groups have thrashed out whether TAVR is a break-even procedure. “We must ask whether in the hospital world TAVR will be something that we can understand from a financial standpoint. Why we are doing it, or are we performing it for an entirely different reason?”

When Biga asked the audience who had a TAVR program in place at their facilities, 68 percent responded that they did not. Additionally, 65 percent said that they would not plan on starting a TAVR program within the next six months.