Shift toward value

It appears that the detested sustainable growth rate formula finally may be repealed in 2014. The replacement likely will lean heavily on provisions designed to ensure value for patients and payers.

This month the Agency for Healthcare Research and Quality released a report on the cost of hospital stays. Five cardiovascular conditions accounted for 13 percent of the $387.3 billion bill. Four of those five conditions achieved a decrease in the hospitalization rates, though. The cost for acute MI, for instance, increased by $5,400 between 1997 and 2011, but the average annual change in aggregate costs rose only 1.1 percent. The overall national average was 3.6 percent.

Lowering costs or lowering volume doesn’t equate to value, though. The real value is in outcomes, and cardiologists and hospitals have made strides in improving acute MI outcomes over the decades. Part of the improvement hinges on better therapeutics and technologies such as pharmaceuticals and stents. Better practices also play a key role, with appropriate use and feedback through registries helping guide patient care.

These drugs and technologies carry a cost, often higher than previous options. You can see those higher costs in the case of acute MI. Practice changes often reduce costs, for instance, by eliminating unneeded testing or imaging. Even protocols that call for more expensive technologies often tamp down cost by reducing complications.

That translates into better outcomes.

In the January issue of Cardiovascular Business, we look at patient selection in transcatheter aortic valve replacement (TAVR). You can be sure that the Centers for Medicare & Medicaid Services is keeping an eagle eye on costs and outcomes for TAVR, which in one analysis placed the average cost in the U.S. at more than $84,000 per patient.

A study published in November in JAMA offered some reassurance. Michael J. Mack, MD, of the Heart Hospital Baylor Plano in Texas, and colleagues found that the rollout of TAVR in the U.S. was proceeding well, with no slip in safety and effectiveness. They analyzed data from the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry, in which all TAVR centers participate.

They also reported the STS predicted risk of operative mortality score was lower than in the trials, possibly indicating that physicians are selecting lower risk patients and therefore getting better outcomes. Mack said in an interview that many other factors could contribute to the lower score, though.

The other slippery slope involves inoperable patients with severe aortic stenosis for whom treatment will be futile. Treating those patients is neither good for them nor provides value.

The House and Senate have until the end of March to work out differences in their “doc fix.” There is no guarantee the repeal will go through, but if it does, how they define and measure value will shape care in the future. Let’s make sure they get it right.     

Candace Stuart

Cardiovascular Business, editor