Uncertainty Abounds for Cath Lab Reimbursement

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Interventional cardiology may face an upward of 32 percent slash to reimbursement beginning Jan. 1, 2012, due to the Medicare Sustainable Growth Rate (SGR) formula. In fact, payments for stent placements are set to decline nearly 4 percent. In the current realm of reimbursement ambiguity and healthcare reform, how will administrators keep their cath lab revenues from fading?

Thinking of creative ways to curb costs without jeopardizing care has presented a challenge for cath lab managers and interventional cardiologists, and strategically implementing new approaches to achieve these goals has become an elusive goal. While many call the impending cuts "unrealistic" and "unreasonable," they are most likely inevitable.  

Shaky horizon

Despite the fact that Congress has yet again suspended implementing the SGR formula until January 2012, many agencies, including the Medical Group Management Association, have urged cardiologists to fight back against the cuts. However, previous cuts and fear of more have forced some independent practices to close and others to change the delivery of services, whether it be cutting off Medicare patients or reducing the number of procedures or inventory.

Several lawmakers, like Rep. Charlie Gonzalez (D-Texas) have called for legislation to keep reimbursement rates at the 2009 Medicare Physician Fee Schedule level. However, if the cuts go through, they have the potential to financially devastate cardiac care.

Last month, the Medicare Payment Advisory Commission (MedPAC) proposed to scrap the SGR formula; however, 42 associations, including the American College of Cardiology, opposed because it contained long-term freezes and cuts. ACC CEO Jack Lewin says the focus instead should be on creating coordination between primary care physicians and specialists, and incentivizing based on performance.

Decreased payments may affect the volume of interventional procedures, which are in high demand from patients with coronary and peripheral artery disease, as well as practices.

"Hospitals and physicians will need to look at every aspect of procedures to ensure that the techniques used, the devices employed and the procedures  performed are truly necessary and beneficial," says David J. Cohen, MD, director of cardiovascular research at Saint Luke's Mid America Heart Institute in Kansas City, Mo. He adds that staff members  now are asked to find the most cost-effective drugs, devices and procedures and ensure that they are deployed efficiently, effectively and appropriately.

As cuts loom, the major blow will be to the progress that interventional cardiology has made over the last 10 to 15 years, says Jon C. George, MD, director of clinical research at the Temple University School of Medicine in Philadelphia.

Parsing out cuts

"As reimbursements decrease further, it will be even harder to perform complex interventions that require multiple catheters, stents and balloons," George offers. "We will not be able to break even with these devices due to the lower reimbursement. Thus, although we have the ability to perform them, we will be limited in terms of what we are paid for the procedure."

Still, even prior to the anticipated hefty cuts, interventional cardiology has struggled with reimbursement, as many procedures are underpaid or disregarded in proper code setting. Here are some pain points:

  • Rotational atherectomy: Currently, only the catheter placed during a rotational atherectomy procedure is reimbursed. The device, used to debulk plaque from the coronaries, was previously reimbursed; however, now cardiologists get a fixed reimbursement for the procedure, no matter how many devices are used before placing the stent, George explains. "The more you debulk the plaque within the artery, the more likely you are to have a successful procedure," he says. "However, now we are being limited by the overhead, which may unfortunately hinder patient outcomes."
  • Cutting balloons: These devices, which are more expensive than regular balloons, are used during peripheral interventions to cut through tight blockages, and are not reimbursed. In fact, the current payment model bills these devices at the same price as a regular balloon. "These types of reimbursement issues really limit us on what devices we are able to use because we are forced to weigh what the lab will get paid for," George notes.
  • Carotid artery stenting (CAS): The CREST trial showed that CAS may be equal or superior to carotid endarterectomy (CEA) for preventing stroke (New Engl J of Med 2010;363[1];11-23). Although the FDA has expanded the indications for CAS to cover lower-risk patients, Medicare currently does not reimburse for these newer indications and only reimburses for patients who are at a high surgical risk and have symptomatic CAS of greater than or equal to 70 percent. "The CMS [Centers for Medicare & Medicaid Services] will pay for one-half of the therapy, but not the other. CAS is more cost-effective, yet CMS, for some reason, is not approving payment," explains Jeffrey Marshall, MD, director of the cardiac cath lab at the Northeast Georgia Medical Center in Gainesville, Ga., and president elect of the Society of Cardiovascular Angiography and Interventions. "These arbitrary coverage decisions by CMS are preventing us from providing the best patient care."

DRG payments for a CAS procedure when a patient has a major complication or comorbidity are $19,680 compared with $9,152 for no comorbidity, according to 2011 Abbott Vascular data. George says that there has always been a lag between the evidence found in clinical studies and reimbursement, particularly with CAS in which case cath labs are left playing a waiting game.

Typically, private payors follow CMS' lead for reimbursement coverage. But, in the case of CAS, private insurers are covering even more broadly than Medicare. Across the U.S., the coverage of private payors varies regionally to not covering CAS to covering all FDA-approved indications for CAS.

While the transition to ICD-10 codes may address some issues, George says, "There will have to be reiterations of coding to allow more billable codes for these types of interventional procedures."

How to compete with cost cutting

Cardiology procedures, whether interventional or other, are facing scrutiny to prove they provide reasonable value and outcomes for their lofty costs. The necessity of elective procedures has garnered even more questions, Cohen says.

"There are more variations in care now," he adds. "We now must attempt to find less expensive drugs or less expensive devices that work just as well. As contribution margins diminish, there will be more pressure to ensure that we are performing the right procedures or using the right devices in the most efficient and effective way."

Also, if interventional cardiologists are hit with another 32 percent cut, how can they ensure that care is not compromised? "This is a big unknown," George says. While he offers that some may be forced to stop treating Medicare patients, others are working to be more resourceful by finding more cost-effective ways to deliver care.

One cost-saving option, according to George, is using the transradial rather than the femoral artery approach to access coronary arteries, which the RIVAL trial recently found had lower vascular complication rates (Lancet 2011;377[9775]:1409-1420). At 30 days, 42 of 3,507 patients in the radial group had hematomas compared with 106 of 3,514 patients in the femoral group. Additionally, George says the procedure may decrease length of stay, which also can curb costs. "Now we can open up a bed for the next patient as an attempt to try to reduce costs," he says.

Reimbursement models eventually will need to change to take into account the shifting healthcare environment. Cohen says newer payment models like accountable care organizations will force physicians and hospital administrators to carefully weigh how beneficial a procedure will be for the patient and whether long-term cost-effectiveness is justified.

While many work to provide solutions that can cut costs while at the same time improve care, what is on the horizon for interventional cardiology remains unknown. However, incentivizing hospitals for performing evidence-based medicine and improving outcomes could be one place to start.