PCI episode payments vary due to readmissions, postacute care

Readmissions and postacute care were the primary drivers of differences in payments to hospitals for 90-day episodes of percutaneous coronary intervention, suggests a study of more than 40,000 PCI procedures from 33 Michigan hospitals.

These findings are particularly relevant as PCI in both inpatient and outpatient settings is included in the Bundled Payments for Care Improvement Advanced model, which proposes to link hospitals’ reimbursement to their expected spending over a 90-day episode of care based on the average risk level of their patient population.

“Substantial hospital-level variation exists in 90-day PCI episode payments,” wrote lead author Devraj Sukul, MD, MSc, with the division of cardiovascular medicine at the University of Michigan, and colleagues in Circulation: Cardiovascular Interventions. “Over half the variation between high- and low-payment hospitals was related to care after the index procedure, primarily because of readmissions and postacute care. Hospitals and policymakers should consider targeting these components when developing initiatives to reduce PCI-related spending.”

Using Medicare fee-for-service and commercial insurance claims from 2012 through October 2016, Sukul et al. found the average risk-adjusted, hospital-level payments for 90-day PCI episodes ranged from $22,154 to $27,205—a difference of more than $5,000. Readmission payments were responsible for 46.2 percent of the variation between hospitals in the lowest and highest quartile of payments, which averaged $23,744 and $26,504 per episode, respectively.

Readmissions were the main driver of payment variation across subgroups, including inpatient versus outpatient PCI and procedures for either acute myocardial infarction or non-acute indications.

Postacute care drove 22.6 percent of the variation, with high- versus low-payment hospitals collecting an additional $336 on average for procedural outpatient facility care and an additional $143 in home health agency payments.

“Hospitals that can safely reduce readmissions after PCI stand to benefit under payment policies where reimbursement is tied to spending within an episode of care,” Sukul and coauthors wrote. “However, not all readmissions are preventable, nor should all readmissions be prevented. … Future research should focus on identifying procedural or postprocedural factors that may be targeted to safely reduce postdischarge healthcare use.”

The researchers acknowledged there could be some unmeasured patient variables that affected the adjustments for case mix between hospitals. They were also unable to discern whether some of the readmissions were planned as part of staged PCI procedures, although recently proposed bundled payment initiatives haven’t specifically accounted for staged PCIs.