Scott Bachik is a Senior Vice President and Stacey is a Senior Vice President at Corazon, Inc., offering strategic program development for the heart, vascular, neuro, and orthopedic specialties. Corazon offers a full continuum of consulting, software solution, recruitment, and interim management services for hospitals, health systems, and practices of all sizes across the country and in Canada. To learn more, visit www.corazoninc.com or call (412) 364-8200. To reach the authors, email sbachik@corazoninc.com or slang@corazoninc.com.

Stroke history

Over the past decade, great strides have been made in developing therapies, processes, and protocols that have the potential to positively impact patients affected by stroke. Since 1996, when tPA was approved for the treatment of acute ischemic stroke, front-line clinicians have recognized that stroke has evolved from a “spectator sport” to a complex, protocol-driven, time-sensitive marathon, the goal of which is positively affecting both mortality rates and functional outcomes in this complex population. 

Though stroke has now fallen to the fifth-leading cause of death in the United States (with annual occurrences at approximately 800,000 with nearly 130,000 deaths), stroke continues to be the leading cause of long-term disability among Americans. The number of stroke deaths declined by more than 21% from 2001 to 2011, and the relative rate of stroke death fell by more than 35%.¹ A positive trend for the industry, and one Corazon believes can be attributed (at least in part) to the aforementioned advances in care for this subspecialty. Our efforts are working!  

Financially, the numbers are more staggering. The economic cost of caring for acute stroke patients is estimated to be nearly $34 billion annually, and the economic impact of patients who survive acute stroke, often with devastating deficits, approaches $80 billion per year.¹ While hypertension-control efforts of the past two decades have had a significant impact on reducing stroke mortality, much work remains to be done (Figure 1). 

The positive effects of expanded treatment options can be seen in decreasing mortality rates. Survival of the acute event also affords healthcare providers the opportunity to provide effective treatment for the co-morbid conditions most commonly associated with stroke. While other diseases of the vascular bed are commonly found in patients suffering from stroke, there is a need to look beyond these “typical” conditions. The recent conclusion of several research trials that performed a retrospective analysis of the effectiveness of endovascular therapies in combination with intravenous thrombolytic therapy demonstrates the dramatic impact that these cutting-edge therapies can have in this patient population. While much has been accomplished, much remains to be done (Table 1).

In today’s healthcare environment, we all must understand and be aware of available abilities to impact finances. The opportunity to keep the financial benefits of stroke patients within an organization exists and can be accomplished by a coordinated approach to the care of these patients across the full continuum. Current and future growth in stroke volumes translates the strong per-case margin into a meaningful aggregate contribution margin for organizations that are positioned to diagnose and treat the co-morbid conditions typically present in stroke patients. Advances in care and changes in reimbursement continue to make stroke care a profitable endeavor when approached in a programmatic manner. 

Consider the following:

• Acute stroke drives IV tPA, craniotomy, and neurointerventional cases.
• All three equate to cardiac procedure or cardiac surgery case contribution margins (payment minus direct cost).
• Can result in a change in payer mix driven by: 

-    Stroke affecting younger individuals;

- Older populations remaining in the workforce longer.

• Best practice and appropriate upstream care of TIA (transient ischemic attack) patients presenting to primary care providers (PCPs) and emergency departments (EDs) is a TIA clinic vs observation status, when screened using ABCD2 Score.
• Sleep apnea diagnosis during acute care qualifies for the WCC (with major complications or comorbidities) diagnosis and reimbursement, thus a higher payment for the care if coded properly.
• Depression diagnosis during acute care qualifies for the WCC diagnosis and reimbursement. Seizure or aspiration during acute care qualifies for the WMCC diagnosis and reimbursement.
• Evidenced-based best practice and appropriate acute stroke downstream care bring additional revenue and margin through:

-    Acute rehabilitation;

-    Sleep studies: sleep apnea has high correlation to stroke;

-    Stroke clinics: modifiable risk factors;

-    Cardiology follow-up: including electrophysiology (EP) (heart strokes);

-    Vascular procedures (large artery strokes);

-    Depression care;

-    Outpatient rehabilitation.

Neurosciences overall is an evolving service line, and stroke is quickly becoming one of the most dynamic areas of development within healthcare, with major overlap with the cardiovascular service line as shown in the bullets above. Access to needed stroke clinical resources is being accomplished through the use of telemedicine. This integration has created many hub-and-spoke networks throughout the country, thereby facilitating and enhancing inter-hospital partnerships and communication, along with coordinated rapid access to necessary care. Furthermore, two of the three main certification organizations (The Joint Commission and Healthcare Facilities Accreditation Program) offer a third level of stroke certification (Stroke Ready). This provides a formal approach to care for hospitals positioned to provide front-line, emergent therapy, but who lack the internal resources to provide inpatient care. This certification is in addition to the existing Primary Stroke and Comprehensive Stroke certifications.

Several key steps are necessary to effectively capture the additional value of stroke:

•    Emerge into the point-of-care world, capturing critical interface days.

Achieving an understanding of all patient needs with respect to co-morbid conditions is difficult in any circumstance. This is particularly so in the case of stroke. Constant decreases in length of stay (LOS) expectations, combined with the complexity of care needs during the acute episode, can lead to missed opportunities. A key role for the program leader is to evaluate data in real-time, during the inpatient stay. This allows a comprehensive plan of care for all necessary follow-up to be developed when face-to-face interaction with the patient is possible, as opposed to attempting to connect post discharge.

•    Add post-acute patient navigation touches.

Post-acute care and post discharge touch points are essential to ensure patient compliance. This assistance, with the navigation of follow-up needs, provides a valuable and necessary means to foster continued engagement by the patient with the organization. 

•    Add post-acute processes and systems of care.

Responsibility for care of the stroke patient no longer stops at the hospital doors. Prescribed follow-up is now a requirement to maintain certification as a stroke center. Beyond these basic requirements, however, are many other opportunities to enhance care and improve outcomes, such as ensuring follow-up with cardiology in the case of atrial-fibrillation related stroke, for example. Referral to the sleep lab to assess for sleep apnea and ensuring compliance and follow-up for stroke patients who also have diabetes are also essential actions. The ability to form multiple linkages between the patient and organization facilitates patient transition from acute care to life-long behavior modification for improved quality of life.

•    Add TIA clinics for better access to meaningful prevention interface.

A structured approach to the necessary follow-up for patients with TIA provides tremendous benefit for both patients and the organization. Reductions in LOS and a coordinated approach to care can net both improved financial and quality outcomes. Reductions in stroke risk that result from timely and complete follow-up are well documented. Compliance by the patient with the prescribed follow-up is essential in managing concurrent risk factors as well as pre-existing co-morbid conditions.

Conclusion

Many hospitals across the country treat stroke patients, but few have a full understanding of the financial impact that this patient population brings to the bottom line. Even fewer understand the full financial potential of this patient population. The 2015 Medicare reimbursement for the stroke DRGs can range from $4,400 to over $16,000 per case. If treated effectively and efficiently, the stroke patient population should have a contribution margin of 35% to 45%, equivalent to or greater than that of total joint replacements. Stroke patients require additional services as they transition through the full continuum of stroke care. These services are key to delivering appropriate care, and have the benefit of driving additional revenue. 

Focusing down to the details of best-practice stroke care creates one of those opportunities where the right thing and the smart thing are the same thing! The intent of moving a specialty program forward should be on improving the quality of care and the financial return related to the services currently provided, by not only creating the appropriate programmatic elements that are missing, but also fine-tuning those already present. Doing so will bring great benefit to the program and the patients. 

References

1. Mozzafarian D, Benjamin EJ, Go AS, et al. on behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart Disease and Stroke Statistics – 2015 Update: a report from the American Heart Association. Circulation. 2015; 131: e29-e322.
2. Centers for Disease Control and Prevention, National Center for Health Statistics. Underlying Cause of Death 1999-2013 on CDC WONDER Online Database, released 2015. Data are from the Multiple Cause of Death Files, 1999-2013, as compiled from data provided by the 57 vital statistics.