What Would Happen to Your Hospital PCI Program Today if CMS Reimbursed for Elective PCI in the Ambulatory Setting?

In this month’s article I am extremely delighted to have a returning author, Anne Beekman, RN, BSN, NEC. However, Anne now writes in her capacity as the Senior Manager, Care Pathways, for Terumo Business Edge. Anne’s extensive experience in working with cardiac programs makes her a perfect addition to our team and in this month’s article, she focuses on a very relevant and growing challenge for many cardiac programs — competing and surviving in this new and rapidly changing healthcare environment, an environment that demands a population health focus with a heavy dose of consumerism.   — Gary Clifton, Vice President, Terumo Business Edge

What would happen to your hospital percutaneous coronary intervention (PCI) program today if CMS reimbursed for elective PCI to be performed in the ambulatory setting? This is an interesting question and generates a variety of responses depending on your program’s geographic location, competitive landscape, and state regulations. In some states such as Florida and Texas, the question they are asking is not if but when. In these states, private payers are already leading the charge and paying for elective PCI work in outpatient labs. In contrast, my home state of Michigan is adjusting to a recent certificate of need (CON) change allowing elective PCI in hospitals without on-site surgical support. Criteria regarding where PCI can be performed has evolved very differently under individual state regulations. However, should CMS allow payment for elective PCI in the ambulatory surgery setting (ASC), all providers of elective PCI would need an immediate strategy addressing outpatient elective PCI in the ambulatory setting.

What makes the movement of PCI to the ambulatory setting such a hot topic right now?  

• CMS has recently proposed additional cardiac services be open for comment as outpatient prospective payments services. Elective PCI is included as a potential procedure.
• The body of knowledge around safe, elective PCI in the ambulatory setting is growing.
• Same-day discharge data demonstrates the safety of eliminating the need for overnight stays
• The drive to reduce costs — and moving elective PCI could save a lab doing 1000 PCIs a year approximately $1 million.¹ 
• Patients are researching and selecting lower-cost care options.

It was not long ago that peripheral work seemed to move overnight to the office-based lab. This migration was directly related to similar CMS payment changes regarding site of service for peripheral work. Many hospital programs were caught off guard and experienced significant loss of procedural revenue during this transition. Should elective PCI follow the same path? Is your program ready to compete in a new ambulatory market? The answer for many programs appears to be no.  

Based on the recently released Society for Cardiovascular Angiography and Interventions (SCAI) document, only 14 percent of United States cardiologists are practicing same-day discharge with their elective PCI patients.² A critical part of an ambulatory strategy is the ability to provide the procedure without an overnight stay. In talking with hospital administrators and physicians, there seems to be a belief that they can “flip a switch” and begin a same-day discharge program when the need is there. The reality is that it takes education and infrastructure to build a successful same-day discharge program. Hospitals are struggling to create unique care pathways for two very different PCI patient populations: those coming in for elective PCI procedures versus those with acute PCI needs. Without diligence around this work, the cost of care for these two very different patient populations looks similar. The reality is that an ambulatory center has a track record of providing care at 53% percent of what CMS paid hospitals; most hospitals are unable to compete.³ The risk hospitals face in not creating these pathways is an ambulatory surgery center has proven the ability to provide this transformational change very effectively and quickly. In addition, patients may prefer the pricing and the experience of the ambulatory centers over an acute care facility. The good news is that there is time for hospitals to take corrective action.

Can a hospital cardiology program compete in the ambulatory market? Yes, looking at other service lines such as gastrointestinal/genitourinary (GI/GU) and orthopedics, there is a model already developed and some systems have made these transitions successfully. Hospitals can ready themselves by creating the necessary ambulatory model for tomorrow within the acute care space today. This not only positions hospitals for the future, but an ambulatory model reduces present-day costs and improves margins for elective PCI.  

 Here are steps to creating an ambulatory model:

• Understand the cost of an elective PCI;
• Quantify the number of outpatients overnighted in inpatient beds;
• Reduce variation and streamline the pre-procedure process;
• Move all pre-work to the office setting;
• Office education supports same-day discharge;
• Proactively schedule follow-up appointments in the office setting prior to the procedure;
• Prep elective PCI patients like outpatients;
• Grow the use of radial access;
• Minimize patient movement within the hospital space;
• Promote safe, same-day discharge;
• Measure patient experience.

Many cardiologists and cardiovascular service line leaders have been waiting for updated guidelines to be released. The good news is SCAI recently updated the 2009 guidelines for same-day discharge for elective PCI. The 2018 SCAI consensus document provides a comprehensive look at what the authors feel are the critical elements for a safe and effective same-day discharge program. The document goes into detail on the studies proving the safety and financial benefits of same-day discharge and radial access. The writers of the document also address the consistent question of legal concerns around same-day discharge. The summary of the report concludes that creating a same-day discharge process is a reasonable action.  

Creating a same-day discharge process and outpatient approach goes beyond the procedure walls. The office setting takes on a pivotal role in the success of a same-day discharge program. Table 1 highlights work done at one cardiac center, and quantifies how costs and workload move within the program.  The times are average times based on comparing elective PCI patients overnighted to elective PCI patients discharged same day. The numbers represent 6 weeks of data for both populations (Terumo Business Edge source data).

This hospital experience reduced minutes of care provided by 75%. Table 1 highlights the work behind this process and the shifting of roles and responsibilities.  The red times indicate more time for that role or location, and the green represents less time. The intra procedure time was unchanged. The overall work resulted in 1,385 minutes of non-value added work eliminated. This accomplishment comes from working with physicians, office staff, procedural staff, pharmacy, information technology, and the patient. The benefits for this program was much-needed inpatient bed space, reduced length of stay (LOS), reduced costs, improved handoffs between the office and hospital, and most importantly, all patients preferred a same-day discharge (per responses to a question in a post procedure call).  

There has been no better time to create your ambulatory strategy. The data is building, the payment models are changing, and SCAI has provided an updated expert consensus document to lead the charge. If you are interested in learning more about how to develop or accelerate your program ambulatory strategy, reach out to me directly to discuss.

Anne Beekman RN, BSN, NEC

anne.beekman@terumomedical.com

Cell: (908) 635-7912

References

1. Amin AP, Patterson M, House JA, Giersiefen H, Spertus JA, Baklanov DV, et al. Costs associated with access site and same-day discharge among Medicare beneficiaries undergoing percutaneous coronary intervention: an evaluation of the current percutaneous coronary intervention care pathways in the United States. JACC Cardiovasc Interv. 2017 Feb 27; 10(4): 342-351.
2. Seto AH, Shroff A, Abu-Fadel M, et al. Length of stay following percutaneous coronary intervention: An expert consensus document update from the society for cardiovascular angiography and interventions. Catheter Cardiovasc Interv. 2018 Apr 24. doi: 10.1002/ccd.27637. [Epub ahead of print]
3. The ASC cost differential. Advancing Surgical Care. August 2016. Available online at https://www.ascassociation.org/advancingsurgicalcare/reducinghealthcarecosts/paymentdisparitiesbetweenascsandhopds. Accessed July 19, 2018.