Following is a discussion of 6 reasons the Centers for Medicare and Medicaid (CMS) should cover percutaneous coronary intervention (PCI) in the ambulatory setting:
Technological advancements like closure devices and radial artery access make PCI procedures faster and safer. Same-day discharge (SDD) rates are rapidly increasing in the hospital setting and access to PCI without on-site surgery has increased dramatically since 2007. States have been making regulatory changes when necessary to improve outpatient access for PCI (Table 1).
There have been multiple studies over the past decade1 related to SDD PCI. All of the studies show a low complication rate and no significant variation in the inpatient vs. outpatient cohorts.
In one of the studies2, patients were divided into two groups based on their length of stay after PCI: same-day discharge or overnight stay. The main outcome measures were death or re-hospitalization within 2 days and by 30 days after PCI. The prevalence of same-day discharge was 1.25% with significant variation across facilities.
SDD patients underwent shorter procedures with less multivessel intervention. There were no significant differences in the rates of death or re-hospitalization at two days or at 30 days. Among patients with adverse outcomes, the median time to death or re-hospitalization did not differ between the groups (same-day discharge, 13 days vs overnight stay, 14 days). After adjustment for patient and procedure characteristics, same-day discharge was not significantly associated with 30-day death or re-hospitalization.
Numerous other registries and randomized clinical trials have replicated these findings across a broad spectrum of patients with stable coronary artery disease and coronary anatomy. The evidence supporting the safety and efficacy of outpatient PCI in properly selected patients is indisputable.3-10
Another study example11: In a cohort of more than 100,000 patients, of the 80% of patients suitable for same-day discharge, none suffered a cardiac event within 24 hours after PCI, and only three patients experienced a vascular complication, with no differences observed in the two groups. The patients assigned to same-day discharge reported significantly higher rates of overall satisfaction and incurred lower costs for the PCI procedure than the patients randomized to standard overnight hospitalization. At one year, no significant differences in outcomes were observed between the two strategies.
2. Better Patient Experience.
As it stands today, if a treatable cardiac condition is diagnosed via approved cardiology diagnostics on a Medicare patient at an ambulatory surgical center (ASC) or a doctor’s office, the physician generally cannot intervene immediately — even if doing so would be medically appropriate, safe, and common practice under private insurance. In many cases, this means that Medicare patients must undergo the intake process, sedation, catheterization, and discharge on multiple occasions at multiple settings before they can be treated appropriately. This can lead to situations that are potentially dangerous to patients’ health, not to mention financially and functionally burdensome. CMS has approved pacemaker and defibrillator procedures in the ASC setting, but has not yet taken the step to add cardiac interventions.
3. Cheaper for CMS.
More and more procedures are reimbursed in the ambulatory setting. There are over 5,500 Medicare-certified ASCs performing roughly two-thirds of all the outpatient surgeries in the United States.12 These ASCs are safely performing complex procedures like total hip replacement and single level spine fusion with significant cost saving over the same procedures in hospitals. If PCI gets CMS approval in the ambulatory setting, savings could be in the billions annually for Medicare and private payers (Table 2).
4. CMS is Already Moving in This Direction.
In the 2018 Outpatient Prospective Payment System (OPPS) proposed rule, a request for comments has significance for cardiovascular care. With the request titled “Definition of ASC Covered Surgical Procedures”, CMS is suggesting that there are “surgery-like” procedures that are currently excluded from coverage in ASCs, but conceivably could be performed there.
CMS is open to considering that “certain cardiac catheterization services, cardiac device programming services, and electrophysiology services should be added to the covered surgical procedures list.”
5. Commercial Payers Are Already Doing It.
Why is there a different standard of care for Medicare patients and patients with private insurance? Commercial insurance such as United Healthcare, Cigna, Humana, and others already allow caregivers to provide coronary intervention in the ambulatory setting. Traditionally, Medicare leads reimbursement and private payers follow; with PCI, it seems to be just the opposite.
6. The Move Toward Value-Based Health Care.
Cardiovascular ASCs could be particularly well positioned for participation in value-based healthcare models like the bundled payment for care improvement (BPCI) initiative. These models link payments for the multiple services that beneficiaries receive during an episode of care. Under the initiative, organizations enter into payment arrangements that include financial and performance accountability for episodes of care. These models may lead to higher quality and more coordinated care at a lower cost to Medicare, and may be delivered at cardiovascular centers.
These centers may also participate in accountable care organizations (ACOs) and other risk-sharing arrangements like narrow networks. As the universe of cardiovascular procedures performed in the outpatient setting expands, and as ACOs and risk-sharing arrangements proliferate, we could see cardiovascular ASCs’ referral base deepen, furthering their importance across the healthcare continuum.
If the potential change in Medicare reimbursement includes allowing cardiac interventions and cardiac rhythm management procedures to be performed in ASCs, we can expect to see a significant increase in cardiologists’ and electrophysiologists’ interest in ASCs, along with increasing concern from hospitals about the loss of these patients and the associated revenue.
With this potential change eminent, we see joint ventures between cardiology groups and health systems becoming a popular vehicle to deliver cardiovascular care. As the “dis-integration” trend continues and cardiology groups once owned by the hospital now become independent, there may be strong interest from these cardiology groups to expand their site of service to include a cardiovascular ASC. Hospitals don’t want to see their PCI cases (the fourth most common hospital-based procedure13) migrate to physician-owned ASCs, so they may be more amenable to a risk-sharing model with the physicians.
PCI in ASC — All key stakeholders win: patients, payers, and physicians.
- Abdelaal E, Rao SV, Gilchrist IC, et al. Same-day discharge compared with overnight hospitalization after uncomplicated percutaneous coronary intervention: a systematic review and meta-analysis. JACC Cardiovasc Interv. 2013 Feb; 6(2): 99-112. doi: 10.1016/j.jcin.2012.10.008.
- Kahn MR, Fallahi A, Kulina R, et al. Outcomes of patients undergoing elective percutaneous coronary interventions in the ambulatory versus in-hospital setting. J Invasive Cardiol. 2014; 26(3): 106-113.
- Bertrand OF, De Larochelliere R, Rodes-Cabau J, et al. A randomized study comparing same-day home discharge and abciximab bolus only to overnight hospitalization and abciximab bolus and infusion after transradial coronary stent implantation. Circulation. 2006; 114: 2636-2643.
- Ziakas A, Klinke P, Fretz DE, et al. Same-day discharge is preferred by the majority of the patients undergoing radial PCI. J Invasive Cardiol. 2004;16:562-565.
- Slagboom T, Kiemeneij F, Laarman GJ, et al. Outpatient coronary angioplasty: feasible and safe. Catheter Cardiovasc Interv. 2005;64:421-427.
- Ziakas A, Klinke P, Mildenberger R, et al. Safety of same day discharge radial PCI in patients under and over 75 years of age. Int Heart J. 2007;48:569-578.
- Glaser R, Gertz Z, Matthai WH, et al. Patient satisfaction is comparable to early discharge versus overnight observation after elective percutaneous coronary intervention. J Invasive Cardiol. 2009; 21: 464-467.
- Ranchord AM, Prasad S, Seneviratne SK, et al. Same-day discharge is feasible and safe in the majority of elderly patients undergoing elective percutaneous coronary intervention. J Invasive Cardiol. 2010; 22: 301-305.
- Gilchrist IC, Rhodes DA, Zimmerman HE. A single center experience with same-day transradial PCI patients: a contrast with published guidelines. Catheter Cardiovasc Interv. 2011; 79: 583-587.
- Muthusamy P, Busman DK, Davis AT, et al. Assessment of clinical outcomes related to early discharge after elective percutaneous coronary intervention. Catheter Cardiovasc Interv. 2013;81:6-13.
- Rao SV, Kaltenbach LA, Weintraub WS, et al. Prevalence and outcomes of same-day discharge after elective percutaneous coronary intervention among older patients. JAMA. 2011; 306: 1461-1467.
- Coker Capital Advisors Newsletter, May, 2017. Available online at https://tinyurl.com/yclds2jk. Accessed June 26, 2018.
- Moussa ID. Ambulatory outpatient percutaneous coronary intervention. Cardiac Interventions Today. 2015 July/Aug. Available online at https://citoday.com/2015/08/ambulatory-outpatient-percutaneous-coronary-intervention/. Accessed June 26, 2018.
Marc Toth can be contacted at firstname.lastname@example.org.