Cath Lab Economics: Pursuit of a Light at the End of the Tunnel

At the SCAI Cath Lab Boot Camp at TCT 2015, experts gathered to discuss improving the economics of running a cath lab in light of recent declines in profitability. 

While clinicians should not lose sight of their intent in taking care of patients, “it is a business,” said session moderator Robert J. Applegate, MD, of Wake Forest School of Medicine in Winston-Salem, N.C. 

Acknowledging that the modern-day cath lab needs to balance quality and use of new technologies alongside profit margins, session participants stressed the need to focus on the timing of patient discharge, the pursuit of TAVR reimbursements and the use of proper anticoagulation regimens in improving economic outcomes. 

“There should be an emphasis on efficiency of care, cost effectiveness and quality of care,” Applegate said. “The days of ‘any procedure-any product-any time’ are over.”

Opt for same-day discharge

Same-day discharge is one method for improving profitability of a cath lab, according to Sunil V. Rao, MD, of Duke University Medical Center in Durham, N.C. In addition to saving on the costs of an overnight stay, same-day discharge opens bed availability and increases the ability to accept hospital transfers. This year’s change in Ambulatory Payment Classification (APC) codes also means that reimbursement rates for outpatient rates have increased substantially.

“Same-day discharge appears to be as safe as overnight observation,” said Rao, referencing recent observational data. “In selected patients, a 6-hour period of observation post-PCI is reasonable before sending the patient home.”

“Ultimately, the decision for same-day discharge is patient-centered,” he added, “although we do have to recognize that there are significant impacts on hospital margins.” He emphasized that centers with same-day discharge should educate patients about complications and, importantly, provide them with contact information in case questions arise.

Optimize TAVR reimbursement

As use of TAVR increases, affordability continues to be a problem, said James Hermiller, MD, of St. Vincent Heart Center of Indiana, Ind. Although cath labs on average lose $7,500 per TAVR case, there are ways to avoid certain losses, he noted. In addition to reducing length of stay, especially in uncomplicated procedures, circumventing complications from TAVR presents “a substantial opportunity for savings.” He suggested that cath labs fully assess and document comorbidities to optimize their TAVR reimbursements. He also advocated strategies to avoid triggering post-acute care treatment (PACT) penalties for early discharge. Cath labs can avoid complications by avoiding non-femoral approaches whenever possible, sizing valves correctly and optimizing patient selection. Hermiller suggested clinicians utilize the Post-TAVR Optimization App available at www.post-tavr.com, a smartphone tool that calculates center-specific TAVR reimbursements while alerting users to the differences in reimbursement between DRG codes and whether or not PACT is incurred.

Choose cost-effective anticoagulants

Patient benefits, cost savings and reduced complications can sometimes go hand in hand, particularly when deciding between two anticoagulants, such as bivalirudin (Angiomax, The Medicines Company) and heparin. Session moderator Ehtisham Mahmud, MD, of Sulpizio Cardiovascular Center of UC San Diego, in San Diego, Calif., noted that bivalirudin is usually more cost-effective, with noninferior MACE and lower rates of major and minor bleeding. It is also ideal for patients with a high risk of bleeding and stent thrombosis, he concluded.

Disclosures:

• Applegate, Hermiller, Mahmud and Rao report relationships with multiple device and pharmaceutical companies. 
• Educational support for the Post-TAVR Optimization App is provided by Edwards  LifeSciences and Medtronic.