Drivers of Variation in 90-Day Episode Payments After Percutaneous Coronary Intervention

Abstract

Background: Percutaneous coronary intervention (PCI) is a common and expensive procedure that has become a target for bundled payment initiatives. We described the magnitude and determinants of variation in 90-day PCI episode payments across a diverse array of patients and hospitals. Methods and Results: We linked clinical registry data from PCIs performed at 33 Michigan hospitals to 90-day episodes of care constructed using Medicare fee-for-service and commercial insurance claims from 1/2012-10/2016. Payments were price-standardized and risk-adjusted using clinical and administrative variables in an observed-over-expected framework. Hospitals were stratified into quartiles based on average episode payments. Payment components between the highest and lowest quartiles were compared to identify drivers of variation (i.e. index hospitalization/procedure, readmissions, post-acute care, professional fees). Among 40,925 90-day PCI episodes, the average risk-adjusted 90-day episode payment by hospital ranged between $22,154 and $27,205 with a median of $24,696 (IQR: $24,190-$25,643). Hospitals in the lowest and highest quartiles had average episode payments of $23,744 and $26,504, respectively (difference: $2,760). Readmission payments were the primary driver of this variation (46.2%), followed by post-acute care (22.6%). Readmissions remained the primary driver of variation in key subgroups including inpatient and outpatient PCI, as well as PCI for acute myocardial infarction (AMI) and non-AMI indications. Conclusions: Substantial hospital-level variation exists in 90-day PCI episode payments. Over half the variation between high and low payment hospitals was related to care after the index procedure, primarily due to readmissions and post-acute care. Hospitals and policymakers should consider targeting these components when developing initiatives to reduce PCI-related spending.

Artificial Intelligence in Percutaneous Coronary Intervention: Improved Prediction of Pci-Related Complications Using an Artificial Neural Network

“…The average age of the patients was 65.6 years. Obesity (body mass index > 30 kg/m 2 , 46.6%), diabetes mellitus (40.4%), dyslipidemia (84.5%), and hypertension (83.8%) chronic renal (26.4%) and chronic lung (17.6%) disease were the commonest comorbidities. The average pre-PCI left ventricular ejection fraction was 52.1%, and a large proportion (varying between 21%-47%) patients had a significant history of heart failure, coronary artery disease, myocardial infarction, peripheral artery disease, or previous cardiac interventions (PCI and/or coronary artery bypass graft(CABG)).…”

“…In fact, alternative payment models such as the Centers for Medicare and Medicaid Services (CMS) episode payment models (EPMs), commonly known as “bundled payments”, are accelerating hospitals to prepare for the shift in reimbursement from ‘payment for volume’ to ‘payment for value’. (2)…”

Trends and outcomes of non-primary PCI at sites without cardiac surgery on-site: The early Michigan experience

“…As health care costs continue to escalate with increasing prevalence of cardiovascular disease and constant advancement of medical technologies and equipment, the economic evaluations of health care delivery are essential. Previous studies have shown that a significant portion of post-PCI costs are related to hospital readmissions, lengths of stay, and post-procedural complications or post-acute care [ 20 – 22 ]. Using large readmission and administrative claim databases, analyzing hundreds of thousands of patients undergoing PCI, these studies have shown clear associations between longer lengths of stay and post-procedural complication rates with increased costs.…”

Interventional economics provide a roadmap to better patient care

“…However, Medicare is introducing episode‐based reimbursement models and pioneering them on patients undergoing PCI. In one study, readmission was the major cause of variation in cost of the PCI episode 4 . Furthermore, Medicare is refining their methodology to identify differences in cost among individual operators 5 .…”