Implications of Payment for Acute Myocardial Infarctions as a 90-Day Bundled Single Episode of Care: A Cost of Illness Analysis

Abstract

Objectives Evaluate the cost of illness associated with the 90-day period following acute myocardial infarction (AMI) and the implication of care pathway (percutaneous coronary intervention [PCI] vs medical management [MM]), in order to assess the potential financial risk incurred by providers for AMI as an episode of care. Perspective Reimbursement payment systems for acute care episodes are shifting from 30-day to 90-day bundled payment models. Since follow-up care and readmissions beyond the early days/weeks post-AMI are common, financial risk may be transferred to providers. Setting AMI hospitalization Centers for Medicare & Medicaid Services (CMS) standard analytical files between 10/1/2015 and 9/30/2016 were reviewed. Methods Included patients were Medicare beneficiaries with a primary diagnosis of AMI subsequently treated with either PCI or MM. Payments were standardized to remove geographic variation and separated into reimbursements for services during the hospitalization and from discharge to 90 days post-discharge. Results were stratified by Medicare Severity Diagnosis Related Groups (MS-DRGs) individually and grouped between patients treated with MM and PCI. Risk-adjusted likelihood of utilization of post-acute nursing care and all-cause readmission was assessed by logistic regression. Results A total of 96,546 patients were included in the analysis. The highest total mean payment (US$32,714) was for MS-DRG 248 (PCI with non-drug-eluting stent with major complication or comorbidity). Total payments were similar between MM and PCI patients, but MM patients incurred the majority of costs in the post-acute period after discharge, with the converse true for PCI patients. MM without catheterization was associated with a twofold increase in risk of requiring post-acute nursing care and 90-day readmission versus PCI (odds ratio [95% confidence interval]: 2.01 [1.92-2.11] and 2.17 [2.08-2.27]). Smaller hospital size, diabetes, peripheral arterial disease, prior AMI, and multivessel disease were predictors of higher healthcare utilization. Conclusions MS-DRGs associated with the lowest reimbursements (and presumably, lowest costs of inpatient care) incur the highest post-discharge expenditures. As the CMS Bundled Payment for Care Improvement and similar programs are implemented, there will be a need to account for heterogeneous post-discharge care costs.

Digital Health Programs to Reduce Readmissions in Coronary Artery Disease

“…1 , 10 Consequently, cardiac readmission rates remain high and result in substantial costs. A major driver of these costs is hospitalization expenditure 11 , 12 with the average cost of a 30-day readmission postacute myocardial infarction (AMI) costing approximately USD $15,000, with a cumulative cost of over USD $1 billion per year. 13 …”

Changes in Cardiovascular Spending, Care Utilization, and Clinical Outcomes Associated With Participation in Bundled Payments for Care Improvement – Advanced

“…8,9,[34][35][36][37] In contrast, for cardiovascular care, PAC contributes less to variation in episode spending, and hospitalizations, which are less amenable to spending reductions, contribute more. 9,10,32,37,38 Furthermore, each cardiac bundle covers hospitalizations that range from elective admissions to life-threatening decompensations. This heterogeneity could lead to substantial variation in within-bundle care processes that resists "one-size-fits-all" efforts to reduce spending, such as blanket decreases in PAC use.…”

“… 8 , 9 , 34 – 37 In contrast, for cardiovascular care, PAC contributes less to variation in episode spending, and hospitalizations, which are less amenable to spending reductions, contribute more. 9 , 10 , 32 , 37 , 38 …”

Ross procedure or mechanical aortic valve, which is the best lifetime option for an 18-year-old? A decision analysis

“…Lastly, healthcare cost expenditures associated with various transition states and postoperative complications were derived from published reports ( Table E4 ). 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 To adjust for inflation, the Consumer Price Index was used to convert the obtained cost values into August 2023 United States Dollar amounts before model entry. More information regarding the literature sources used for deriving input parameters for both baseline and sensitivity analysis can be found in Table E5 , Table E6 , Table E7 , Table E8 , Table E9 .…”

“…Furthermore, the study reported hospital charges, which may not reflect the total costs associated with an episode of transient ischemic attack. Allen et al E27 Description This study investigated costs of illness in the 90-d period after acute myocardial infarctions from 2015 to 2016 in 96,546 patients using Centers for Medicare & Medicaid Services standard analytical files. Strengths/applicability The study used multicenter data and had a large sample size, offering relatively substantial external validity.…”