It seems as though every day I hear about the next big thing. Sometimes there is merit, and sometimes there isn’t. There is undoubtedly merit to the coming changes in Transcatheter Aortic Valve Replacement (TAVR), and they are exciting. The changes are going to revolutionize how we use TAVR and how we contract to provide TAVR services. By contracting for TAVR, I’m referring to ways in which TAVR services are sold, which can mean negotiating with private payers, participating in bundles with CMS via BPCI-A, or working with jumbo employers to create bundles for TAVR procedures.
For starters, TAVR will soon be available for low risk patients. The Partner 3 (Edwards Lifesciences) and Evolut (Medtronic) low risk trials announced at the American College of Cardiology Scientific Sessions 2019, indicate that TAVR is either equal to, or superior to Surgical Aortic Valve Replacement (SAVR) at 1 year, or noninferior to SAVR at 2 years. The data from these studies paves the way to obtain an indication for TAVR for low risk patients. We expect a large percentage of those eligible patients to be converted to a TAVR procedure as opposed to utilizing SAVR, which has been the standard for low-risk patients. With this new indication and the conversion of many SAVR procedures to TAVR procedures, programs may require a refinement in the resource bandwidth allocated to their TAVR program.
The coming change in indication is not just an opportunity to put more resources into the TAVR arena, it’s also a time to look more closely at the provision of care and care pathways. For example, should the protocol be to perform PCIs before, during, or after a TAVR procedure? How long should you keep patients after a procedure? How do you educate patients on TAVR? What type of rehabilitation, and in what environment, is appropriate, post-TAVR? The questions are numerous, yet what is important is attempting to reduce variation in your care pathways and only deviate when it’s in the best interest of patient care. However, without a defined pathway, physicians have little guidance as to when they’re actually deviating and why. This reduction in variation not only helps to provide better care, but also more cost-effective care, which is critical in a bundled payment environment. The focus on the cost side of the value equation brings me to my next point – bundled payments have created a challenging environment for TAVR and that is about to improve.
To date, TAVR has fallen under the cardiac valve bundle in BPCI-A and has not had its own dedicated bundle. While that poses some challenges for providers, the real difficulty is when a TAVR gets lumped into a PCI bundle. If a patient receives a stent pre-TAVR, and has a TAVR procedure three weeks later, the TAVR gets counted as a readmission event under the PCI bundle. I don’t have to tell you how detrimental that is to the cost equation.
While the details have yet to be released, CMS is looking into options to resolve the problem of staged TAVRs being lumped into PCI bundles. One option may be to exclude from the reconciliation process PCI episodes that have a TAVR post discharge. Keely Macmillan of Archway Health notes that because CMS recategorized TAVRs into DRGs 266 and 267 starting 10/1/14, it now has enough data to determine the consistency of the claims data and was able to include this bundle for Model Year 3 of the BPCI-A program. CMS is listening and altering the program to create fairness, transparency, and a payment model that reflects the work being done and promotes the best outcomes for the patient.
TAVR has the eye of clinicians, CV programs, and CMS. Preparing for the onslaught of low risk patients by standardizing care pathways and protocols, and reducing variation to help improve outcomes and lower costs, is a worthwhile activity for your TAVR program. Per Archway Health, the national average for standardized 90-day spending for a TAVR bundle is approximately $57,600. The cost of the anchor procedure is approximately $44,000 (for both hospital and physician spending), which comprises 77% of total bundle spend (on average). These are high priced bundles and represent a lot of opportunity to improve both sides of the value equation. Separating out TAVR as its own bundle will help encourage more CV programs to focus on their TAVR program, but it will also open the door to more success in the PCI bundle, and hopefully encourage more participation in that bundle as well. We anticipate having more clarity on this issue by end of June.
If you have a TAVR program, this is an exciting time of change. Your program will certainly grow in the coming years and you have options to explore as to how you want to contract for that service across various payer groups. Until we actively optimize both our cost and quality profiles, we’ll never fully reach patient-centric, value-based care.
MedAxiom’s aim is to help practices proceed down both of those paths (quality and cost), and drive value into the healthcare system. On behalf of MedAxiom we appreciate your partnership in helping us achieve that mission, and as always, we are here to help.