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Is the change in health care being driven solely on a financial basis?
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The movement toward more outpatient procedures will undoubtedly be beneficial for hospitals and patients. In cardiology, this movement is led by the use of outpatient percutaneous coronary intervention. There remains much controversy, however, as to the safety and feasibility of this practice.
First, as technology advances, smaller catheter systems become increasingly available, and as radial access gains popularity, patients can ambulate early with far less bleeding risk. Conversely, patients continue to become more complex with advancing age and multiple comorbid conditions. Physicians struggle with the safety of allowing a patient to go home after PCI. The dynamics of their social situation now enter into the decision, as does consideration for their probability of having an adverse event, medication reactions, or the need for a follow-up laboratory assay to assess hemoglobin, platelet count or renal function.
 Frank W. Smart |
 Jeffrey E. Epstein |
As with other areas of medicine, the physician is supposed to decide which course of action best suits their individual patient. Hospitals, however, are now routinely penalized for physicians’ decisions through recovery audit contractors and denial of payment by Medicare intermediaries’ refusal to reimburse for the procedure. Most hospitals today operate on single-digit margins, and the CV service line is a financially important one. When the reimbursement for complex procedures becomes interrupted, hospitals and physicians are pressured into treating patients in a manner that is less than ideal, this could potentially jeopardize individual patient outcomes.
Reports of individual physicians not being allowed to treat their patients the way they deem appropriate may seem a scare tactic of opponents of health care reform, but the practice is in fact happening today.
Internal controls vs. external assessment
At a large community teaching hospital in the Mid-Atlantic region, physicians and hospital administrators have followed the trend of outpatient PCI. In fact, in 2006, almost no outpatient/extended-recovery PCI was performed. In 2010, more than half of the cases were outpatient/extended-recovery procedures, which means an observation-type stay with reimbursement that is about 60% of the inpatient reimbursement rate. This evolution has been challenging because physicians are comfortable with the outstanding success rates they enjoyed. Patients and families were also comfortable with the assurance that they or their loved one were under the watchful eye of experienced and compassionate hospital staff.
To facilitate this movement toward the outpatient procedure, a group of senior cardiologists at the hospital assembled a set of criteria based on the risk of the patient and the risk of the procedure. These were published internally and provided to the cath lab personnel as well. Nurse case managers reviewed charts to assure compliance, and when a practitioner seemed to be slightly off course with the new trend, the department chairman and physician in charge of supervising quality would meet and discuss the individual cases. The process seemed to be working well, based on quality and performance indicators. They, however, had not accounted for the CMS.
Review by the CMS intermediary in the region had determined the high-risk cases that were coded as inpatient procedures by the cardiologist and the hospital were in fact miscoded and should have been outpatient/extended-recovery procedures. As with all CMS payment rulings, the hospital appealed to the Level-1 and Level-2 appeal processes. Each was more detailed than the first. The attending physician and department chairman, both board-certified cardiologists, found themselves justifying the admission status to administrative people with a check list or, at best, a physician of some other specialty
who had little appreciation for the complexity of the case. In no instance was a case reversed based on these appeals. Fortunately, a Level-3 appeal to an administrative law judge found that five of six cases were justified as inpatient, based on the testimony of the cardiologists and legal counsel of the hospital.
This approach to reimbursement is, of course, far too cumbersome and costly for any hospital or physician practice to long endure. So in light of the favorable decisions from the administrative judge, the hospital went back to the medical director of the CMS intermediary and its reviewers.
Continued uncertainty
The discussion proved enlightening, although not particularly helpful. It seems the CMS reviewers regarded an inpatient stay based on complications the patient experienced after the procedure. The prospective risk and comorbidities had no effect on the status and neither did the physician’s concern, procedure complexity or the social situation of the patient. Only a complication justified a higher reimbursement rate. This method of paying for poor performance seemed opposite the recent recommendations by the Institute of Medicine and leaders in health care reform. When the dichotomy was pointed out, the CMS reviewers refused to cite one example of a case that would have been justified for inpatient status prospectively.
The hospital has continued its efforts to appropriately stratify patients for inpatient or outpatient/extended-recovery procedures. The reimbursement game continues, and physicians and patients are caught in the middle. If health care reform eliminates physicians from making decisions about patients for fear of altered or denied reimbursement, our system will have suffered a major setback. We are all acutely aware that continuing escalations in health care costs are unsustainable. What remains to be seen is how the damage being imposed upon the US health care system by a lack of applied rules and guidance by payers will affect the quality, satisfaction and the cost of paying for poor performance.
Frank W. Smart, MD, is the Dorothy and Lloyd Huck Chair of the Department of Cardiovascular Medicine at Atlantic Health in Morristown, N.J., and is a member of the HF and Transplantation section of the Cardiology Today Editorial Board. Jeffrey E. Epstein, MD, is the medical director and physician adviser at Morristown Memorial Hospital in Morristown, N.J.