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6 reasons CMS should cover coronary stenting in the ambulatory setting

1. Safety

Technological advancements like closure devices and radial access make Percutaneous Coronary Intervention (PCI) procedures faster and safer. Same Day Discharge (SDD) rates are rapidly increasing in the hospital setting and access to PCI without on-site surgery has increased dramatically since 2007.

Numerous other registries and randomized clinical trials have replicated these findings across a broad spectrum of patients with stable coronary artery disease and coronary anatomy. The evidence supporting the safety and efficacy of outpatient PCI in properly selected patients is indisputable.

2. Better Patient Experience
As it stands today, if a treatable cardiac condition is diagnosed via approved cardiology diagnostics on a Medicare patient at an ASC or a doctor’s office, the physician generally cannot intervene immediately – even if doing so would be medically appropriate, safe, and common practice under private insurance.

In many cases, this means that Medicare patients must undergo the intake process, sedation, catheterization, and discharge on multiple occasions at multiple settings before they can be treated appropriately. This can lead to situations that are potentially dangerous for patients’ health, not to mention financially and functionally burdensome. CMS has approved pacemaker and defibrillator procedures in the ASC setting; but has not yet taken the step to add coronary stenting.

3. Cheaper for CMS
With ASCs safely performing complex procedures like total hip replacement and single level spine fusion, coronary stenting is a logical step in the cardiology outpatient migration. If PCI gets CMS approval in the Ambulatory setting, savings could be in the billions annually for Medicare and private payers:

4. CMS is Already Moving in this Direction
In the 2018 Outpatient Prospective Payment System (OPPS) proposed Rule, a request for comments has significance for cardiovascular care. With the request titled “Definition of ASC Covered Surgical Procedures” CMS is suggesting that there are “surgery-like” procedures that are currently excluded from coverage in ASCs, but conceivably could be performed there.

CMS is open to considering “certain cardiac catheterization services, cardiac device programming services, and electrophysiology services should be added to the covered surgical procedures list.”

5. Commercial Payors Already Doing It
Why is there a different standard of care for Medicare patients and patients with private insurance? Commercial insurance such as United Healthcare, Cigna, Humana and others already allow care givers to provide coronary stenting in the Ambulatory setting. Traditionally, Medicare leads reimbursement and private payers follow, with PCI is seems to be just the opposite.

6. The Move Toward Value Based Healthcare
Cardiovascular ASCs could be particularly well positioned for participation in value based healthcare models like the Bundled Payment for Care Initiative (BPCI). These centers could also participate in Accountable Care Organizations (ACOs) and other risk-sharing arrangements like narrow networks. As the universe of cardiovascular procedures performed in the outpatient setting expands, and as ACOs and risk-sharing arrangements proliferate, we could see Cardiovascular ASCs’ referral base deepen, furthering their importance across the healthcare continuum.

If the potential change in Medicare reimbursement includes allowing cardiac interventions to be performed in ASCs, we can expect to see a significant increase in cardiologists’ and electrophysiologists’ interest in ASCs – along with increasing concern from hospitals about the loss of these patients and the associated revenue.

With this potential change eminent, we may see Joint Ventures between Cardiology groups and health systems become a popular vehicle to deliver cardiovascular care. As the dis-integration trend continues and cardiology groups once owned by the hospital now become independent, there may be strong interest from these cardiology groups to expand their site of service to include a Cardiovascular ASC. Hospitals don’t want to see their PCI cases (the 4th most common hospital based procedure) migrate to physician owned ASCs, so they may be more amenable to a risk sharing model with the physicians.

PCI in ASC - All key stakeholders win – patients, payers and physicians.

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