7.13.23
When transcatheter aortic valve replacement (TAVR) became commercially available in 2011, 简历项目面临的挑战是“首先进入市场”,” attracting new patients to their organization and elevating their brand. 这需要大量的投资来启动一个新的TAVR项目, 包括聘用和培训云顶集团40011官网, pre-purchasing devices, 发展优质基础设施, and for many programs, constructing new hybrid catheterization laboratories or operating rooms.
TAVR不再是一种新颖的治疗方法. Today, 全国有700多个项目在运作超过30万名患者接受了TAVR治疗. 它已经成为大专简历项目的基石. The challenge now, 随着TAVR继续扩大其影响范围, 项目是否专注于维持健康的财务利润率, 这意味着要改进病人的选择, optimizing revenue capture, 管理医院和供应成本, 评估人力资源.
Refine Patient Selection and 提供者资格认证过程
Given the less invasive nature of TAVR and the shorter recovery times, patients and providers tend to favor the therapy over traditional open-heart surgery when clinically appropriate. Therefore, patient selection is foundational for a successful and high-quality TAVR program. This requires programs to appropriately identify patients with the potential to benefit from TAVR and to individualize treatment for each case, 包括程序方法或访问站点, 以及阀门的类型和通径. Some key considerations related to patient selection that should be carefully evaluated by the multidisciplinary heart team include:
- Patient age, frailty, and comorbid diseases impacting life expectancy and quality of life.
- 阀门耐久性和寿命管理策略.
- 患者解剖和钙化模式.
- 患者发生新的传导障碍的风险.
除了设计合适的病人选择程序, an important part of maintaining a high-quality and safe TAVR program is ensuring a rigorous provider credentialing process of TAVR care team members, including cardiologists, cardiac surgeons, 和高级实践提供者(app). Program leaders should periodically review provider credentialing criteria to ensure alignment with national and best practice recommendations.
Enhancing Revenue Capture
TAVR programs are inherently resource-intensive, and ensuring accurate revenue capture is essential. 接受TAVR的患者通常有合并症, 而且只对住院病人开放, TAVR is currently classified either into MS-DRG 266 (with major complications or comorbidities [MCCs]) or MS-DRG 267 (without MCCs). Since procedural coding is largely dependent on physician documentation, TAVR proceduralists should be aware of documentation requirements and guidelines and receive ongoing education related to documentation integrity.
In particular, accurately capturing patient comorbidities has an impact on measuring and improving quality metrics, 以及重大的财政影响. The 2023 国家医疗保险未调整支付率 for MS-DRG 266 is $45,278, and $35,399 for MS-DRG 267, representing a $10,每道工序的付款差额为000美元.
投资于编码和文档完整性计划
Because DRG classification can vary depending on factors such as procedure complexity, length of stay (LOS), and patient comorbidities, program leaders should invest in a coding and documentation integrity (CDI) program. The goal of a CDI program is to ensure that physician documentation adequately captures patient complexity and acuity.
As part of this effort, many programs will report on the percentage of TAVR procedures coded with MCCs and compare this to the current national rate of 36%.[1]This metric should be tracked over time and shared with proceduralists to gauge whether coding outcomes are in alignment with clinical assessments, clinical management, LOS, and clinician expectations. 编码人员的参与也是必不可少的, and as a best practice, organizations often include a dedicated CV coder and documentation specialist in TAVR team meetings to provide ongoing education and feedback.
捕获术后和附加编码
Effective revenue capture means programs should appropriately bill for all clinical care provided, and since TAVR does not currently have a global post-operative period, evaluation and management (E&M) encounters performed after the procedure should be separately billable.
- Some programs utilize APPs to assist in the pre- and post-procedural care of TAVR patients, 因此,对这些供应商进行独立认证是有益的. In addition, APPs can help ensure clinical documentation accurately captures comorbidities and assist with responding to coding queries to minimize the time it takes for a claim to be submitted.
- Any procedural imaging, such as transesophageal echocardiogram (TEE) or intracardiac echocardiogram (ICE), also has separate professional billing codes that should be used to capture performed work.
- Lastly, while programs benefit from accurate provider documentation from a revenue-capture perspective, it is equally important for accurately measuring quality and clinical registry data, 其中大部分是公开报道的.
管理医院和供应成本
一旦TAVR收益得到优化, 项目应仔细评估其费用结构, 包括程序性LOS和供应费用. Stratifying TAVR patients based on risk and up-front discharge planning, 包括当天或第二天的出院计划, 可以帮助减少无并发症患者的LOS. TAVR目前不被认为是一种紧急治疗方法, so the majority of patients receive their pre-procedural workup as an outpatient. On occasion, 当病人在住院期间接受TAVR检查时, 程序前测试被捆绑在MS-DRG付款中, 这些案件通常会导致经济损失. Therefore, 及时的沟通和协调是关键, 特别是考虑到测试的数量, imaging procedures, 需要对提供者进行评估. A simple pre-procedural checklist can help the multidisciplinary team members track the workup progress and minimize unnecessary LOS-related costs.
Further, 因为TAVR仍然是住院患者的手术, programs should monitor and regularly report on patient discharge statuses and all post–acute care transfer policy (PACT) payments. Patients receiving TAVR a decade ago were often discharged to another facility; however, a 2019 report by the 美国心脏病学会 highlighted that the majority of patients (90.3%) are discharged home, 6.6%到康复或延长护理机构.45% to a nursing home. A TAVR program with an extended LOS and/or above-average PACT utilization, yet a disproportionately low volume of cases classified into MS-DRG 266, for example, will benefit from engaging CDI specialists to evaluate whether their clinical documentation is appropriately capturing expected clinical outcomes based on procedure classification. In this example, the TAVR program will have a higher cost structure due to the extended LOS and PACT penalty and will receive the lower of the two MS-DRG payments, representing an opportunity to evaluate coding and documentation accuracy.
Managing Procedural Supplies
除了管理住院医院LOS和相关费用之外, 项目从评估程序供应成本中受益, 最值得注意的是TAVR瓣膜和手术备用供应. TAVR valves remain significantly more expensive than surgical valves, and the cost, 这通常是手术瓣膜的五到六倍, 导致TAVR程序的边际狭窄.
- The cost of valves should decrease as new models enter the US market, but CV program leaders should partner with vendors to identify opportunities for cost savings. This might include purchasing valves on consignment or taking advantage of rebates and discounted purchase prices when buying a certain number of valves on a monthly or quarterly basis.
- Similarly, surgical supply packs should only be opened at the discretion of the cardiothoracic (CT) surgeon. Many mature TAVR programs leave these supplies unopened for most or all cases (reserving them only for higher-risk procedures), 从而降低了使用和清洁这些用品的成本.
评估人力资源
Like all structural heart procedures, TAVR requires a multidisciplinary team. At the center of this care team is the “valve coordinator” or nurse program coordinator or nurse navigator, 随着角色的不断演变. Nursing coordination is essential to managing a high-performing and high-volume TAVR program, 因为病人需要广泛的教育, 包括多项测试的详细的程序前检查, specialized imaging, and physician collaboration. The nurse coordinator will have an extended relationship with TAVR program patients, beginning at referral and extending to or even beyond the patient’s one-year post-procedure evaluation, 使这一立场对实现护理的连续性至关重要. TAVR programs should align nurse coordinators and APP resources with the program size and growth expectations, 如图2所示. 所有TAVR项目至少需要一名护士项目协调员, and typically, once a program grows to a size such that it’s performing around 150 TAVRs annually, 它受益于添加了一个APP.
In this model, the nurse program coordinator’s role is to support and educate patients, align care across care sites, 并确保及时的预程序流程. The APP is therefore able to expand physician capacity by assisting with inpatient pre-procedural workups, 进行一些测试和咨询, 在诊所为病人做术后评估, 独立的,与云顶集团40011官网并行的. Both the nurse coordinator and the program APP play an important role in continuity of care and assuring all guideline-driven interventions are addressed. Maintaining the right ratio of nurses and APPs to programmatic volumes, 以及适当的工作范围和职责, is key to managing resources.
Surgical Staff and Perfusion
The Centers for Medicare & Medicaid (CMS) requires both an interventional cardiologist and a CT surgeon to be present for every TAVR procedure. This is a hotly debated topic, but the presence of both physicians remains the current mandate and standard of care.
While the cost of the surgeon’s time is therefore attributable to each TAVR case, 项目已经开始评估外科护士是否, techs, 灌注师也必须在场, 或者是否存在安全的替代方案. In 2019, cardiopulmonary bypass was used in less than 0.41% of TAVR cases, and as such, some programs have begun redeploying surgical staff to other nonclinical tasks. A perfusionist is still typically present in the case during valve deployment; however, 他们可能能够在过程之外执行其他工作, 只要它们在紧急情况下随时可用. Perfusion equipment can also be left outside of the room, particularly for lower-risk cases.
Imaging Cardiologists
While most TAVR programs find the involvement of an echocardiologist during the procedure valuable, dedicating another physician resource is costly and adds to the already high procedural overhead. To minimize this, 以及少数需要程序性TEE的案件, some programs utilize the cardiac anesthesiologist to perform this role.
Similarly, for the remainder of cases requiring a transthoracic echocardiogram (TTE), 通常,回声超声仪能够获取图像, and the interventional cardiologist is able to review these in lieu of the additional echocardiologist. These adjustments provide safe alternatives to involving an imaging cardiologist during the TAVR procedure.
Healthy Programmatic Growth
一旦收入捕获优化和间接费用的调整, programs should focus on growth of TAVR and structural heart volumes. Best practices to continue programmatic growth include the following:
- 通过建立评估扩展机会 协作式护理网络.
- 避免不必要的术前检查延误. 门诊病人通常需要几周的时间来接受检查, and as a best practice, organizations aim to keep this workup process to less than four weeks. Checklists and frequent care team engagement can help ensure smooth and timely processes.
- As operator experience increases, consider offering alternative catheter approaches (e.g., carotid, axillary/subclavian, as well as valve-in-valve procedures).
- Foster multidisciplinary structural heart clinics to drive volume to surgical valve programs (which tend to have historically healthy margins).
- Consider involvement in mitral and tricuspid valve research trials to expand clinical offerings and attract new patients to the organization.
- 追求通过认证成为阀门卓越中心 美国心脏病学会.
- 继续投资资源以支持质量, and regularly monitor all publicly reported patient safety and quality data.
Best Practice TAVR Programs
Given the strong financial headwinds that many organizations are currently facing, optimizing financial margins of all service lines and procedures is prudent; however, 应优先考虑诸如TAVR之类的资源密集型程序. As we look to the future, TAVR手术的持续增长, as well as transcatheter replacement of mitral and tricuspid valves, seems likely. Successful CV programs are those that are able to continue their growth trajectory with high-quality outcomes while managing margins through revenue optimization and efficient resource utilization.
ECG’s cardiovascular consulting team is passionate about improving CV care delivery and since 2010 has conducted nearly 300 CV engagements across more than 100 parent companies.
Learn MoreEdited by: Matt Maslin
Footnotes
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来源:截至2021年9月的2021年医疗保险索赔数据.