Recently, cardiovascular programs have experienced increased scrutiny over inappropriate inpatient admissions. As a result, many patients that were historically admitted as inpatients are now being classified as observation patients. To address some of the top-of-mind questions regarding this trend, Brian Contos, Executive Director of the Cardiovascular Roundtable, shares early insights on the financial and operational implications of providing observation services.
Q: Why have observation services garnered so much attention recently?
Observation status has existed for many years; however, recent events have placed a spotlight on this outpatient designation. Of particular note, this April, a for-profit hospital chain filed suit against another for-profit chain calling into question its admission practices - specifically alleging that it routinely admitted patients as inpatient, rather than observation, to bolster revenues. While the merits of the case are debated, the lawsuit emphasizes the weightiness, confusion and outright controversy associated with observation status.
Yet the attention to observation has deeper roots. Specifically, an increasing share of inpatient medical cases is short stay in nature. Cardiovascular medicine is a prime example with approximately 75 percent of chest pain, 50 percent of arrhythmia, and 25 percent of heart failure cases requiring inpatient stays of just one or two days. Moreover, CMS and other payers perceive many short stay inpatient cases as medically unnecessary. The Recovery Audit Contracts (RACs), which are now active across the entire country, have invested significant resources in identifying unnecessary admissions. The risk of revenue take-backs has certainly captured the attention of hospital leaders. Adding to this pressure, a national focus on reducing preventable readmissions has providers scrutinizing the necessity of index admissions.
Notwithstanding this regulatory scrutiny, hospitals are seeking more efficient, efficacious approaches to monitoring, diagnosing, and establishing treatment plans for medical cases - particularly those that present to the emergency department. As an immediate financial incentive, correct use of observation status allows providers to bill separately for the observation component of care. Further down the road, shared savings payment models will spur hospitals to provide care in the lowest cost setting, and outpatient observation is nearly always more economical than inpatient placement.
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As reported in today's Daily Briefing, widespread adoption of evidence-based treatments for severe myocardial infarctions (MIs) has led to a "sharp drop" in patient deaths, according to study in JAMA, NPR's "Shots" reports.
For the study, Swedish researchers analyzed national coronary care registry data for more than 61,000 patients who suffered an ST-elevation MI (STEMI)--a deadly MI that accounts for about 29% of all MIs--between 1996 and 2007. Across the 12-year study period, the use of evidence-based MI treatments, such as clot-busting drugs and rapid angioplasty, increased nationwide.
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Last week, the American College of Cardiovascular Administrators (ACCA) held its annual meeting in Chicago, IL. While sessions on physician integration and health reform served to kick off the meeting, several sessions on transcatheter valve devices provided a look into current experience and future potential--both good and bad--for this still investigational field. On the heels of ACC, where clinical results of the hotly anticipated PARTNER trial were released, much of the discussion at ACCA focused on future reimbursement and profitability for these procedures.
Attendees were given the chance to hear a first-hand experience from Elizabeth Walsh, Director of the Aortic Clinical Trials Division at Penn Medicine. A leader in the cardiovascular field, Penn has been at the forefront of the transcatheter valve market as an early trial site for PARTNER. Although Penn has now enrolled roughly 100 patients in the PARTNER trial, this has been no easy feat. Several years of planning, training, and administrative work have been required to operate the growing TAVI program. In addition to physician and staff training, the center has invested time and money into expanding their hybrid operating room capabilities and administrative support. These two investments have been costly, but are also crucial to Penn's experience thus far.
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CMS on Tuesday released its proposed inpatient prospective payment system (IPPS) rule for fiscal year (FY) 2012, which would reduce average payments by about 0.5%, or roughly $498 million, Modern Healthcare reports.
The proposed rule assumes a 2.8% market basket update in FY 2012 for the 3,400 acute care facilities that submit data on quality measures under the IPPS system. The proposed rule includes a 1.1% increase to payments to correct a technical error related to the rural floor budget neutrality adjustment.
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Nearly half of patients receiving a left ventricular assist device (LVAD) are readmitted within six months of implantation, according to a recent analysis of the Interagency Registry for Mechanical Assisted Circulatory Support (INTERMACS) database presented at the International Society for Heart & Lung Transplantation 2011 Scientific Sessions. The primary causes for first-time readmissions were infection and bleeding. Despite these findings, Dr. Pramond Bonde, who led the study, considered the readmission rates for LVADs to be acceptable, citing they was better than those rates seen with traditional heart failure therapies.
By analyzing 2,442 adult patients in the INTERMACS registry that underwent a primary LVAD implantation from June 2006 to March 2010, researchers aimed to gain a better understanding of reasons for readmissions in a real-world population of LVAD patients, which had not previously been reported.
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Maryland's House and Senate has signed the Maryland Cardiovascular Patient Safety Act without a mandatory cath lab accrediation requirement, which was originally included in the bill. As reported previously, the SCAI and ACC's Maryland charter have been lobbying both the Maryland House and Senate to pass the Maryland Cardiovascular Patient Safety Act, which would improve oversight of cath labs in the state.
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The Cardiovascular Roundtable recently launched an ambitious benchmarking initiative to assess members' experience developing and managing integrated heart and vascular programs. Insights gleaned from the contributions of 126 participants are now available in our latest study, "The Heart and Vascular Integration Benchmarking Initiative Results."
While efforts to bring vascular services into the cardiac service line are not new, for many programs progression has been somewhat slow and foundational challenges persist on several fronts: structuring the service line, achieving collaboration across specialties, defining principled standards for credentialing, and so on.
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An analysis of NCDR Cath PCI registry showed that overall only 4.1 percent of PCIs were classified as inappropriate according to the 2009 coronary revascularization appropriate use criteria. However, there remains an opportunity to reduce unnecessary elective procedures.
Dr. Paul Chan from St. Luke's Mid-America Heart Institute in Kansas City, MO, presented results from a retrospective analysis of the NCDR Cath PCI registry at the American College of Cardiology's 2011 Scientific Session. The study includes over half a million procedures that were performed between July 2009 and June 2010 and is the largest of its kind. When PCI utilization was analyzed in aggregate, 84.6 percent of the procedures were classified as appropriate, 4.1 percent were deemed inappropriate, and 11.2 percent were classified as uncertain according to the coronary revascularization appropriate use criteria.
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