Blog Post

How to address PACT—a hidden threat to your TAVR margins

August 10, 2017

    Facing challenging TAVR finances? You're not alone. In addition to device, infrastructure, and operating costs, it turns out that an often-overlooked CMS policy may be eating away at your margins–but that doesn't have to be the case.

    CMS's Post-Acute Transfer (PACT) policy costs hospitals nationwide more than pay-for-performance penalties; at least 1,300 hospitals lose more than $500,000 per hospital in Medicare fee-for-service inpatient revenue annually because of PACT.

    Under PACT, CMS reimburses certain MS-DRGs at a lower rate if the inpatient length of stay (LOS) is shorter than average and patients are discharged to a qualifying post-acute care setting. The policy effectively encourages programs to discharge patients only when ready and, then, to the appropriate level of care—ideally their home, whenever possible. And TAVR's DRGs—266 and 267—are both included under PACT.

    The Cardiovascular Roundtable's new analysis of Medicare data demonstrates the real threat that PACT poses to TAVR finances. In 2015, between 6% and 18%of TAVR cases triggered PACT, with reimbursement cuts of over $12,000 per case.

    PACT policy impact on TAVR cases
    Medicare, 2015

    It's clear that CV service line leaders should prioritize reducing PACT's impact in order to maximize TAVR finances. Through our recent research, we've uncovered three critical steps to doing so:

      1. Use post-acute care only when necessary

    At many structural heart programs, TAVR patients are enrolled in home health or even sent to a skilled nursing facility (SNF) as the default care plan. If discharge occurs before the average LOS, these patients will trigger PACT. But critically, as TAVR has become less invasive, fewer patients clinically require post-acute care.

    To combat this pattern, Centura Health in Colorado transitioned from using home health as the default for post-TAVR patients to discussing its appropriateness on a case-by-case basis and only using it when necessary. As a result of this change, along with provider education, they successfully reduced TAVR cases triggering PACT by 49%.

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      2. Align expectations for discharge

    It's important that everyone involved in the case—providers, patients, and their families—fully understand the discharge plan. From the outset at screening, program staff should engage patients and families in discussions about discharge plans.

    Physicians and other structural heart care team members may not be aware of the PACT policy or its financial implications, so CV leaders need to educate them. For example, physicians, nurses, and support staff should be exposed to data on the program's PACT data to date. Case managers, too, should understand that TAVR patients have different needs than post-surgical patients, and be prepared to plan for their discharge accordingly.

      3. Enhance post-discharge care

    A primary cause of unnecessary discharges to post-acute care is physician concern about the potential for patient complications and readmissions post-TAVR. However, many TAVR patients don't truly require post-acute care. To allay physician concerns, structural heart programs should focus on strengthening post-discharge care management.

    We've seen programs put several strategies in place. First, many go beyond the TVT Registry's requirements and offer more frequent follow-up visits and phone calls during the patient's first days and month after TAVR. Forward-thinking programs also set up each patient's first post-TAVR appointment with their referring provider. Other strategies include increasing patient participation in outpatient cardiac rehab and employing remote monitoring to assess patient status post-TAVR.

    To learn more about these strategies and others for succeeding in today's complex structural heart market, access our recent webconference on the Playbook for Optimizing Structural Heart Programs, and subscribe to our Cardiovascular Insights mailings to hear when our latest structural heart publication is released.

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