Cardiovascular Rounds

VAD program adoption is growing—but is it the right move for you?

by Megan Tooley and Dhananjai Seth

Optimizing management of heart failure (HF) patients has been a priority for cardiovascular programs for years, and CV leaders are continuing to evaluate new opportunities to better treat this growing patient population. In fact, the American Heart Association expects the prevalence of heart failure to grow by 46%, to 8.5 million individuals, by 2030.

Your guide to VAD investment and program development

Of this growing population, 5% to 10% are advanced heart failure (AHF) patients, and are appropriate candidates for advanced technologies such as ventricular assist devices (VAD) and/or heart transplants. However, there's strong evidence that many of these patients are not identified or treated appropriately. While studies show that 60,000 to 100,000 VAD-eligible patients are currently living with AHF, only 32,000 VADs were implanted between 2004 and 2014 according to Healthcare Cost and Utilization Project (HCUP) data. This differential suggests a high latent demand for VADs.

In addition to the potential growth opportunities, VAD implants can also be profitable—teaching hospitals received a median reimbursement of $214K per case for VAD patients in 2016. High latent demand, coupled with high per case revenue, has made VAD program investment an attractive proposition for cardiovascular programs across the country. As a result, HCUP data shows a 44% increase in VAD implants from 2010 to 2014.

VAD implementation isn't without challenges

Although increasing market demand and potential profitability paint a favorable picture for VAD investment, high operational costs from VAD implantation pose a significant challenge for CV programs. Advisory Board research estimates median supply cost per case of $93K, median length of stay of 22 days, and a median readmissions rate of 23% for VAD patients. These high programmatic costs make overall VAD program profitability difficult to achieve.

Furthermore, these patients require long-term, resource-intensive outpatient care and follow-up. Maintaining a cost-effective program while delivering high-quality care requires additional resource investments, such as support staff to manage patient length of stay and readmissions, as well as clinic investments to improve long-term outcomes.

Given the substantial resource investments required to operate a successful VAD program, CV leaders must define their CV program's broader HF strategy to identify if such a program is a right strategic move for their institution. VAD investment can be profitable when aligned with a comprehensive AHF or transplant program, since VAD programs benefit from an existing referral base and investments for patient management. A VAD program can also help transplant centers capture bridge-to-transplant cases, increasing lucrative transplant volumes. If an AHF program does not have transplant capabilities, a VAD program can help round out a program's broader HF service portfolio, ensuring patients stay within an institution's care network for all HF care needs.

Once a CV program has a defined vision, it is important to evaluate the program's readiness to make the substantial investments a sustainable VAD program requires. Specifically, the program must: 1) meet CMS Destination Therapy VAD certification requirements to receive reimbursement, and 2) invest in the services necessary to manage length of stay, prevent readmissions, and manage patients across the continuum.

Destination therapy certification requirements

CMS' National Coverage Determination sets minimum standards that programs need to achieve in order to receive destination therapy VAD program reimbursement. Here are three key standards programs must include as part of their VAD program:

  1. Transplant partnership: For institutions that do not have an existing transplant program, CMS requires that a VAD program develop a partnership with a qualified transplant program to be certified as a destination therapy program.

  2. Qualified VAD physicians: CMS also requires institutions to hire qualified surgeons to perform VAD procedures. Surgeons must have experience implanting 10 VADs in the last 36 months, with at least one implant taking place in the last year. In addition, VAD programs must also employ a HF specialist. As part of the VAD program, the HF specialist drives early referrals to the program. Furthermore, they manage the patient's continued care after implant.
  3. Multidisciplinary support staff: In addition to physicians, a comprehensive multidisciplinary VAD team must include VAD coordinators, HF navigators, VAD and transplant psychologists, and specialized social workers.

Maximizing your AHF investment

Given the high-resource investment to develop and maintain a VAD program, CV leaders should identify opportunities to contain program costs while also maintaining a high quality program. Here are three tactics programs can employ to ensure effective cost management:

  1. Early patient identification and referral: To improve care outcomes and also effectively manage length of stay, VAD programs must create a culture of early disease detection and referrals. Since easily identifiable symptoms only present late in disease progression, referring cardiologists and other CV staff must be trained to identify patients before advanced symptoms appear.
  2. Multifaceted patient selection criteria: In addition to clinical criteria for appropriate patient selection, VAD programs must also evaluate patients on social criteria, such as patient support post discharge, patient's psychological condition, and patient's socioeconomic condition. Risk stratification based on social criteria can help programs manage patients more appropriately to help reduce extended length of stay and avoidable readmissions.
  3. Patient-support infrastructure: Once a patient has been discharged, a VAD program also needs to manage the patient's on-going HF treatment to ensure long-term survival and quality outcomes. To do this, leading programs often invest in an AHF clinic, typically managed by advanced practice providers.

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