What your C-suite needs to know about CV services in 2019

The cardiovascular market is rapidly evolving, and CV service lines face mounting pressure to grow the business while still managing payer and consumer demands to lower overall costs. Add to this the ambulatory shift of CV services, specialist shortages, and growing competition, and CV leaders have much to consider when building a strategy.

It’s important to make sure your executive team knows what your CV program is up against to justify your investments and goals—and we can help. Share our key takeaways on trends that are both shaping the CV market as well as your strategy for 2019 to get everyone on the same page.

1. CMS's transition to risk is now a foregone conclusion—and CV remains in the spotlight

Despite mixed signals from Washington in recent years, you should expect CMS to place the burden of episodic cost control increasingly on the hospital’s shoulders. CV programs should consider current voluntary CMS risk-centered initiatives as an opportunity to prepare for the wholesale transition to payment for episodic performance in CV services, and the potential rollout of more mandatory models.

Heart failure was the second most selected clinical episode in the first round of BPCI Advanced, the voluntary CMS bundling model introduced in 2018. CMS and HHS leadership have also signaled a desire to bring back mandatory alternative payment models in the future—including the CV episodic payment models for CABG and AMI.

2. The private sector now leads the charge on payment transformation

Health plans, employers, and retailers are pursuing disruptive new strategies to control outsized health care costs—particularly for costly cardiovascular conditions and procedures. CV leaders are already seeing private payers steering to lower-cost clinics for diagnostic screening, building Centers of Excellence (COEs) for high-end CV procedures, and requesting greater price transparency.

In order to maintain competitive advantage, CV programs will need to monitor local private sector activity, and selectively pursue opportunities for engagement or risk being locked out of a network.

Medicare Advantage (MA) is projected to enroll 40% of Medicare participants by 2025—an important number to watch for CV programs, where the majority of patients are Medicare age. MA plans are actively testing value-based insurance design models, steerage, and methods to control overall cost.

3. Long-term cost avoidance must be a factor in CV investment and treatment decisions

CV investments have tended to be informed by profitability. While revenue growth remains essential, CV leaders must also consider strategies that can help eliminate unnecessary costs and improve long-term outcomes as this will be increasingly tied to payment under bundles, MACRA, and pay-for-performance initiatives. Selective investments in CV prevention, telemedicine, and earlier patient identification can reduce unnecessary utilization and improve long-term financial sustainability.

Under MACRA, the "cost" category will make up 30% of the MIPS performance score by 2022. Rather than focusing on acute cost, this category includes eight episodic cost measures—three of which are specific to CV.

4. CV is becoming an ambulatory business—and the competition is heating up

While the outpatient shift is not a new phenomenon in CV services, site-neutral payment regulation, private-payer steerage, and expanding CMS reimbursement are pushing your CV program further into the ambulatory space than ever before.

This has led to increasing competition not only from other hospitals who are shifting outpatient services to lower-cost private practice care settings, but ASCs and office-based labs that can perform more CV services (and are well-incentivized to do so). CV leaders need to be proactive in developing a strategy to meet ambulatory competitors in their market, as ACOs and at-risk purchasers are already looking to partners who can deliver more cost-efficient CV outpatient care.

CMS has added 17 diagnostic cardiac cath codes to the ASC Covered Procedure List for 2019. This change signals CMS's increasing embrace of CV procedures performed in lower-cost care settings—and opens the door for private ASCs to capture more of the CV market.

5. Not every hospital can be the CV COE, nor should they try to be

Historically, CV investment strategy has been driven by internal factors and desire to provide the latest technology. But now, CV leaders must first look to the local health care ecosystem to determine where there is a need. As demand shifts away from inpatient CV procedures, fewer programs will be able to maintain the volumes necessary for high-quality, cost effective advanced procedures.

Instead, consider a hub-and-spoke model for advanced CV services, partnering within or outside your network to provide the full continuum of CV care offerings.

Between 2013 and 2016, 60 hospitals closed their cardiac surgery programs. Between 2015 and 2016, 22 programs stopped performing transcatheter mitral valve repair. Programs need a data-driven strategy to ensure they’re opening the right programs for their market—and, if necessary, proactively consolidate before the market forces them to.

Our 2019 Cardiovascular Roundtable National Meeting explores each of these trends in greater detail—and guides programs on how to respond.

Members: Register today to join us.

Not a member? Email us at cardiovascular@advisory.com to learn more.

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