ANN ARBOR, MI — Increased use of early PCI improves 6-month survival and limits overall cost increases in patients with acute MI (AMI), according to a new Medicare expenditure study[1].
On the other hand, overall inflation- and risk-adjusted 180-day expenditure, which has increased about 14% since 1999–2000, shows only a weak association with case fatality.
“What we found is that the biggest signals are what you spend the money on, not what your overall spending was,” said principal investigator Dr Donald S Likosky (University of Michigan, Ann Arbor) in an interview. Likosky is a health services researcher and cardiovascular epidemiologist in the department of cardiac surgery.
It is well-known that not all healthcare spending improves outcomes, but most studies have looked at total expenditures rather than considering whether the money is spent for cost-effective or ineffective services.
Comparing mean expenditure in 479,893 fee-for-service Medicare beneficiaries admitted to the hospital with AMI during three periods of study (1999–2000, 2008, and 2013–2014), the researchers found that adjusted expenditures per patient increased 13.9%, or by $4486, over 15 years. All of the increase in expenditure (14.4%) occurred by 2008, after which a small, 0.5% decline in risk- and inflation-adjusted spending was noted.
Total spending grew just 6.1% up to 30 days, with the rest of the increased expenditure occurring during the postacute period.
Increased expenditure in many domains was unrelated to improvements in AMI-related mortality at 180 days. Increased spending on inpatient services (Medicare Part A), testing, and outpatient visits was not associated with improvements in mortality, nor was postacute care spending on home health, hospice, and durable medical equipment. In the postacute period, only spending on skilled nursing facilities was related to reduced case fatality.
Likosky’s group also subdivided their findings according to the 5% of hospitals (n=61) with the most rapid growth in mean expenditure and the 5% of hospitals with the slowest expenditure growth (n=61).
Mean expenditure in the top spending hospitals increased by 44.1% ($12,828) from 1999 to 2014, while it decreased 18.7% ($7384) in the hospitals showing the slowest growth. Likosky said they have not yet analyzed the associated mortality and spending components in these two hospital groupings.
In an editorial[2], Dr Jason Wasfy and Dr Robert Yeh (Harvard Medical School, Boston, MA) congratulated Likosky and colleagues on “breaking into this critical area” and noted that the researchers “set a high bar for establishing efficacy by attempting to demonstrate an association with 180-day mortality.”
Early PCI a Winner
Early PCI (on day 1 of admission) increased 102.9% during the study period and had a “large, statistically significant, and robust” effect on case fatality, said Likosky et al, with larger impact seen in patients with ST-segment-elevation MI (STEMI) relative to NSTEMI.
Over the 180-day post-AMI period, PCI utilization increased by 48.9% from 1999 to 2014, while CABG rates decreased 35.3%.
Spending on cardiac procedures (excluding PCI) was associated with increased 180-day mortality.
When the researchers further “decomposed” postacute care spending according to PCI use they found that increased early PCI led to some savings down the line. Hospitals in the top quartile of PCI use, relative to the lowest growth quartile, had lower 6-month mean spending for skilled nursing facilities (-$700 per beneficiary) and lower home-health agency, hospice, and durable medical equipment spending (-$298).
“The data in this study affirm the importance of PCI in the acute setting and suggest that its proliferation has led to improvements in outcomes without increasing the overall episode of care payments for patients treated at PCI-adopting facilities,” said Yeh in an email exchange with theheart.org | Medscape Cardiology.
Bundled Payments to Contain Costs
In a sign that the fixed diagnosis-related group (DRG) payments for AMI have helped to reduce spending since 1999, the researchers found “fairly well-contained” spending within 30 days after admission and a 2-day (average) shorter length of stay during the index hospitalization.
Likosky suggested that perhaps a DRG-type bundling of payment for services occurring beyond 30 days might help further moderate spending growth.
“We saw that the bundled payment in the 30-day period was quite effective, and one way to address this issue would be to expand the time period of that,” said Likosky.
In the accompanying editorial, Wasfy and Yeh bemoaned the cancellation of the mandatory cardiac episode payments models (EPMs). Mandatory EPMs were announced by Obama administration and were a key component in its value-based care initiative but were canceled by the Trump administration in 2017.
“The program would have set a quality-adjusted target price for the total 90-day episode of care, with the initial hospital bearing two-sided risk with retrospective reconciliation of payments,” they write.
In a two-sided financial risk model, the provider (hospital) bears the risk for overspending but also has the opportunity to share in some portion of the savings.
“This would have created strong incentives for the index hospital to improve specific quality benchmarks and reduce costs, not only during the index hospitalization but also after discharge.”
The EPMs were set to take effect in January 2018 but were formally canceled by the Centers for Medicare and Medicaid Services (CMS) in late November[3]. The CMS has expressed an intention to increase opportunities for providers to participate in voluntary cost-containment initiatives rather than imposed mandatory bundled payment models.
“In the context of the cancellation of EPMs for AMI, the importance of the findings by Likosky et al become clearest,” write Wasfy and Yeh. “Given the substantial spending without clear benefit demonstrated here, reintroducing strong incentives to improve quality and value seems urgent to best help out patients now and improve the sustainability of the healthcare system.”
Likosky added, “Unless we provide the feedback to the providers I think we’ll probably remain in the same situation. They are likely the ones to know what they do and why they do it and who stands to benefit. So, what we see is that the natural history here is that people are well-intentioned and spend money in the areas of practice that they think are important, but our findings suggest that not all spending is actually effective.”
Likosky has no relevant financial relationships. Disclosures for the coauthors are listed in the paper. Yeh reported no relevant financial relationships. Wasfy has served on the Learning and Action Network Committee on Episode-Based Payment for Cardiac Conditions, a public-private partnership established by the US Department of Health and Human Services.
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