Cardiovascular Procedures 2019: Is the Future Here?

As our healthcare industry evolves and innovates, providers, payers, life sciences companies, and the government are facing challenges every day. Key stakeholders are working to improve care and outcomes, while reducing costs and spending. A part of that innovation includes transformational technologies and clinical trends impacting the cardiovascular market. One new trend beginning to cement itself as a rock-solid strategy is the evolution of the cardiovascular hybrid ambulatory surgery center (ASC).

Centers for Medicare and Medicaid Services (CMS) recently published the 2019 Proposed Payment Schedule for Hospital Outpatient Services and Ambulatory Surgery Centers, which will be finalized in November and go into effect January 1, 2019. As per usual, there are rate fluctuations in many codes that send every doctor, special interest, and industry group scrambling to understand the impact on their particular site of service. In the cardiovascular space, new coronary procedure codes have been proposed for the ASC, and we can see volatility in the physician office and ASC rates for peripheral arterial disease (PAD) and fistula work. 

CMS comments in the Proposed 2019 ASC rule note:

“We are proposing to update the list of ASC-covered surgical procedures by adding 12 cardiac catheterization procedures… After reviewing the clinical characteristics of these procedures and consulting with stakeholders and our clinical advisors, we determined that these 12 procedures are separately paid under the OPPS, would not be expected to pose a significant risk to beneficiary safety when performed in an ASC, and would not be expected to require active medical monitoring and care of the beneficiary at midnight following the procedure.”

Many insiders are articulating the idea that adding these procedures well may be a test to see how well the migration to outpatient for low-risk diagnostic caths will be handled by physician groups, as well as patients. The outpatient migration of PAD procedures from the hospital to the office-based lab (OBL) over the past 10 years has demonstrated how these procedures can be performed safely and comfortably in an outpatient setting. 

The addition of the ASC site of service (or creating a hybrid OBL/ASC) will allow cardiologists to offer versatility and diversify procedures. This strategy allows risk mitigation when CMS dramatically changes payment rates and can put cardiologists back into the driver’s seat in the delivery of innovative, high-quality cardiovascular care.

Heart Care Centers of Illinois was founded in the 1970’s to meet the growing demand for convenient cardiac care in their community. The group has always advanced care in optimized settings and offer services with top-tier outcomes. Dr. Robert Iaffaldano, medical director of a new ASC for cardiovascular care for his practice, notes, “Cardiovascular care of the future will be in the care setting most appropriate for the patient and the procedure being done. Twenty years ago, no one could have imagined restoring blood flow to a limb with ischemia outside of the hospital. Today that is the most common site for these types of procedures. Private insurances have always been supportive of this type of innovation, so it is good to see Medicare/CMS take a step toward cardiac cath outside of hospital settings.”

The history and evolution of the ASC has favored an expanding scope of service. As operators, tools, and technology have advanced, the ASC has consistently become a safer and more cost-effective site of service for procedures. In addition to venous and dialysis vascular access work, the cardiovascular procedure outpatient shift accelerated with the migration of electrophysiology implantable procedures and PAD procedures to the outpatient site of service. The continuing advancement of minimally invasive services into the ASC is evident with the proposed addition of diagnostic coronary caths for 2019. 

There has been a flurry of articles related to the outpatient migration of cardiovascular services. The shifting of percutaneous coronary intervention (PCI) and other cardiovascular procedures to the ASC could be considered a logical progression, based on the following reasons:

1) Safety;

2) Improved patient experience;

3) Cost;

4) CMS already moving in this direction;

5) Commercial payers already supporting this strategy;

6) Procedures in ASCs support the goals of accountable care organizations (ACOs) and value-based models of care.  

These arguments, and the proposed approval of diagnostic coronary caths in 2019, are paving the way for an expansion of cardiovascular services in the ASC setting. CMS responded to input from stakeholders that certain procedures outside the Current Procedural Terminology (CPT) surgical range, but similar to surgical procedures currently covered in an ASC setting, should be ASC-covered surgical procedures. More specifically, stakeholders recommended adding certain cardiovascular procedures to the ASC Covered Procedures List (CPL), due to their similarity to currently covered peripheral endovascular procedures in the surgical code range for surgery and cardiovascular systems. Based on this review, CMS is proposing to update the list of ASC-covered surgical procedures by adding 12 cardiac catheterization procedures to the list for CY 2019 (Table 1).

CMS has determined that these 12 procedures are separately paid under the Medicare Hospital Outpatient Prospective Payment System (OPPS), would not be expected to pose a significant risk to beneficiary safety when performed in an ASC, and would not be expected to require active medical monitoring and care of the beneficiary at midnight following the procedure. CMS seems willing to tread into this domain, with their eye on safety and cost to the system. 

With the clinical success of diagnostic cardiac procedures performed safely in the ASC, this will quickly open the door to PCI. Notably, CMS published the following addendum to the Professional Fee Schedule for 2019 (Table 2). Is this foreshadowing the approval of PCI? Many applaud CMS’ focus on the “continuum of care” for patients. Why allow a diagnostic angiogram and not allow the intervention in the same site of service?

We have seen rapid approval progression in other specialties such as orthopedics, which now allows total joint replacements and level 1 spinal fusion in the ASC setting. If you can replace hips and knees and fuse the spine in an ASC, why couldn’t interventionists deploy a stent? n

ACA Cardiovascular wants to keep you abreast of ambulatory strategies and promote the peer-to-peer learnings of those who begin or already include an ASC as a part of their ambulatory strategy. We are hosting a webinar on 2019 CMS Proposed Payment Schedule for Ambulatory Strategy and the Cardiovascular ASC on September 25th at 1 pm EST. 

Visit https://www.acacardiovascular.com/ to learn more, or contact Marc Toth at mtoth@acacardiovascular.com.