Improving Post-TAVR Care and Reimbursement with a New Free Optimization App

 Disclosure: Dr. Meduri reports he is a speaker and consultant to Edwards Lifesciences, and has received grants from the company.

“Post-TAVR Optimization”, developed by Christopher U. Meduri, MD, MPH, and Brian J. Potter, MD, MSc, is a free mobile application. It can be downloaded from www.post-tavr.com, the Apple store, or Google Play.

How will the Post-TAVR Optimization app help providers?

The focus of this app is to assist centers in optimizing care post transcatheter aortic valve replacement (TAVR) by providing access to easily implemented clinical pathways. Data show that implementing clinical pathways post procedure can improve outcomes, reduce the economic burden for the hospital, and also eventually for society. At least in the U.S., we haven’t seen widespread implementation of clinical pathways post-TAVR procedure. Thought leaders in the United States (Figure 1), including David Brown and Michael Mack at Baylor, Steven Ramee at Oschner, Brian Whisenant at Intermountain Healthcare, and Christian Spies at The Queen’s Medical Center, as well as many others, have been instrumental in taking this challenge head on, recognizing that the opportunity exists to reduce length of stay in the U.S., and working to formulate clinical pathways (Figure 2) that can facilitate a reduced length of stay. Medicare data from 2012 show TAVR’s average length of stay, just for transfemoral access procedures, was 7.8 days. Our hope is that use of the app will safely reduce length of stay by improving patient outcomes through the use of clinical pathways. 

When Edwards Lifesciences started training people in 2008-2009 for the PARTNER study sites and in 2012 for the commercial sites, patients were treated similarly to surgical aortic valve replacement patients. Most of the care recommendations were based on the surgical experience and included surgical cut downs, relatively aggressive anesthesia, and prolonged hospital courses. After my own experience at the Karolinska Institute in Stockholm, Sweden, under Andreas Rück and Magnus Settergren, as well as through discussions with U.S. thought leaders, we knew a safe reduction in length of stay was entirely possible and realized that this was the direction that care must take in the U.S. as well.

However, some U.S. centers that started aiming for shorter lengths of stay saw significant reductions in their reimbursement, leading to a reluctance to continue to strive for streamlined post-procedure care. Through discussions with those centers, it became clear that this reduction in revenues often resulted from a lack of understanding of Medicare’s reimbursement policies. It was alarming that suboptimal care and an increased burden on the healthcare system might result, simply because understanding TAVR reimbursement posed such a complex challenge. We felt that these two ideas — finding ways to reduce length of stay and understanding how the healthcare reimbursement system works for TAVR — had to be addressed as part of a two-pronged approach to the problem of post-TAVR optimization, and we also believed that these two concepts could be best communicated to a wide audience through the development of an accessible educational vehicle. We thought that we could help teach centers how to improve post-procedure care, which would lead to appropriate reductions in length of stay, and avoid getting unnecessarily penalized from a reimbursement standpoint by putting all of the essential information in the palms of their hands. That was the birth of this mobile medical application (Figure 3).

What is the challenge with reimbursement?

The challenge has to do with Medicare’s post-acute care transfer policy (PACT). Triggering particular criteria means a reduction in reimbursement. These criteria are: 1. Is there a transfer DRG? (All valve-related procedures have a transfer DRG, so that first criteria already exists.); 2. Was the patient discharged earlier than the mean national length of stay for that DRG?; and 3. Was the patient transferred to a qualifying post-acute care setting (e.g., skilled nursing facility, inpatient rehab or home health)? If all three of these criteria are met, your reimbursement is significantly reduced. In 2012, 35% of Medicare TAVR cases triggered this PACT policy, leading to an average reduction of $8,000 per triggered case. Clearly, you can see why centers would be alarmed. Many centers do not understand how these policies work and the individuals who might understand are rarely the ones making discharge decisions. Without that understanding, it is easy to falsely arrive at the conclusion that the only way to not have your reimbursement reduced is to keep patients in the hospital longer. 

How do you envision the app affecting TAVR centers?

Our hope is that it will give centers a starting point for optimizing post-procedure care. The goal is to improve care for the patient. If we improve care, and patients have better outcomes and practitioners understand how the PACT policy really works, reductions in length of stay will begin to occur. What our healthcare system cannot afford is to have people staying in hospitals longer than they need to because centers are concerned about reimbursement. We think that the app has the potential to also reduce costs to the institution through streamlined care and improved outcomes. So our goals with the app are to: 1. Improve outcomes 2; Shorten length of stay; 3. Reduce the financial burden on the hospital center. If these three goals are accomplished, it will improve the long-term viability of TAVR programs and ensure that this technology remains available to patients. 

Is the app purely informational, or is it more interactive?

It is very interactive. The app is comprised of three main components. The first component is the post-procedure clinical pathway (Figure 2), broken into 0-4hrs, 4-12hrs, and then post-op day 1, as well as recommendations for discharge criteria and follow-up. These are very easy to navigate, straightforward recommendations that can easily be incorporated into daily routine care. These are things that people know and understand, but have trouble incorporating as a whole when not part of a formal clinical pathway. If you make it a pathway with check boxes and clear goals and milestones to be achieved, it really seems to make a difference. The second component is the TAVR reimbursement resources (Figure 4). We worked over a long period to distill a great deal of complex information down to the essentials in order to demystify Medicare reimbursement. The goal was to present the information in a way that was easily understood by people without much experience with healthcare reimbursement issues. The third component is extremely interactive. It is a center-specific reimbursement calculator. If you just tell people how reimbursement works, some will understand it. We felt, though, that the only way to ensure that everyone understood reimbursement was to, in a sense, have them experience it. With this calculator, an individual can examine what the impact of patient level factors will have on reimbursement at their particular center. We obtained the specific reimbursements for every Medicare-accepting hospital in the U.S., almost 10,000 hospitals, and then got the specifics for each individual DRG. The app calculator has 5 specific inputs (Figure 5). First, you input your center. Second, you input whether or not you are going to perform a cardiac catheterization (and we explained when that is actually appropriate to bill for cardiac cath). This is followed by selecting your patient’s comorbidities. The comorbidities and complications list in the app contains 99% of the comorbidities billed in 2012 to Medicare for TAVR. The calculator knows which of these are MCC (major comorbidities and complications), CC (comorbidities and complications), and which are neither (non-comorbidities and complications). Once everything is entered, you are presented with a summary screen that includes the projected full reimbursement for that hospitalization (Figure 6). The user can then change the day of discharge and discharge disposition, and see what impact that has on reimbursement. The calculator will tell the user whenever PACT is triggered.  The user is free to move back and forth in the calculator in order to experience how all the information entered impacts reimbursement. 

Do you anticipate this app being used by all members of the TAVR team?

It will mostly be used by the people assisting in the post-procedure care. This includes the physicians performing the procedure as well as the nurse practitioners that are usually very involved in the post-procedure management. The unit nurses directly involved in post-procedure care will likely use the checklist as well. Also, we hope that the application might help physician leaders and hospital administration to more effectively collaborate in ensuring the sustainability of TAVR programs.

Is there a fee to download the app? Is it available for different platforms?

No, it is completely free of charge. It can be downloaded for both iOS and Android from our website, post-TAVR.com, or from the iStore or Google Play.

How was the app created?

The app was a solution to a particular problem that my co-fellow, Dr. Brian Potter, and I were wrestling with. I had seen in Europe that length of stay could be safely shortened compared to what was common in the U.S. and Brian had a similar experience in Canada, but we also understood that the reimbursement question was a significant hurdle. It just so happened that we had some training in cost-effectiveness and healthcare economic modeling and analysis. We first set out to understand the problem ourselves and learn about Medicare’s reimbursement policies, and then to figure out how to best communicate that understanding to our colleagues in the field.

When Brian and I came up with the idea of having an app-based educational tool, we were very fortunate to find an interested partner in Edwards Lifesciences. They were well aware of the problems surrounding reimbursement and the challenge that it posed to the viability of TAVR programs, as well as efforts at reducing length of stay. We presented our idea and some data to them, and they were both excited and very supportive of our initiative. We applied for and won an educational grant from Edwards that we put towards the development of the app. The next hurdle was to find a creative app developer with experience in the healthcare field who could understand our vision. We discussed our ideas with a few developers, but when we eventually connected with Customedialabs, based out of Philadelphia, we knew we had found the right partner. They had done similar work before and we were impressed with the product. Most importantly, even though we were coming from very different perspectives, we were able to work together to understand each other’s point of view, develop a common vocabulary, and ultimately, provide them with what they needed to create the product that we had envisioned. 

How long was the development period?

The idea first took shape in September 2013. Edwards Lifesciences provided grant preliminary approval in early December 2013 and we were still hashing out some of the finer details until mid-December of that year. The app development itself started in January 2014. It was a very involved process with a lot of close communication with the developers. The process concluded in time for our official presentation and release of the app at the 2014 American College of Cardiology (ACC) meeting. Normally, it would probably take another few months for development, but we felt that ACC was the perfect stage to release the app and hopefully get people talking about post-procedure care, so we gave ourselves an aggressive timeline and the developers came through for us. 

What information would you like to add to the app in the future?

In the next year, we really hope to take mobile education on TAVR to the next level. We envision an application that will optimize care from a patient’s first encounter with the heart team in valve clinic all the way through post-procedure follow-up. This will include detailed information on patient screening, appropriately identifying symptomatic aortic stenosis, pre-procedure planning, and procedural consideration, in addition to expanding the current content. We are currently talking with thought leaders across the U.S., Canada, and Europe to get their help in developing this new content, and are very excited about how much interest there is out there. People seem to agree that there is value in this type of tool. 

How has this experience affected you personally?

Never in my wildest dreams did I think I would ever be part of developing a mobile application, let alone one designed to do what this app does, but this was our solution to a very particular problem. It wasn’t the natural way for a physician to look at things. The way physicians are trained, there isn’t much thinking outside the box and there is very little thinking about healthcare dollars and hospital reimbursement. I think that the training in cost-effectiveness that Brian and I had allowed us to think differently and, in medicine, like elsewhere, if we look outside the box, sometimes we find truly novel solutions to some of the most challenging problems we face. 

It has been a very interesting process. I have a new respect for how challenging and complicated the world outside of medicine is. I used to imagine app development consisted of 18-year-old programmers just throwing together some code and, in a few days, they have this new thing to put in the Apple store. Clearly, app development doesn’t function that way.  Or, at least, it shouldn’t, if you want a well-designed app that truly reflects the client’s vision. Also, it takes a lot of commitment and collaboration from the clients in order to deliver the best product possible. Brian and I spent a great deal of time revising and refining the product with the developers.

There are several people I’d like to thank for their contribution to the app’s development: First, obviously, my co-fellow and partner in producing this application, Dr. Brian Potter, who has been instrumental in the development process throughout the entire project. Second, my mentor, Dr. Jeff Popma. Though he wasn’t involved in this project, he has mentored me over the last four years and he always encouraged me to think outside the box and look at things in a new way. None of this would have happened if I hadn’t had him as a teacher. I would also like to mention the people at the Piedmont Heart Institute in Atlanta, Georgia, who I will be joining this summer. They are taking concrete steps to be on the cutting-edge of optimizing care for valve patients and I am looking forward to being a part of their team. With the recent $20 million dollar grant to Piedmont to establish the Marcus Heart Valve Center, the sky is truly the limit. Lastly, and most importantly, I must thank my wife and children, who have been incredibly supportive during this busy process. I couldn’t do this without their help. 

“Post-TAVR Optimization” can be downloaded from www.post-tavr.com, the Apple store, or Google Play.