Reimbursement Issues in the Era of Drug-Eluting Stents

Drug-eluting stents, like many breakthrough technologies, may present a tremendous opportunity for hospitals, both in terms of potentially advancing the quality of patient care and the efficiency with which they provide health care services. This new technology also presents a challenge because realizing these potential opportunities requires re-examining business and financial analysis practices to reflect the changing economics of cardiovascular disease, stenting procedures, and the cardiac catheterization lab or cardiovascular unit. Drug-eluting stents may present hospitals with both opportunities and challenges, as this technology may impact hospitals along dimensions of case mix, procedure volumes, and technology cost. Coping with practice shifts due to new technology can be difficult to manage if third-party payment does not reflect the incremental costs associated with it. As part of their drug-eluting stent programs, medical device companies are proactively identifying strategies to help reduce the lag time between the anticipated introduction of drug-eluting stents and appropriate reimbursement for procedures using them. For example, Boston Scientific is working with hospitals to assess the potential impact of drug-eluting stents on cardiovascular practices as hospitals consider the potential impact of this technology into their service mix. Hospitals and Boston Scientific are evaluating the potential effects of drug-eluting stents within the hospital at multiple levels, including: Procedure Disease Cardiac Catheterization Lab Cardiovascular Unit Hospital Health Care Systems The company has completed a series of analyses that consider the economic drivers relevant to hospitals’ use of drug-eluting stents, including possible changes in resource use (immediate stenting procedure, reintervention rate, and shifts to and from other services, including coronary artery bypass graft), as well as the costs and clinical outcomes associated with these resources. The purpose of these analyses is to estimate the effect of drug-eluting stents in order to support reimbursement from insurers, as well as to assist providers in resource use and practice management. Medical industry including device companies and professional societies are also working collaboratively in other strategic efforts to secure Medicare inpatient payment that recognizes the clinical value of drug-eluting stents. A recent announcement by the Centers for Medicare and Medicaid Services (CMS and formerly HCFA) represents the first critical milestone for this effort. For fiscal year 2003, CMS intends to create two new ICD-9 procedure codes for coronary and peripheral drug-eluting stents. While there is no increased payment associated with these codes at this time, they can be used to track claims where drug-eluting stents have been used, representing a first step towards appropriate reimbursement. At the same time, some companies are engaged in activities focused on all payer groups involved in the U.S. health care system, both public and private, with the goal of aligning payment for drug-eluting stents with their value and cost. For example, Boston Scientific Corporation is incorporating input from providers, cath lab administrators, physicians, billing personnel, and insurance officials both at the federal program and private companies, in shaping these activities and in advocating that the costs and numbers used in economic models accurately reflect real-world use and expectations. Drug-eluting stents potentially present an opportunity for patient care and a financially challenged health care system. Medical industry is working diligently in preparation for a day when drug-eluting stents may be a standard of patient care and to help secure timely and appropriate reimbursement and payment for this technology that is commensurate with its outcomes-based value

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