What Does CMS’ Proposed Addition of PCI in ASCs Mean for Hospitals?

The outpatient migration of cardiovascular procedures started in 2016 when the Centers for Medicare & Medicaid Services (CMS) added pacemaker implants to the list of approved surgical procedures for ambulatory surgery centers (ASCs). A new proposed CMS rule may clear the way for percutaneous coronary interventions (PCI) to be performed in an ASC in 2020, creating financial uncertainty for hospitals regarding Medicare payment for the cardiology service line.

In 2019, 17 diagnostic cardiac cath procedures were added to the list of ASC-approved procedures. CMS has proposed adding 6 cardiac interventional procedures to the approved list for 2020. Adding PCI to the ASC approved list of procedures should address the concern many have about performing diagnostic cases without the approval to do a corresponding intervention. This continuum of care concern may have slowed the adoption of diagnostic caths in ASCs in 2019.

What does this mean for hospitals’ profitable cardiology service line? Medicare beneficiaries underwent more than 523,000 diagnostic cardiac catheterizations at outpatient hospital centers, resulting in an estimated $682 million in payments in 2016. The PCI market substantially larger than the diagnostic market, at an estimated 900,000 cases in the U.S., with Medicare payments in excess of $10 billion annually. How many of these cases are appropriate for the ASC setting is debatable. If a 25% shift of the current hospital PCI caseload to the ASC occurred, this could cost hospital cardiac programs over $3 billion annually.

What are the options for health systems across the country?

• A joint venture with cardiologists in an ASC, possibly on campus;

• Buy the remaining independent cardiology groups.

• Currently, approximately 70+% of cardiology groups are employed by health systems*, a number that could be affected with an increasing number of cardiovascular procedures shifting to ASCs;

• Allow cardiology groups owned by the health system to “disintegrate” or leave the health system, and open their own ASC;

• Add cardiology procedures to existing multi-specialty ASCs.

With PCI shifting to ASCs, projections show that the savings to Medicare could be several hundred million dollars over the next 10 years, and many patients will enjoy significantly lower coinsurance costs. Hospitals can also benefit from this outpatient cardiovascular migration if they are able to participate with cardiologists in joint-venture ASCs. In the end, patients, providers, and payers all win with PCI in the ASC. n

*MedAxiom Cardiovascular Provider Compensation & Production Survey, 2018.

CMS has proposed adding 6 cardiac interventional procedures to the approved list for 2020:

1. PTCA; single coronary artery
2. PTCA; each additional branch of coronary artery
3. Angioplasty & stent; single coronary artery or branch
4. Angioplasty & stent; each additional branch of coronary artery
5. Angioplasty & DES; single coronary artery
6. Angioplasty & DES; each additional branch of coronary artery

PTCA = percutaneous transluminal coronary angioplasty; DES = drug-eluting stent

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