Medicare reimbursement fails to adequately cover cost of care after open bypass surgery among most CLTI patients

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For most patients with critical limb-threatening ischemia (CLTI), Medicare reimbursement for lower extremity bypass surgery does not adequately account for case complexity in the compensation of vascular surgeons, a study published in the September issue of the Journal of Vascular Surgery finds.

The research was carried out by senior author Richard J. Powell, MD, the section chief of vascular surgery at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire, and colleagues. They argued in favor of a re-evaluation of Medicare’s diagnosis- and Current Procedural Terminology (CPT)-based reimbursement categories.

In a retrospective examination of infrainguinal bypass procedures performed at Dartmouth-Hitchcock Medical Center from 2011 to 2017, 68 patients with hemodynamically confirmed CLTI were analyzed.

Patients were identified by assignment to a diagnosis-related group based on the level of complexity—other vascular procedure with major complication/comorbidity, with complication/comorbidity, and without complication/comorbidity.

Additional clinical data were incorporated from the Vascular Quality Initiative (VQI) clinical registry, the researchers explained. For non-Medicare patients, reimbursement was indexed to Medicare rates. Contribution margins (reimbursement minus cost) from technical and professional services were analyzed for each patient and summarized by diagnosis.

The mean age of the cohort was 66.1 years, with 69% male, 49% diabetic, 44% current smokers and 4% on dialysis. In general, total infrainguinal bypass cost was adequately compensated for patients assigned only the most complex diagnosis (median: $2,490; interquartile range [IQR]: -$1,621 to $10,080).

But in the majority of patients with less complex diagnoses—with complication/ comorbidity (median: -$3,100; IQR: -$8,499 to $109) and without complication comorbidity (median: -$4,902; IQR: -$9,259 to $1,059)—reimbursement did not cover the cost of care, the investigators explain. Both technical costs and professional costs varied significantly with the complexity of diagnosis. Total reimbursement for inpatient hospitalizations is composed of the professional reimbursement for the vascular surgeon performing the procedure and the technical reimbursement for the hospitalization costs.

“Although reimbursement from technical services increased alongside increasing complexity of diagnosis, there was insignificant variation in professional reimbursement as [diagnosis] complexity increased,” the authors write. “On multivariable modeling, longer length of stay (-$2,547 per additional day) and preoperative dialysis (-$5,555) were significantly associated with negative margins.”

The investigators noted another key finding: Professional contribution margins were negative for all three diagnosis groups. By way of contrast, technical reimbursement and cost increased alongside diagnosis complexity, and technical reimbursement exceeded the cost for all three groups. “This finding may not be surprising, given recent studies showing that vascular surgeon reimbursement has decreased significantly in the last decade,” the authors continue. “This finding is strongly indicative of the need for a reevaluation of the professional component of Medicare reimbursement for lower extremity bypass for patients with CLTI. It is unclear what impact this negative financial picture has had on the decreasing use of lower extremity bypass in Medicare beneficiaries to treat patients with CLTI.”

They concede a number of limitations to the study. An intrinsic one, the researchers admit, is their characterization of lower extremity bypass reimbursement at a single academic, tertiary care center. Another was the decision to index reimbursement for non-Medicare patients to Medicare rates, they add. In conclusion, the authors write: “Professional service payments do not cover professional service costs for the majority of CLTI surgical procedures performed at our tertiary medical center, and this discrepancy was especially applicable for the least complex cases.”

SOURCE: DOI.ORG/10.1016/J.JVS.2020.01.062

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