Background

In the current era of cost containment, the financial impact of high-cost procedures such as endovascular aneurysm repair (EVAR) remains an area of intensive interest. Previous reports suggested slim to negative operating margins with EVAR, prompting widespread initiatives to reduce cost and to improve reimbursement. In 2015, the Centers for Medicare and Medicaid Services (CMS) announced the reclassification of EVAR to more specific diagnosis-related group (DRG) coding and predicted an overall increase in hospital reimbursement. The potential impact of this change has not been described.

Methods

Patients undergoing elective EVAR at a single institution between January 2014 and December 2018 were identified retrospectively, then stratified by date. Group 1 patients underwent EVAR before DRG change in 2015 and were classified with DRG 237/238, major cardiovascular procedure. Group 2 patients underwent EVAR after the change and were classified as DRG 268/269, aortic/heart assist procedures. The total direct cost included implant cost, operating room (OR) labor, room and board, and other supply costs. Net revenue reflected real payer mix values without extrapolation based on standard Medicare rates. Hospital profit was defined as the contribution to indirect (CTI), subtracting total direct cost from net revenue.

Results

A total of 188 encounters were included, 67 (36%) in group 1 and 121 (64%) in group 2. Medicare patients composed 84% of group 1 and 81% of group 2. CTI (profit) increased by $4447 (+123%) from $3615 in group 1 to $8062 in group 2. Net revenue per encounter increased by $2054 (+7.1%). In group 1, the higher reimbursement DRG code 237 was applied in 5 of 67 (7.5%) patients, whereas DRG code 268 was assigned in 19 of 121 (15.1%) patients in group 2. Total direct cost per encounter decreased by $2012 (−7.9%). This decrease in cost was driven by a reduction in implant cost, from a mean $16,914 per encounter in group 1 to a mean $15,655 in group 2 (−$1259 or −7.4% per encounter) and by a decrease in OR labor cost, $2838 in group 1 to $2361 in group 2 (−$477 or −17.0% per encounter).

Conclusions

A significant improvement in hospital CTI was observed for elective EVAR during the course of the study. The increased DRG reimbursement after the Centers for Medicare and Medicaid Services coding changes in 2015 was a major driver of this salutary change. Notably, efforts to reduce implant and OR cost as well as to improve coding and documentation accuracy over time had an equally important impact on financial return.

中文翻译：

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现代血管内主动脉修复的财务可行性。

背景

在当前成本控制的时代，血管内动脉瘤修复 (EVAR) 等高成本手术的财务影响仍然是一个备受关注的领域。先前的报告表明，EVAR 的营业利润率微乎其微，从而推动了降低成本和改善报销的广泛举措。2015 年，医疗保险和医疗补助服务中心 (CMS) 宣布将 EVAR 重新分类为更具体的诊断相关组 (DRG) 编码，并预测医院报销的整体增加。尚未描述此更改的潜在影响。

方法

回顾性确定 2014 年 1 月至 2018 年 12 月期间在单一机构接受选择性 EVAR 的患者，然后按日期分层。第 1 组患者在 2015 年 DRG 改变前接受了 EVAR，并被分类为 DRG 237/238，主要心血管手术。第 2 组患者在改变后接受了 EVAR，并被归类为 DRG 268/269，主动脉/心脏辅助手术。总直接成本包括植入成本、手术室 (OR) 人工、食宿和其他供应成本。净收入反映了真实的付款人组合价值，无需根据标准医疗保险费率进行推断。医院利润定义为对间接 (CTI) 的贡献，从净收入中减去总直接成本。

结果

总共包括 188 次就诊，第 1 组 67 (36%) 次和第 2 组 121 (64%) 次。医疗保险患者占第 1 组的 84% 和第 2 组的 81%。CTI（利润）增加了 4447 美元（+ 123%）从第 1 组的 3615 美元增加到第 2 组的 8062 美元。每次遭遇的净收入增加了 2054 美元（+7.1%）。在第 1 组中，67 名患者中的 5 名 (7.5%) 应用了更高报销的 DRG 代码 237，而第 2 组的 121 名患者中有 19 名 (15.1%) 使用了 DRG 代码 268。每次就诊的总直接成本减少了 2012 美元（ −7.9%）。成本的下降是由于植入物成本的降低，从第 1 组每次就诊的平均 16,914 美元到第 2 组的平均 15,655 美元（每次就诊 - 1259 美元或 -7.4%）以及手术室劳动力成本的降低，2838 美元第 1 组至第 2 组的 $2361（每次遭遇 -$477 或 -17.0%）。

结论

在研究过程中观察到选择性 EVAR 的医院 CTI 显着改善。2015 年医疗保险和医疗补助服务中心编码更改后增加的 DRG 报销是这一有益变化的主要驱动力。值得注意的是，随着时间的推移，降低植入和手术室成本以及提高编码和文档准确性的努力对财务回报也产生了同样重要的影响。