Money Talk: Cardiologists Must Weigh Costs as Transcatheter Therapies Ascend

Novel transcatheter cardiovascular interventions for structural heart disease, though promising in terms of safety and efficacy, may face economic barriers that deter widespread adoption, a new paper highlights. The authors argue that cardiologists should become more aware of the financial concerns behind healthcare decisions, especially at the hospital level.

“The economic sustainability of both physicians and facilities is a necessary reality that must be faced,” the researchers urge. “Practicing interventional cardiologists are uniquely positioned to balance the oftentimes competing priorities of patient access to novel endovascular technologies and the financial health of facilities.”

These trade-offs are expected to grow more pressing in the coming years, with the rise in interventions like transcatheter valve replacement and repair, as well as left atrial appendage occlusion (LAAO). Demand for transcatheter valve procedures, according to a report from consulting company Sg2, is expected to increase by 49% over the next 5 years.

Speaking with TCTMD, co-author Ashwin S. Nathan, MD (University of Pennsylvania, Philadelphia), said this study follows a long line of others he and his colleagues have done exploring access to novel cardiovascular therapeutics. Financial pressures have “always been a kind of elephant in the room,” he said.

For these newer therapies—such as transcatheter mitral or tricuspid valve replacement, transcatheter edge-to-edge repair, and LAAO—it’s important to ask how the costs associated with them, though “sometimes opaque,” might affect access, Nathan noted. “That really got us to dive pretty deeply into thinking about the finance of medicine” as it relates to structural cardiology.

The resulting document, he continued, is aimed at both practicing clinicians and policymakers. Whether at the physician, hospital, or health-system level, finance “is hyper relevant to the current practice of medicine,” stressed Nathan, who added, “It’s nice to get everything on the same page for everyone. . . . These are revolutionary therapies that are helping people, and we should make sure that they have access to care.”

The paper, by Nathan along with lead author Kriyana P. Reddy, BS, and Jay Giri, MD (both from University of Pennsylvania), was published online recently in JACC: Cardiovascular Interventions.

The ‘Elephant in the Room’

Reddy and colleagues offer a primer on how facilities and physicians are reimbursed, from relative value units to procedure codes, the Medicare Physician Fee Schedule, and beyond. This knowledge is “not something that we are exposed to at all in medical training . . . so you kind of have to learn on the go,” with the particulars varying by practice environment, said Nathan.

Additionally, the authors provide an overview of the “evolving financial landscape” at a time when healthcare delivery is changing. Procedures that once were done exclusively in a hospital setting, for example, have begun migrating to ambulatory surgery centers, private equity has changed the industry, and the consolidation seen across healthcare has begun to trickle down to cardiologists. All these factors, together, stand to affect what options patients and clinicians can choose from.

Importantly, Reddy et al say, there are misconceptions about how cost is considered in decision-making.

As Nathan explained, “there’s a difference between benefit to society and benefit to an individual hospital or health system. . . . The incentives are not necessarily aligned between those two.”

“Rarely would the societal benefit, as captured by traditional cost-effectiveness studies, affect a hospital’s decision to offer a transcatheter cardiovascular intervention given the differing incentives between hospitals/health systems and payers,” the authors write, pointing out that the Centers for Medicare & Medicaid Services (CMS), when making coverage determinations, “does not conduct or consider cost-effectiveness analyses.”

Thus, while there are multiple studies showing the cost-effectiveness of transcatheter cardiovascular interventions, these data may not bear fruit in actual practice.

A better metric may be contribution margin analyses, which “offer a significant real-world advantage in that they quantify the profitability of a procedure based on claim-level reimbursements and costs,” the authors suggest. “These calculations are better approximations of true procedural profits, which are core considerations for health systems choosing to adopt novel cardiovascular therapies and to continue offering them.”

There’s a difference between benefit to society and benefit to an individual hospital or health system. Ashwin S. Nathan

For aortic valve replacement, these sorts of pressures are already playing out, said Nathan. “The margins surrounding TAVR are frankly negative for a lot of hospitals in the country,” something that potentially could sway decisions between surgical and transcatheter AVR and affect what individual institutions offer, he said.

Yet, the situation is set to grow more complicated as novel therapies continue to ascend, Nathan predicted. “With these more complex and more expensive therapies, I think that certain environments may just not be able to afford them over time if the costs are too high to provide this and the reimbursement is not enough.”

Possible solutions that might facilitate wider access include site-neutral payment policies that reimburse procedures at the same rate regardless of where they are performed and other reforms that could improve the financial health of hospitals, with CMS playing a key role in pricing decisions.

“As payment reforms continue to take shape, it will be essential to monitor their effects on access to care, rollout of novel therapies, hospital financial viability, and long-term cost containment,” Reddy and colleagues conclude.