Proposed Medicare Cuts May Hit TAVR Especially Hard

Medicare shoulders the vast majority of reimbursement for transcatheter aortic valve replacement in the United States, contributing around $2.1 billion toward TAVR hospitalizations over a recent 3-year period, researchers have found. Given this, recently proposed cuts to the Centers for Medicare & Medicaid Services (CMS) budget could put a strain on patients and healthcare providers, they say.

“This is very timely, considering we are looking at health policy changes at a national level for a lot of things, and cardiology procedures are just a part of that,” said senior author Pankaj Arora, MD (University of Alabama at Birmingham).

Based on an October 2017 estimate by the Congressional Budget Office, the cuts would reduce the net federal expenditure on Medicare by $473 billion over the next 10 years, Arora, along with lead author Nirav Patel, MD (University of Alabama at Birmingham), and colleagues note in a research letter recently published in JACC: Cardiovascular Interventions. Specific to TAVR hospitalizations, CMS has separately proposed an approximate 6% decrease in reimbursement starting in 2018, they say.

“The motivation for this study partly came from the current political climate of uncertainty around [healthcare policy],” Arora told TCTMD. TAVR stands out as one of the biggest advancements in cardiology, he added, so it was a logical choice for illustrating these trends.

As Patel noted via email, the idea was to link policy and practice. “Studying the impact of proposed healthcare policy changes on how we provide care to our patients with severe aortic stenosis was an innovative approach that formed the basis of this study,” he explained.

How to Pay for TAVR?

Patel et al gathered details from the National Inpatient Sample (NIS) on 40,875 TAVR hospitalizations from 2012 to 2014. Medicare was the primary payer for 36,787 (90%) of those. With the rise in TAVR cases, Medicare spending increased 2.5-fold during the 3 years, from $400 million in 2012 to $1 billion in 2014.

Using propensity-score matching, the researchers determined that the mean hospitalization cost was $4,500 lower for TAVR versus SAVR ($57,290 vs $61,792), with a median length of stay that was 3 days shorter with the less-invasive approach (6 vs 9 days; P < 0.001 for both).

Given that the mean age of TAVR patients in the data set was 81 years, it’s not surprising that Medicare would make up such a large slice of the pie, Arora commented. What this means, though, is that any change in the federal healthcare budget is especially meaningful for TAVR reimbursement.

“If there are going to be funding cuts, we do need to understand which procedures it’s going to impact,” with discussions among physicians and other stakeholders, he said. The idea, Arora noted, is that these cuts will be compensated for by raising premiums for Medicare beneficiaries, an action that would burden patients.

For TAVR, the big-picture question of how the procedure will be paid for will become ever more acute as the treatment is offered to a growing population of younger and lower-risk patients, he predicted. Better patient selection will help make the most of limited healthcare dollars, Arora suggested. “The other way is to make sure [that any cuts] are disease-specific and procedure-specific,” such that lifesaving treatments like TAVR are spared.

Arora said that, when it comes to making reimbursement decisions, he doesn’t want to put too much weight on the cost differential between transcatheter and surgical aortic valve replacement. But it is valuable to see that these NIS numbers match up with what has been shown in randomized controlled trials, namely, that TAVR offers economic advantages, he added.