Medicare's PCI codes typically reimburse in the range of $21,000 to $39,000, about 40% less than the ones for major cardiothoracic procedures. The CMS said in the rule that using the more intensive range of codes would mean providers would be “significantly overpaid” for the minimally invasive implantation of the MitraClip. The agency is expected to issue a final payment rule around Aug. 1.
Because the device itself costs more than $30,000, the proposed reimbursement rate would make it “prohibitive for hospitals to be able to offer this significant care so badly needed for a large majority of our patients,” Dr. Gregory Helmer, a cardiologist at the University of Minnesota, said in comments submitted to the CMS.
Abbott's MitraClip, the only device of its kind on the market, was approved last year by the Food and Drug Administration. In May this year, the CMS recommended that Medicare cover it, citing a study estimating that as many as 5 million people could suffer from mitral valve regurgitation by 2030, double the number who had the condition in 2000.
Implanting MitraClip typically takes three to six hours and is technically challenging, often requiring multiple clips and usually necessitating four physicians: an anesthesiologist, an echocardiographer, an interventional cardiologist and another assisting physician, providers told the CMS. Many of the patients—often selected because they're poor candidates for invasive surgery—are elderly with comorbidities that require longer hospital stays and raise the risk of complications, providers said.
The DRGs the CMS proposed for the MitraClip procedure are typically used for patients requiring hospital stays ranging from four to eight days. Providers are arguing the procedure should be assigned to DRGs used when patients need to be hospitalized from five to 15 days.
“We are aware of institutions that have declined to provide this service to patients because they would lose so much money it would drag down other areas of the hospital,” Patrick O'Gara, president of the American College of Cardiology, said in a comment to the CMS.
Comments from the Providence Valve Center at Providence St. Vincent Medical Center in Portland Oregon, and Oklahoma Heart Institute at Hillcrest Medical Center, Cedars Sinai Medical Center and East Carolina University told the CMS they would have to limit or end their use of the device with Medicare patients.
Follow Virgil Dickson on Twitter: @MHVDickson