当经导管主动脉瓣置换术(TAVR)在2011年商业化时, the challenge for CV programs was to be “first to market,吸引新患者加入他们的组织,提升他们的品牌. This required considerable investments to begin a new TAVR program, including hiring and training physicians, 预购买设备, developing a quality infrastructure, 对于很多项目来说, 新建混合式导尿室或手术室.
TAVR is no longer a novel therapy. 今天, over 700 programs operate across the country, and more than 300,000 patients have been treated with TAVR. It’s become a cornerstone of tertiary CV programs. 现在的挑战是, as TAVR continues to expand its reach, is for programs to focus on maintaining healthy financial margins, which means refining patient selection, 优化收益获取, managing hospital and supply costs, and evaluating staffing resources.
优化患者选择和 Provider Credentialing Processes
鉴于TAVR的侵入性较小,恢复时间较短, 在临床上合适的情况下,患者和云顶集团40011官网倾向于选择这种疗法,而不是传统的心内直视手术. 因此,患者选择是TAVR项目成功和高质量的基础. 这就需要适当地识别有可能从TAVR中获益的患者,并针对每个病例进行个体化治疗, including the procedural approach or access site, as well as the valve type and size. 多学科心脏团队应该仔细评估的与患者选择相关的一些关键考虑因素包括:
- 患者的年龄、虚弱和合并症影响预期寿命和生活质量.
- Valve durability and lifetime management strategies.
- Patient anatomy and calcification pattern.
- Patient risk for developing a new conduction disturbance.
除了 to designing proper patient selection processes, 维持高质量和安全的TAVR计划的一个重要部分是确保TAVR护理团队成员的严格提供者资格认证过程, 包括心脏病专家, 心脏外科云顶集团40011官网, and advanced practice providers (APPs). 项目负责人应定期审查提供者资格认证标准,以确保与国家和最佳实践建议保持一致.
加强收入捕获
TAVR项目本质上是资源密集型的,确保准确的收入获取至关重要. Patients undergoing TAVR often have comorbid conditions, and as an inpatient-only procedure, TAVR目前分为MS-DRG 266(有主要并发症或合并症[mcs])和MS-DRG 267(无mcs)。. 因为程序编码很大程度上依赖于云顶集团40011官网的文档, TAVR程序学家应了解文件要求和指导方针,并接受与文件完整性有关的持续教育.
特别是, 准确捕获患者合并症对测量和改进质量指标有影响, as well as significant financial implications. 2023年 national Medicare unadjusted payment rate MS-DRG 266的价格是45美元,278, 和35美元,MS-DRG 267为399, 代表10元,000 difference in payment per procedure.
Invest in a Coding and Documentation Integrity Program
因为DRG分类可以根据程序复杂性等因素而变化, 逗留时间(洛杉矶), 以及患者的合并症, 项目负责人应该投资于编码和文档完整性(CDI)项目. CDI项目的目标是确保云顶集团40011官网的记录充分反映病人的复杂性和敏锐度.
作为这项努力的一部分, 许多程序将报告用mcc编码的TAVR程序的百分比,并将其与目前全国36%的比率进行比较.[1]这一指标应该随着时间的推移而被跟踪,并与程序学家共享,以衡量编码结果是否与临床评估一致, 临床管理, 洛杉矶, 以及临床云顶集团40011官网的期望. Engagement of coding staff is also essential, 作为最佳实践, 组织通常会在TAVR团队会议上安排一名专门的简历编码员和文档专家,以提供持续的教育和反馈.
Capture Post-Operative and Add-On Coding
有效的收入获取意味着项目应该为所提供的所有临床护理适当收费, 并且由于TAVR目前没有一个全球性的术后期, 评价与管理(E)&M)手术后的偶遇应单独计费.
- 一些项目利用app来协助TAVR患者的术前和术后护理, 因此,对这些供应商进行独立认证是有益的. 除了, app可以帮助确保临床文档准确捕获合并症,并协助响应编码查询,以最大限度地减少提交索赔所需的时间.
- 任何程序性成像, 如经食管超声心动图(TEE)或心内超声心动图(ICE), 还具有单独的专业计费代码,应用于捕获已执行的工作.
- 最后, 而从收入获取的角度来看,项目受益于准确的供应商文档, 准确测量质量和临床登记数据同样重要, much of which is publicly reported.
Managing Hospital and Supply Costs
Once TAVR revenue is optimized, programs should carefully evaluate their expense structure, including the procedural 洛杉矶 and supply costs. 基于风险和预先出院计划对TAVR患者进行分层, including same- or next-day discharge planning, can help minimize 洛杉矶 for uncomplicated patients. TAVR is not currently considered an emergency treatment therapy, 所以大多数病人都是作为门诊病人接受手术前检查的. 有时, when patients do receive a TAVR workup while an inpatient, the pre-procedure tests are bundled into the MS-DRG payment, and often these cases result in a financial loss. 因此, timely communication and coordination are key, particularly given the number of tests, 成像过程, and provider evaluations required. 简单的手术前检查表可以帮助多学科团队成员跟踪检查进度,并最大限度地减少不必要的los相关成本.
进一步, since TAVR remains an inpatient-only procedure, 项目应监测和定期报告患者出院状况和所有急性后护理转移政策(PACT)付款. Patients receiving TAVR a decade ago were often discharged to another facility; however, a 2019年的报告 美国心脏病学会(American College of Cardiology)的一项研究强调,大多数患者(90.3%)出院回家.6% to a rehabilitation or extended care facility, and 2.45%去了养老院. 具有扩展洛杉矶和/或高于平均水平的PACT利用率的TAVR程序, 然而,归类为MS-DRG 266的病例数量却少得不成比例, 例如, 是否会从CDI专家评估他们的临床文件是否恰当地捕捉到基于程序分类的预期临床结果中获益. 在这个例子中, 由于延长了洛杉矶和PACT的处罚,TAVR项目将具有更高的成本结构,并将获得较低的MS-DRG付款, 表示有机会评估编码和文档的准确性.
程序耗材管理
Beyond managing inpatient hospital 洛杉矶 and associated expenses, programs benefit from evaluating procedural supply costs, most notably the TAVR valve and surgical backup supplies. TAVR瓣膜仍然比外科瓣膜贵得多, 还有成本, which is often five to six times greater than surgical valves, drives the narrow margin of TAVR procedures.
- 随着新型阀门进入美国市场,阀门的成本应该会下降, 但CV项目负责人应该与供应商合作,以确定节省成本的机会. 这可能包括以寄售方式购买阀门,或者在每月或每季度购买一定数量的阀门时利用回扣和折扣价格.
- 类似的, 只有在心胸外科云顶集团40011官网的决定下才能打开手术供应包. 许多成熟的TAVR项目对大多数或所有病例都不开封这些材料(只在高风险的手术中保留它们)。, thus reducing the cost of using and cleaning these supplies.
Evaluating Staffing Resources
像所有心脏结构手术一样,TAVR需要一个多学科的团队. 这个护理团队的核心是“瓣膜协调员”或护士项目协调员或护士导航员, as the role has continued to evolve. 护理协调是必不可少的管理一个高性能和高容量TAVR计划, since patients require extensive education, a detailed pre-procedural workup involving multiple tests, 专门的成像, 云顶集团40011官网合作. 护士协调员将与TAVR项目的患者建立长期的关系, 从转诊开始,延伸到甚至超过患者一年的术后评估, making this position critical to achieving continuity of care. TAVR项目应使护士协调员和APP资源与项目规模和增长预期保持一致, as illustrated below in figure 2. All TAVR programs need at least one nurse program coordinator, ,通常, 一旦一个项目发展到每年执行大约150次tavr的规模, it benefits from the addition of an APP.
在这个模型中, 护士项目协调员的角色是支持和教育病人, 在各个护理站点协调护理, and ensure a timely pre-procedure process. 因此,APP能够通过协助住院病人进行术前检查来扩大云顶集团40011官网的能力, performing some testing and consultations, and seeing patients in clinic for post-operative evaluations, independently and in parallel to a physician. 护士协调员和项目APP在护理的连续性和确保所有指南驱动的干预措施得到解决方面发挥着重要作用. 维持适当比例的护士和应用程序的规划量, as well as appropriate job scopes and responsibilities, 管理资源的关键是什么.
手术人员与灌注
医疗保险中心 & 医疗补助(CMS)要求介入心脏病专家和CT外科云顶集团40011官网在每次TAVR手术中都在场. 这是一个热议的话题, 但这两位云顶集团40011官网的存在仍然是当前的授权和护理标准.
而外科云顶集团40011官网的时间成本因此可归因于每个TAVR病例, programs have begun evaluating whether surgical nurses, 拆弹专家, and perfusionists must also be present in the case, or whether a safe alternative exists. In 2019, 心肺旁路 在小于0.41%的TAVR病例, 因此, 一些项目已经开始将外科人员重新部署到其他非临床任务中. A perfusionist is still typically present in the case during valve deployment; however, they may be able to perform other work outside of the procedure, provided they remain readily available in case of an emergency. 灌注设备也可以放在室外,特别是对于低风险病例.
成像心脏病专家
虽然大多数TAVR项目发现超声心动图专家在手术过程中的参与是有价值的, 投入另一名云顶集团40011官网资源是昂贵的,并且增加了已经很高的程序开销. 为了最小化这个, and for the minority of cases that require a procedural TEE, 有些项目利用心脏麻醉师来完成这个角色.
类似的, 其余需要经胸超声心动图(TTE)的病例, typically an echo sonographer is able to acquire images, 介入心脏病专家可以代替额外的超声心脏病专家来检查这些. 这些调整提供了在TAVR过程中涉及成像心脏病专家的安全替代方案.
健康的计划性成长
Once revenue capture is optimized and overhead expenses are aligned, 计划应侧重于TAVR和结构性心脏容积的增长. 继续计划性增长的最佳做法包括:
- Evaluate expansion opportunities by establishing collaborative networks of care.
- Avoid unnecessary delays in the pre-procedure workup. Outpatients often take several weeks to undergo a workup, 作为最佳实践, 组织的目标是将这个过程控制在四周以内. 检查清单和频繁的护理团队参与可以帮助确保流程的顺利和及时.
- 随着操作者经验的增加,可以考虑提供其他的导管入路.g.(颈动脉,腋窝/锁骨下,以及瓣中瓣手术).
- 培养多学科心脏结构诊所,推动外科瓣膜项目的发展(这些项目往往具有历史上健康的边缘).
- 考虑参与二尖瓣和三尖瓣的研究试验,以扩大临床云顶集团并吸引新患者加入组织.
- Pursue credentialing as a valve center of excellence through the American College of Cardiology.
- Continue investing in resources to support quality, 并定期监测所有公开报告的患者安全和质量数据.
最佳实践TAVR程序
考虑到许多组织目前面临的强劲的财务逆风, optimizing financial margins of all service lines and procedures is prudent; however, resource-intensive procedures such as TAVR should be prioritized. 当我们展望未来, continued growth in TAVR procedures, as well as transcatheter replacement of mitral and tricuspid valves, 似乎. 成功的CV项目是那些能够以高质量的结果继续保持增长轨迹,同时通过收入优化和有效的资源利用来管理利润的项目.
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Source: 2021 Medicare claims data through September 2021.
出版于2023年7月13日