Response to Letter Regarding Article, “Facility Level Variation in Hospitalization, Mortality, and Costs in the 30 Days After Percutaneous Coronary Intervention: Insights on Short-Term Healthcare Value From the Veterans Affairs Clinical Assessment, Reporting, and Tracking System (VA CART) Program”

Abstract

CorrespondenceWe appreciate the interest in our article 1 by Drs Wasfy, Dominici, and Yeh. We agree with their viewpoint about the importance of reducing unnecessary readmissions following percutaneous coronary intervention in optimizing quality and eliminating unnecessary costs. However, we would like to clarify the differences in cost perspective taken by Wasfy and colleagues and our article. Wasfy and colleagues apply a Medicare reimbursement perspective in considering costs. In this payer perspective, the index hospitalization is a nonmodifiable cost. In contrast, we determined the cost of percutaneous coronary intervention care from the Veterans Affairs health system perspective by using its internal costing system. This costing approach is based on an activity-based costing approach, which is similar to microcosting, and includes direct costs such as healthcare products and staff time, and indirect costs, as well, such as overhead.2 Based on this perspective, and with the use of this costing approach, the cost of the index percutaneous coronary intervention hospitalization varies significantly and is potentially modifiable. In fact, we demonstrated that the hospital-level risk-standardized costs of percutaneous coronary intervention care varied >5-fold, and this variation in cost was largely attributable to the cost of the index hospitalization.1 These findings suggest a significant opportunity to modify the costs of care provided during the index hospitalization to achieve higher value care.The costing perspective has significant implications for addressing healthcare value. Typically, discussions of cost reflect the reimbursement perspective proposed by Wasfy and colleagues. However, reimbursement bears little relationship to actual costs and offers few insights on inefficient and low-value processes that contribute cost without improving outcomes.3 Our approach reflects the actual costs of providing care and opportunities to reduce the costs of care delivery itself, not just reimbursement. The conclusions drawn from both Wasfy and our article are correct based on their respective perspectives. However, as healthcare reimbursement moves to bundled payments for care delivery cycles, medical centers will need to know what it actually costs to provide care and how to spend less while optimizing outcomes. 4 Our approach to costing based on healthcare delivery, rather than reimbursement, provides these needed insights. DisclosuresNone.

Exploring the Healthcare Value of Percutaneous Coronary Intervention

“…However, our results differ from prior investigations in the VA Healthcare System (8,9). Unlike these studies, we found an association between higher risk-adjusted costs and higher readmissions and mortality.…”

“…Yet prior work in this area has understudied appropriateness in its assessments. In a large population of patients undergoing PCI in the Veterans Affairs (VA) Healthcare System, investigators reported variability in outcomes and costs across hospitals, but did not assess appropriateness 9,10 . In an analysis of the National Cardiovascular Data Registry (NCDR) CathPCI registry, appropriateness of PCI was found to be uncorrelated with procedural complications in the hospital; however, no examination of post-discharge outcomes or costs was performed 11 .…”

Future of the PCI Readmission Metric

“…Importantly, if compensation for PCI and post-PCI care is aggregated into bundled payments, the small proportion of cost attributable to readmissions may limit provider enthusiasm for focusing on readmissions rather than index episodes of care. 11 Furthermore, PCI readmission does not appear to relate closely to procedural complications. In particular, a medical record review of 262 early PCI readmissions at Geisinger Medical Center in Danville, Pennsylvania, demonstrated that only 11.9% of readmissions are related to procedural complications.…”

“…Because the cost of PCI readmission reflects only 5.8% of the cost of total PCI episodes of care, 11 some have argued that focusing on the index PCI may offer more effective opportunities to improve value. Alternative possibilities for cost savings include reducing inappropriate PCI or limiting waste during the index episode of care.…”

Etiologies, trends, and predictors of readmission in ST‐elevation myocardial infarction patients undergoing multivessel percutaneous coronary intervention

“…15 The Medicare Payment Advisory Committee identified PCI as one of the seven conditions that accounted for nearly a third of the total readmission costs in the U.S. 16 Readmissions after PCI have been extensively studied previously. 12,17,18 However, the readmission rates in the high-risk subgroup of multivessel PCI in STEMI are unknown. In this context, we extend the work of prior investigators by studying the causes and factors associated with readmission in patients undergoing multivessel PCI for STEMI.…”