IPPS PROPOSED RULE DISCUSSION MS-DRG 215 (OTHER HEART ASSIST SYSTEM IMPLANT) July 2017 2 ISSUE SUMMARY • DRG 215 comprises critically ill cardiovascular patients who require the implantation of a heart pump in the operating room or catheterization lab after a heart attack or decompensating heart failure • Proposed decrease of 35% for DRG 215 is the largest reduction in the Proposed Rule (other DRGs in the same category ranging from -7% to 3.5%) • Dramatic decrease is not the result of a new policy proposal, and is contrary to the goal of ICD-10 implementation to accurately replicate ICD-9 DRG assignments and avoid unintended payment redistributions • As a result of ICD-10 coding changes, some cases that were assigned to DRG 215 in FY 2016 are now reassigned which has significantly affected the type of cases in DRG 215 and dramatically reduced the relative weight of the DRG • Recent AHA coding changes and new FDA indications not accounted for in the proposed rule will result in higher acuity and cost patients being assigned to DRG 215 in FY 2018 • In FY 2018 Final Rule CMS should provide a transition period for DRG 215, and other DRGs that have a decrease greater than 10% due to shift to ICD-10 3 IPPS PROPOSED RULE: DRG 215 INSTABILITY MEDICARE MS-DRG 215 WEIGHTS 10 YR TREND Significant decrease impacted by: $96K 1. 1st yr. ICD10 coding & related DRG 215 mapping 2. DRG volume extremely low, <300 cases /yr $63K 3. A few surgical LVAD moves, high cost 4. A few new PVAD related claims included FY08 FY09 FY10 FY11 FY12 FY13 FY14 FY15 FY16 FY17 FY18 5. Prior to new AHA Coding Clinic guidance, new FDA Indications & majority were new hospitals 4 IPPS MS-DRG PROPOSED RULE – MOST SIGNIFICANT REDUCTION FY 2018 PROPOSED RULE, TABLE 5.—LIST OF MEDICARE SEVERITY DIAGNOSIS-RELATED GROUPS (MS-DRGS) MS-DRG MS-DRG Title 215 OTHER HEART ASSIST SYSTEM IMPLANT 780 332 517 333 454 734 770 455 768 334 423 867 327 830 326 951 712 769 290 344 981 777 148 713 346 453 FALSE LABOR RECTAL RESECTION W MCC OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W/O CC/MCC RECTAL RESECTION W CC COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W CC PELVIC EVISCERATION, RAD HYSTERECTOMY & RAD VULVECTOMY W CC/MCC ABORTION W D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W/O CC/MCC VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C RECTAL RESECTION W/O CC/MCC OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES W MCC OTHER INFECTIOUS & PARASITIC DISEASES DIAGNOSES W MCC STOMACH, ESOPHAGEAL & DUODENAL PROC W CC MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS W OTHER PROCEDURE W/O CC/MCC STOMACH, ESOPHAGEAL & DUODENAL PROC W MCC OTHER FACTORS INFLUENCING HEALTH STATUS TESTES PROCEDURES W/O CC/MCC POSTPARTUM & POST ABORTION DIAGNOSES W O.R. PROCEDURE ACUTE & SUBACUTE ENDOCARDITIS W/O CC/MCC MINOR SMALL & LARGE BOWEL PROCEDURES W MCC EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W MCC ECTOPIC PREGNANCY EAR, NOSE, MOUTH & THROAT MALIGNANCY W/O CC/MCC TRANSURETHRAL PROSTATECTOMY W CC/MCC MINOR SMALL & LARGE BOWEL PROCEDURES W/O CC/MCC COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W MCC CHANGES IN RELATIVE WEIGHTS FY 2018 Proposed Weights compared to FY 2017 Weights (% Change) -35% -28% -24% -24% -21% -21% -20% -20% -20% -20% -19% -19% -18% -18% -15% -15% -15% -14% -14% -13% -13% -12% -12% -12% -11% -11% -11% >10% Reduction N=27 IMPELLA HEART PUMP: HOW IT WORKS ® Placement in Left Ventricle Impeller and blood outflow Animation Click here 6 CLINICAL VALUE OF IMPELLA – HEART RECOVERY Unloads the Heart End Organ Perfusion Left & Right Support Right Side Impella RP IMP-119-17 Left Side Impella 2.5/CP/5.0 Ambulation 7 CONTEXT OF PROPOSED IPPS RULE CHANGE 2015 - 2016 2016 - 2017 NEW FDA PMA APPROVALS NEW AHA CODING GUIDANCE New AHA Coding Clinic Guidance to Address FDA Indications, Multiple Products New Impella Technologies and New First of a Kind Clinical indications • FDA PMA Indication for AMI Cardiogenic Shock, Heart Recovery, 4-6 days • Left side heart failure, right side heart failure, bi-ventricular • FDA PMA Indication for PCI in high risk patients, 6 hours – 2days • Treatment in cath lab, OR, ICU and hospital transfer scenarios • FDA HDE Indication for right side heart failure, use as bi-ventricular support with left side. PMA expected 2017. • • Impella (PVAD) product line expanded to Impella 2.5, CP, 5.0, LD, RP with unique FDA labeling for each Impella 2.5, CP, 5.0, LD, RP 2018 (proposed) IPPS PAYMENT PROPOSAL Proposed IPPS Rule Base Rate Tables * 8 PROPOSED RECOMMENDATIONS: TRANSITION Option 1: Option 2: Revise assignment of ICD-10 codes to replicate MS-DRG assignments based on ICD-9 codes Cap Reductions at 10% Reduction For MS-DRGs with >10% Reduction For MS-DRGs with >10% Reduction MEDICARE MS DRG 215 WEIGHTS 3 YEAR AVE FY18 14.16 MS-DRG 215 FY17 Base Rate 16.108 FY18 Base Rate Recommendation 14.497 N = 285 claims % Change -10% 9 SUMMARY • IPPS Proposed rule adversely effects a severely ill Medicare population with new FDA indicated therapies for cardiac assist now available • Changes would be a disincentive for hospitals treating the sickest Medicare heart failure patients (i.e. cardiogenic shock, advanced heart failure with PCI) • Proposed FY 2018 relative weight for DRG 215 would not accurately reflect the cost of the higher acuity cases moving into DRG 215 in FY 2018 • In the Final Rule should provide a transition period by either: – Revising the assignment of ICD-10 codes to MS-DRG 215 for the calculation of FY 2018 relative weights to replicate the MS-DRG assignments based on ICD-9 codes; or – Implementing a multi-year transition period for or cap on cuts in relative weight in excess of 10%