Site of Service Influence on Stent Utilization for Hemodialysis Access Interventions

Abstract

With unsustainably rising health care spending in the United States, the Centers for Medicare and Medicaid Services (CMS) has in recent years attempted to use reimbursement rates to influence utilization of less expensive care sites for covered patients, such as ambulatory surgery facilities and office-based interventions in lieu of hospital service sites. It has been suggested that cost savings have not been realized because of an increase in procedure numbers performed by physicians with ownership interests in nonhospital facilities. CMS has proposed massive reimbursement changes for 2019 that will reduce access angioplasty reimbursement in the ambulatory surgery center setting by 75.9%, whereas stenting would be increased by 12.1% over current levels. The clinical utility of adjunctive stenting in treating access stenosis remains controversial and highly discretionary. Our group performs such procedures in both a hospital and a nonhospital facility in which we have equity interest. We reviewed the prevalence of stent deployment in patients in both settings since 2014 to determine whether site of service affected stent utilization. Between 2014 and 2018, there were 739 total angioplasty or angioplasty with stenting procedures performed by our group; 599 were done in the hospital setting, whereas 140 were performed in an ambulatory facility, initially as a physician office site of service and since 2018 as an ambulatory surgery center. Patients’ demographics and variables were compared. There was no difference in any clinical or demographic variable between the hospital and nonhospital groups, other than a higher incidence of Medicaid patients in the hospital setting (P < .001). In hospital-treated patients, 190 of 599 procedures included adjunctive stenting (33.2%), whereas in the non-hospital-treated patients, 45 of 140 had stents (32.1%), despite financial incentives for both professional and facility reimbursement in favor of stenting (P = .94). Whereas financial incentives have not yet had an appreciable influence in stent utilization within previous reimbursement paradigms, the dramatic changes proposed by CMS may well alter this dynamic and lead to substantially higher overall costs without proven clinical advantage. With very high failure and reintervention rates and increasingly expensive adjuncts (drug-coated balloons and stents, covered stents), the cost implications of attempts to incentivize interventionalists toward a specific site of care are substantial, and unintended negative consequences are likely to occur.