The CMS Changes to a US ECMO Reimbursement: The Financial Impact upon ECMO Programs

Abstract

Purpose Non-US (United States) countries differentiate reimbursement based on support type and indication. Historically, the US has reimbursed all ECMO cases at the same rate while most non-US countries use single payer systems. US reimbursement for ECMO has recently changed. Effective October 1st , 2018 The Center for Medicare Services (CMS) changed the ECMO associated Diagnostic Related Grouping (DRG) codes, varying reimbursement. Based almost exclusively on cannulation site, US reimbursement for ECMO cases may be lowered by 30%- 90%. The aim of this study was to investigate the financial impact from the DRG changes of US ECMO programs. Methods We reviewed adult cardiac ECMO cases performed during 2016 and 2017. Reimbursement was calculated applying the US national average dollar amount for ECMO support as done in the year 2017 (plan A). Subsequently, cases were categorized by cannulation site, and presence of Ventricular Assist Device (VAD). Reimbursement was calculated using the 2018 US CMS DRG and the associated national average dollar amount (plan B). Reimbursement amounts were compared. Results When comparing the difference in calculated reimbursement for 2016 and 2017 using plan A and B, estimated losses of 1.2 and 3.3 million dollars in reimbursement were identified respectively. Conclusion The US CMS changes to DRG codes and payment for ECMO support are largely driven by cannulation site and may result in a significant decrease in revenue for hospitals caring for these patients. Single payer systems across the globe reimburse ECMO support based on mode and indication for support, a more accurate way to determined resources spent. This impact could potentially affect ECMO programs through-out the US. Further research is needed to compare to non-US countries.