The Cost of Care and Medicare Reimbursement for Patients With Carotid Artery Occlusive Disease Varies Based on the Type of Carotid Intervention Chosen

Abstract

The costs incurred by health care systems and patients for different carotid revascularization interventions have yet to be compared. This study compared the costs and revenue of transfemoral carotid artery stenting (TF-CAS), transcarotid artery revascularization (TCAR), and carotid endarterectomy (CEA) among Medicare beneficiaries. Hospital billings systems and institutional Vascular Quality Initiative data were used to measure cost, revenue, and outcomes from a single-center review of 259 patients who underwent TF-CAS, TCAR, and CEA from 2017 to 2018. Direct technical cost was measured on a line item basis and included hospital devices, operating room supplies, and so on. Indirect technical costs were statistically allocated and included nursing, space, support services, laundry, and so on. Professional cost included services provided by surgeons, anesthesiologists, and consultants. Professional revenue was generated by CPT codes, and technical (hospital) revenue through diagnosis related group codes. To better quantify the specific impact of Medicare reimbursement, patients with private insurance or Medicaid were indexed to Medicare rates. As shown in Table I, TF-CAS patients were more frequently asymptomatic and had a lower American Society of Anesthesiologists class compared with TCAR and CEA (P < .001). Mean professional, technical, and total costs for TF-CAS were lower than TCAR and CEA (mean total cost TF-CAS, $13,539 ± $5590; total cost TCAR, $23,278 ± $7303; total cost CEA, $16,422 ± $7414; P = .001; Table II). Technical reimbursement (diagnosis related group) for TF-CAS and TCAR were significantly higher than for CEA (TF-CAS reimbursement, $18,532 ± $6001; TCAR reimbursement, $19,515 ± $3017; CEA reimbursement, $14,812 ± 6115; P = .001). Combined hospital and professional margin for TF-CAS was substantially higher than for TCAR or CEA, and resulted in a net negative (financial loss) margin (total margin TF-CAS, $7085 ± 5420; total margin TCAR, $–262 ± 7677; total margin CEA, $420 ± 8358; P = .003). For all three procedures professional reimbursement did not cover professional costs. Medicare reimbursement for TCAR and CEA does not cover the total cost of care and in many cases results in a net financial loss. The substantially better positive margin for TF-CAS compared to TCAR and CEA could influence health care systems toward a procedure that has inferior outcomes particularly in patients with symptomatic carotid occlusive disease.Table IDemographicsTypeCEA (n = 217)TF-CAS (n = 19)TCAR (n = 33)P valueVariable Age (SD)71.5 (9.2)71.1 (6.0)71.0 (9.6).954 White1001001001 Male57.173.760.6.363Symptoms Asymptomatic35.742.127.3<.001 HTN82.489.584.4.718 Active smoking2515.812.5.218 Diabetes27.847.431.3.195 CAD19.463.243.8<.001 COPD1942.128.1.041 ASA class2635.30<.001378.247.181.8<.001415.717.718.2<.001ASA, American Society of Anesthesiologists; CAD, coronary artery disease; CEA, carotid endarterectomy; COPD, chronic obstructive pulmonary disease; HTN, hypertension; SD, standard deviation; TCAR, transcarotid artery revascularization; TF-CAS, transfemoral carotid artery stenting.Values are percent unless otherwise indicated. Open table in a new tab Table IICost and reimbursementCEA (n = 217)TF CAS (n = 19)TCAR (n = 33)P valueProfessional cost4214 (2224)2896 (2032)6362 (3169).001Technical cost12208 (5885)10644 (4331)16916 (6235).009Total cost16422 (7414)13539 (5590)23278 (7303).001Professional reimbursement2288 (1261)1057 (445)2085 (642)–Technical reimbursement14812 (6115)18532 (6001)19515 (3017).04Total reimbursement17100 (6597)19589 (6064)21600 (3079).0001Total margin420 (8358)7085 (5420)-262 (7677).003CEA, Carotid endarterectomy; TCAR, transcarotid artery revascularization; TF-CAS, transfemoral carotid artery stenting.Values are mean (standard deviation). Open table in a new tab