Valuing innovative endoscopic techniques: per-oral endoscopic myotomy for the management of achalasia

Abstract

Unclear reimbursement for new and innovative endoscopic procedures can limit adoption in clinical practice despite effectiveness in clinical trials. The aim of this study was to determine maximum cost-effective reimbursement for per-oral endoscopic myotomy (POEM) in treating achalasia. We constructed a decision-analytic model assessing POEM versus laparoscopic Heller myotomy with Dor fundoplication (LHM) in managing achalasia from a payer perspective over a 1-year time horizon. Reimbursement data were derived from 2017 Medicare data. Responder rates were based on clinically meaningful improvement in validated Eckardt scores. Validated health utility values were assigned to terminal health states based on data previously derived with a standard gamble technique. Contemporary willingness-to-pay (WTP) levels per quality-adjusted life year (QALY) were used to estimate maximum reimbursement for POEM using threshold analysis. Effectiveness of POEM and LHM was similar at 1 year of follow-up (0.91 QALY). Maximum cost-effective reimbursement for POEM was $8033.37 to $8223.14, including all professional and facility fees. This compares favorably with contemporary total reimbursement of 10 to 15 total relative value units for advanced endoscopic procedures. Rates of postprocedural GERD did not affect the preference for POEM compared with LHM, assuming at least 10% cost savings with POEM compared with LHM in cost-minimization analysis, or at least 44% cost savings in cost-effectiveness analysis (WTP= $100,000/QALY). LHM was only preferred over POEM if both procedures were reimbursed similarly, and these findings were primarily driven by lower rates of postprocedural GERD. The rate of conversion to open laparotomy due to perforation or bleeding was infrequent in published clinical practice experience, thus did not significantly affect reimbursement. POEM is an example of an innovative and potentially disruptive endoscopic technique offering greater cost-effective value and similar outcomes to the established surgical standard at contemporary reimbursement levels.