Current Medicare Reimbursement for Complex Endovascular Aortic Repair is Inadequate Based on Results from a Multi-Institutional Cost Analysis
Clayton J. Brinster1, Samuel R Money1, Aaron Hayson1, Rene Gurdian, Jr.1, Ross Milner2, Kayla Polcari2, Konstantinos D.J. Arnaoutakis3, Chong Li4, Thomas Maldonado4, Andrew J Meltzer5
1Ochsner Health, New Orleans, LA;2University of Chicago Medicine, Chicago, IL;3University of South Florida Health, Tampa, FL;4NYU Langone Health, New York, NY;5Mayo Clinic, Scottsdale, AZ
INTRODUCTION:
Complex endovascular juxta-, para- and suprarenal abdominal aortic aneurysm repair (com-EVAR) is frequently accomplished with commercially available fenestrated (FEN) devices or off-label use of aortoiliac devices with parallel branch stents (chEVAR). We sought to evaluate the implantable vascular device costs incurred with these procedures as compared to standard Medicare reimbursement to determine the financial viability of com-EVAR in the modern era.
METHODS:
Five geographically distinct institutions with high-volume, complex aortic centers were included. Implantable aortoiliac and branch stent device cost data from 25 consecutive, recent, com-EVAR in the treatment of juxta-, para- and suprarenal aortic aneurysms at each center were analyzed. Cases of rupture, thoracic aneurysms, reinterventions, and physician-modified EVAR were excluded, as were ancillary costs from non-implantable equipment. Data from all institutions were combined and stratified into an overall cost group and two individual cost groups: FEN or chEVAR. These groups were compared, and each respective group was then compared to weighted Medicare reimbursement for DRG codes 268/269. Median device costs were obtained from an independent purchasing consortium of >1,000 medical centers, yielding true median cost-to-institution data rather than speculative, administrative projections or estimates.
RESULTS:
A total of 125 cases were analyzed: 70 FEN, 53 chEVAR - two cases of combined FEN/chEVAR were included in total cost/case analysis but excluded from direct FEN versus chEVAR comparison. Median Medicare reimbursement was calculated as $35,755/case. Combined average implantable device cost for all analyzed cases was $28,470/case, or 80% ($28,470/$35,755) of median reimbursement. Average FEN device cost/case ($26,499) was significantly lower than average chEVAR cost/case ($32,122, P<.002). Device cost was 74% ($26,499/$35,755) of total reimbursement for FEN, and 90% ($32,122/$35,755) for chEVAR.
CONCLUSIONS:
Results from this multi-institutional analysis show that implantable device cost alone represents the vast majority of weighted total Medicare reimbursement per case with complex EVAR, and that chEVAR is significantly more costly than FEN. Inadequate Medicare reimbursement for these cases puts high-volume, high-complexity aortic centers at a distinct financial disadvantage, effectively disincentivizing complex EVAR. In the interest of optimizing care for patients with complex aortic pathology, this data suggests a reconsideration of previously established, outdated, DRG coding and Medicare reimbursement for complex EVAR.
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