Optimizing Your TAVR Program’s Financial Margins

When transcatheter aortic valve replacement (TAVR) became commercially available in 2011, the challenge for CV programs was to be “first to market,” attracting new patients to their organization and elevating their brand. This required considerable investments to begin a new TAVR program, including hiring and training physicians, pre-purchasing devices, developing a quality infrastructure, and for many programs, constructing new hybrid catheterization laboratories or operating rooms.

TAVR is no longer a novel therapy. Today, over 700 programs operate across the country, and more than 300,000 patients have been treated with TAVR. It’s become a cornerstone of tertiary CV programs. The challenge now, as TAVR continues to expand its reach, is for programs to focus on maintaining healthy financial margins, which means refining patient selection, optimizing revenue capture, managing hospital and supply costs, and evaluating staffing resources.

Refine Patient Selection and Provider Credentialing Processes

Given the less invasive nature of TAVR and the shorter recovery times, patients and providers tend to favor the therapy over traditional open-heart surgery when clinically appropriate. Therefore, patient selection is foundational for a successful and high-quality TAVR program. This requires programs to appropriately identify patients with the potential to benefit from TAVR and to individualize treatment for each case, including the procedural approach or access site, as well as the valve type and size. Some key considerations related to patient selection that should be carefully evaluated by the multidisciplinary heart team include:

• Patient age, frailty, and comorbid diseases impacting life expectancy and quality of life.
• Valve durability and lifetime management strategies.
• Patient anatomy and calcification pattern.
• Patient risk for developing a new conduction disturbance.

In addition to designing proper patient selection processes, an important part of maintaining a high-quality and safe TAVR program is ensuring a rigorous provider credentialing process of TAVR care team members, including cardiologists, cardiac surgeons, and advanced practice providers (APPs). Program leaders should periodically review provider credentialing criteria to ensure alignment with national and best practice recommendations.

Enhancing Revenue Capture

TAVR programs are inherently resource-intensive, and ensuring accurate revenue capture is essential. Patients undergoing TAVR often have comorbid conditions, and as an inpatient-only procedure, TAVR is currently classified either into MS-DRG 266 (with major complications or comorbidities [MCCs]) or MS-DRG 267 (without MCCs). Since procedural coding is largely dependent on physician documentation, TAVR proceduralists should be aware of documentation requirements and guidelines and receive ongoing education related to documentation integrity.

In particular, accurately capturing patient comorbidities has an impact on measuring and improving quality metrics, as well as significant financial implications. The 2023 national Medicare unadjusted payment rate for MS-DRG 266 is $45,278, and $35,399 for MS-DRG 267, representing a $10,000 difference in payment per procedure.

Invest in a Coding and Documentation Integrity Program

Because DRG classification can vary depending on factors such as procedure complexity, length of stay (LOS), and patient comorbidities, program leaders should invest in a coding and documentation integrity (CDI) program. The goal of a CDI program is to ensure that physician documentation adequately captures patient complexity and acuity.

As part of this effort, many programs will report on the percentage of TAVR procedures coded with MCCs and compare this to the current national rate of 36%.^[1]This metric should be tracked over time and shared with proceduralists to gauge whether coding outcomes are in alignment with clinical assessments, clinical management, LOS, and clinician expectations. Engagement of coding staff is also essential, and as a best practice, organizations often include a dedicated CV coder and documentation specialist in TAVR team meetings to provide ongoing education and feedback.

Capture Post-Operative and Add-On Coding

Effective revenue capture means programs should appropriately bill for all clinical care provided, and since TAVR does not currently have a global post-operative period, evaluation and management (E&M) encounters performed after the procedure should be separately billable.

• Some programs utilize APPs to assist in the pre- and post-procedural care of TAVR patients, so independently credentialing these providers can prove beneficial. In addition, APPs can help ensure clinical documentation accurately captures comorbidities and assist with responding to coding queries to minimize the time it takes for a claim to be submitted.
• Any procedural imaging, such as transesophageal echocardiogram (TEE) or intracardiac echocardiogram (ICE), also has separate professional billing codes that should be used to capture performed work.
• Lastly, while programs benefit from accurate provider documentation from a revenue-capture perspective, it is equally important for accurately measuring quality and clinical registry data, much of which is publicly reported.

Managing Hospital and Supply Costs

Once TAVR revenue is optimized, programs should carefully evaluate their expense structure, including the procedural LOS and supply costs. Stratifying TAVR patients based on risk and up-front discharge planning, including same- or next-day discharge planning, can help minimize LOS for uncomplicated patients. TAVR is not currently considered an emergency treatment therapy, so the majority of patients receive their pre-procedural workup as an outpatient. On occasion, when patients do receive a TAVR workup while an inpatient, the pre-procedure tests are bundled into the MS-DRG payment, and often these cases result in a financial loss. Therefore, timely communication and coordination are key, particularly given the number of tests, imaging procedures, and provider evaluations required. A simple pre-procedural checklist can help the multidisciplinary team members track the workup progress and minimize unnecessary LOS-related costs.

Further, since TAVR remains an inpatient-only procedure, programs should monitor and regularly report on patient discharge statuses and all post–acute care transfer policy (PACT) payments. Patients receiving TAVR a decade ago were often discharged to another facility; however, a 2019 report by the American College of Cardiology highlighted that the majority of patients (90.3%) are discharged home, 6.6% to a rehabilitation or extended care facility, and 2.45% to a nursing home. A TAVR program with an extended LOS and/or above-average PACT utilization, yet a disproportionately low volume of cases classified into MS-DRG 266, for example, will benefit from engaging CDI specialists to evaluate whether their clinical documentation is appropriately capturing expected clinical outcomes based on procedure classification. In this example, the TAVR program will have a higher cost structure due to the extended LOS and PACT penalty and will receive the lower of the two MS-DRG payments, representing an opportunity to evaluate coding and documentation accuracy.

Managing Procedural Supplies

Beyond managing inpatient hospital LOS and associated expenses, programs benefit from evaluating procedural supply costs, most notably the TAVR valve and surgical backup supplies. TAVR valves remain significantly more expensive than surgical valves, and the cost, which is often five to six times greater than surgical valves, drives the narrow margin of TAVR procedures.

• The cost of valves should decrease as new models enter the US market, but CV program leaders should partner with vendors to identify opportunities for cost savings. This might include purchasing valves on consignment or taking advantage of rebates and discounted purchase prices when buying a certain number of valves on a monthly or quarterly basis.
• Similarly, surgical supply packs should only be opened at the discretion of the cardiothoracic (CT) surgeon. Many mature TAVR programs leave these supplies unopened for most or all cases (reserving them only for higher-risk procedures), thus reducing the cost of using and cleaning these supplies.

Evaluating Staffing Resources

Like all structural heart procedures, TAVR requires a multidisciplinary team. At the center of this care team is the “valve coordinator” or nurse program coordinator or nurse navigator, as the role has continued to evolve. Nursing coordination is essential to managing a high-performing and high-volume TAVR program, since patients require extensive education, a detailed pre-procedural workup involving multiple tests, specialized imaging, and physician collaboration. The nurse coordinator will have an extended relationship with TAVR program patients, beginning at referral and extending to or even beyond the patient’s one-year post-procedure evaluation, making this position critical to achieving continuity of care. TAVR programs should align nurse coordinators and APP resources with the program size and growth expectations, as illustrated below in figure 2. All TAVR programs need at least one nurse program coordinator, and typically, once a program grows to a size such that it’s performing around 150 TAVRs annually, it benefits from the addition of an APP.

In this model, the nurse program coordinator’s role is to support and educate patients, align care across care sites, and ensure a timely pre-procedure process. The APP is therefore able to expand physician capacity by assisting with inpatient pre-procedural workups, performing some testing and consultations, and seeing patients in clinic for post-operative evaluations, independently and in parallel to a physician. Both the nurse coordinator and the program APP play an important role in continuity of care and assuring all guideline-driven interventions are addressed. Maintaining the right ratio of nurses and APPs to programmatic volumes, as well as appropriate job scopes and responsibilities, is key to managing resources.

Surgical Staff and Perfusion

The Centers for Medicare & Medicaid (CMS) requires both an interventional cardiologist and a CT surgeon to be present for every TAVR procedure. This is a hotly debated topic, but the presence of both physicians remains the current mandate and standard of care.

While the cost of the surgeon’s time is therefore attributable to each TAVR case, programs have begun evaluating whether surgical nurses, techs, and perfusionists must also be present in the case, or whether a safe alternative exists. In 2019, cardiopulmonary bypass was used in less than 0.41% of TAVR cases, and as such, some programs have begun redeploying surgical staff to other nonclinical tasks. A perfusionist is still typically present in the case during valve deployment; however, they may be able to perform other work outside of the procedure, provided they remain readily available in case of an emergency. Perfusion equipment can also be left outside of the room, particularly for lower-risk cases.

Imaging Cardiologists

While most TAVR programs find the involvement of an echocardiologist during the procedure valuable, dedicating another physician resource is costly and adds to the already high procedural overhead. To minimize this, and for the minority of cases that require a procedural TEE, some programs utilize the cardiac anesthesiologist to perform this role.

Similarly, for the remainder of cases requiring a transthoracic echocardiogram (TTE), typically an echo sonographer is able to acquire images, and the interventional cardiologist is able to review these in lieu of the additional echocardiologist. These adjustments provide safe alternatives to involving an imaging cardiologist during the TAVR procedure.

Healthy Programmatic Growth

Once revenue capture is optimized and overhead expenses are aligned, programs should focus on growth of TAVR and structural heart volumes. Best practices to continue programmatic growth include the following:

• Evaluate expansion opportunities by establishing collaborative networks of care.
• Avoid unnecessary delays in the pre-procedure workup. Outpatients often take several weeks to undergo a workup, and as a best practice, organizations aim to keep this workup process to less than four weeks. Checklists and frequent care team engagement can help ensure smooth and timely processes.
• As operator experience increases, consider offering alternative catheter approaches (e.g., carotid, axillary/subclavian, as well as valve-in-valve procedures).
• Foster multidisciplinary structural heart clinics to drive volume to surgical valve programs (which tend to have historically healthy margins).
• Consider involvement in mitral and tricuspid valve research trials to expand clinical offerings and attract new patients to the organization.
• Pursue credentialing as a valve center of excellence through the American College of Cardiology.
• Continue investing in resources to support quality, and regularly monitor all publicly reported patient safety and quality data.

Best Practice TAVR Programs

Given the strong financial headwinds that many organizations are currently facing, optimizing financial margins of all service lines and procedures is prudent; however, resource-intensive procedures such as TAVR should be prioritized. As we look to the future, continued growth in TAVR procedures, as well as transcatheter replacement of mitral and tricuspid valves, seems likely. Successful CV programs are those that are able to continue their growth trajectory with high-quality outcomes while managing margins through revenue optimization and efficient resource utilization.

_{Edited by: Matt Maslin}

Published July 13, 2023