Alignments
What are your alignments? This question addresses the issue of surgeon and interventional cardiologist alignments in either doing open AVR or TAVR. In Germany, one-third of patients are done by TAVR because institutions get paid more for TAVR and surgeons are essentially employed by the institutions, although numbers do count. However, the German healthcare system has realised this and now a senior surgeon is required to approve patients for TAVR. In Belgium, the government will not pay for TAVR and so surgeons and cardiologists do TAVRs for free and hospitals absorb the costs but limit the annual number they permit, to for example 15. In the US the situation varies from institution to institution. If both cardiologist and surgeon are in private practice, there is little support for moderate-risk TAVR. If surgeons are in combined practice plans there is more accommodation since fees are split and a surgeon gets half of the AVR fee. In institutions where both are on salary and the perception is for the greater good, accommodation of TAVR is more based on medical imperatives and less influenced by financial potential arbitrations. On the contrary, however, it is likely in the latter scenario that surgeons will be more prepared to give up complex reoperations for TAVR if there are no rewards to do the complex cases, even though previous coronary artery bypass grafting (CABG) patients in the PARTNER A trial did much better (p<0.05) with open AVR.
Who Will Pay
The moral question of whether society will pay? Centers for Medicare & Medicaid Services (CMS) posed the question of whether “the evidence (is) adequate to conclude that transcatheter aortic valve replacement improves health… for Medicare beneficiaries with severe aortic stenosis”? It is worth noting that CMS has three departments and the evaluation of effectiveness is done by a group separate from the payment department. The issue is that in 2009 (financial data is a minimum of two years behind) CMS spent US$133 billion on in-hospital patient care (estimate US$170 billion, 2013); while the total estimated expenditure by CMS in 2013 was US$1,125 billion according to the CBO, with 36 % of all US patient care paid for by CMS (Medicare, Medicaid, CHIP, etc.). Currently, 42 % of patients are covered by government insurance but our predication is that in a decade it will be 75 %. Consequences are that CMS will determine directly or indirectly the level of reimbursement (for example, exchanges will pay physicians 5 % above Medicare rates and hospitals at the Medicare rate). Hence, with the financial problems, poor job growth and the budget deficit, healthcare will be under increasingly severe ‘spending caps’ as recommended by the CBO. In turn, CMS will be under pressure to cut costs. Clearly, while AVR and TAVR are among the most effective cardiovascular treatments to improve symptoms, quality of life, Kansas City Cardiomyopathy Questionnaire (KCCQ) score and long-term survival, both treatments cost more than ‘medical treatment’.9,10 This then is the moral question as to who should receive treatments within the group of patients at increased risk. The determination of CMS for TAVR in high-risk patients was “TAVR provided no mortality benefit but significant risk of harm. … coverage… should be restricted only to clinical trials rather than registries.” Hence, the TVT Registry™/ NCDR® database. Furthermore, based on CMS reimbursement on the valves costing US$32,500, some hospitals lose US$4,000–14,000 per TAVR (average cost was US$78,000 with a mean 1.5 nine-year survival gain) and analysts’ predict that CMS could end up paying a predicated US$2.6–6.0 billion per year for percutaneous valves in contrast to half a billion for AVR.11