优化您的TAVR计划的财务利润率

7.13.23

当经导管主动脉瓣置换术(TAVR)在2011年商业化时, 简历项目面临的挑战是“首先进入市场”,吸引新患者加入他们的组织，提升他们的品牌. 这需要大量的投资来启动一个新的TAVR项目, 包括聘用和培训云顶集团40011官网, 预购买设备, 发展优质基础设施, 对于很多项目来说, 新建混合式导尿室或手术室.

TAVR不再是一种新颖的治疗方法. 今天, 全国有700多个项目在运作超过30万名患者接受了TAVR治疗. 它已经成为大专简历项目的基石. 现在的挑战是, 随着TAVR继续扩大其影响范围, 项目是否专注于维持健康的财务利润率, 这意味着要改进病人的选择, 优化收益获取, 管理医院和供应成本, 评估人力资源.

优化患者选择和 提供者资格认证过程

鉴于TAVR的侵入性较小，恢复时间较短, patients and providers tend to favor the therapy over traditional open-heart surgery when clinically appropriate. 因此，患者选择是TAVR项目成功和高质量的基础. This requires programs to appropriately identify patients with the potential to benefit from TAVR and to individualize treatment for each case, 包括程序方法或访问站点, 以及阀门的类型和通径. Some key considerations related to patient selection that should be carefully evaluated by the multidisciplinary heart team include:

• 患者的年龄、虚弱和合并症影响预期寿命和生活质量.
• 阀门耐久性和寿命管理策略.
• 患者解剖和钙化模式.
• 患者发生新的传导障碍的风险.

除了设计合适的病人选择程序, an important part of maintaining a high-quality and safe TAVR program is ensuring a rigorous provider credentialing process of TAVR care team members, 包括心脏病专家, 心脏外科云顶集团40011官网, 和高级实践提供者(app). Program leaders should periodically review provider credentialing criteria to ensure alignment with national and best practice recommendations.

加强收入捕获

TAVR programs are inherently resource-intensive, and ensuring accurate revenue capture is essential. 接受TAVR的患者通常有合并症, 而且只对住院病人开放, TAVR is currently classified either into MS-DRG 266 (with major complications or comorbidities [MCCs]) or MS-DRG 267 (without MCCs). 因为程序编码很大程度上依赖于云顶集团40011官网的文档, TAVR proceduralists should be aware of documentation requirements and guidelines and receive ongoing education related to documentation integrity.

特别是, accurately capturing patient comorbidities has an impact on measuring and improving quality metrics, 以及重大的财政影响. 2023年 国家医疗保险未调整支付率 MS-DRG 266的价格是45美元,278, 和35美元,MS-DRG 267为399, 代表10元,每道工序的付款差额为000美元.

投资于编码和文档完整性计划

因为DRG分类可以根据程序复杂性等因素而变化, 逗留时间(洛杉矶), 以及患者的合并症, 项目负责人应该投资于编码和文档完整性(CDI)项目. The goal of a CDI program is to ensure that physician documentation adequately captures patient complexity and acuity.

作为这项努力的一部分, 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, 临床管理, 洛杉矶, 以及临床云顶集团40011官网的期望. 编码人员的参与也是必不可少的, 作为最佳实践, organizations often include a dedicated CV coder and documentation specialist in TAVR team meetings to provide ongoing education and feedback.

捕获术后和附加编码

有效的收入获取意味着项目应该为所提供的所有临床护理适当收费, 并且由于TAVR目前没有一个全球性的术后期, 评价与管理(E)&M)手术后的偶遇应单独计费.

• 一些项目利用app来协助TAVR患者的术前和术后护理, 因此，对这些供应商进行独立认证是有益的. 除了, 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.
• 任何程序性成像, 如经食管超声心动图(TEE)或心内超声心动图(ICE), 还具有单独的专业计费代码，应用于捕获已执行的工作.
• 最后, 而从收入获取的角度来看，项目受益于准确的供应商文档, 准确测量质量和临床登记数据同样重要, 其中大部分是公开报道的.

管理医院和供应成本

一旦TAVR收益得到优化, 项目应仔细评估其费用结构, 包括程序性洛杉矶和供应费用. 基于风险和预先出院计划对TAVR患者进行分层, 包括当天或第二天的出院计划, 可以帮助减少无并发症患者的洛杉矶. TAVR目前不被认为是一种紧急治疗方法, 所以大多数病人都是作为门诊病人接受手术前检查的. 有时, 当病人在住院期间接受TAVR检查时, 程序前测试被捆绑在MS-DRG付款中, 这些案件通常会导致经济损失. 因此, 及时的沟通和协调是关键, 特别是考虑到测试的数量, 成像过程, 需要对提供者进行评估. A simple pre-procedural checklist can help the multidisciplinary team members track the workup progress and minimize unnecessary 洛杉矶-related costs.

进一步, 因为TAVR仍然是住院患者的手术, 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年的报告 美国心脏病学会(美国心脏病学会)的一项研究强调，大多数患者(90.3%)出院回家.6%到康复或延长护理机构.45%去了养老院. 具有扩展洛杉矶和/或高于平均水平的PACT利用率的TAVR程序, 然而，归类为MS-DRG 266的病例数量却少得不成比例, 例如, will benefit from engaging CDI specialists to evaluate whether their clinical documentation is appropriately capturing expected clinical outcomes based on procedure classification. 在这个例子中, the TAVR program will have a higher cost structure due to the extended 洛杉矶 and PACT penalty and will receive the lower of the two MS-DRG payments, 表示有机会评估编码和文档的准确性.

程序耗材管理

除了管理住院医院洛杉矶和相关费用之外, 项目从评估程序供应成本中受益, 最值得注意的是TAVR瓣膜和手术备用供应. TAVR瓣膜仍然比外科瓣膜贵得多, 还有成本, 这通常是手术瓣膜的五到六倍, 导致TAVR程序的边际狭窄.

• 随着新型阀门进入美国市场，阀门的成本应该会下降, 但CV项目负责人应该与供应商合作，以确定节省成本的机会. 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.
• 类似的, 只有在心胸外科云顶集团40011官网的决定下才能打开手术供应包. Many mature TAVR programs leave these supplies unopened for most or all cases (reserving them only for higher-risk procedures), 从而降低了使用和清洁这些用品的成本.

评估人力资源

像所有心脏结构手术一样，TAVR需要一个多学科的团队. At the center of this care team is the “valve coordinator” or nurse program coordinator or nurse navigator, 随着角色的不断演变. 护理协调是必不可少的管理一个高性能和高容量TAVR计划, 因为病人需要广泛的教育, 包括多项测试的详细的程序前检查, 专门的成像, 云顶集团40011官网合作. 护士协调员将与TAVR项目的患者建立长期的关系, beginning at referral and extending to or even beyond the patient’s one-year post-procedure evaluation, 使这一立场对实现护理的连续性至关重要. TAVR programs should align nurse coordinators and APP resources with the program size and growth expectations, 如图2所示. 所有TAVR项目至少需要一名护士项目协调员, ,通常, 一旦一个项目发展到每年执行大约150次tavr的规模, 它受益于添加了一个APP.

在这个模型中, 护士项目协调员的角色是支持和教育病人, 在各个护理站点协调护理, 并确保及时的预程序流程. The APP is therefore able to expand physician capacity by assisting with inpatient pre-procedural workups, 进行一些测试和咨询, 在诊所为病人做术后评估, 独立的，与云顶集团40011官网并行的. Both the nurse coordinator and the program APP play an important role in continuity of care and assuring all guideline-driven interventions are addressed. 维持适当比例的护士和应用程序的规划量, 以及适当的工作范围和职责, 管理资源的关键是什么.

手术人员与灌注

医疗保险中心 & Medicaid (CMS) requires both an interventional cardiologist and a CT surgeon to be present for every TAVR procedure. 这是一个热议的话题, 但这两位云顶集团40011官网的存在仍然是当前的授权和护理标准.

而外科云顶集团40011官网的时间成本因此可归因于每个TAVR病例, 项目已经开始评估外科护士是否, 拆弹专家, 灌注师也必须在场, 或者是否存在安全的替代方案. In 2019, 心肺旁路 在小于0.41%的TAVR病例, 因此, 一些项目已经开始将外科人员重新部署到其他非临床任务中. A perfusionist is still typically present in the case during valve deployment; however, 他们可能能够在过程之外执行其他工作, 只要它们在紧急情况下随时可用. 灌注设备也可以放在室外，特别是对于低风险病例.

成像心脏病专家

While most TAVR programs find the involvement of an echocardiologist during the procedure valuable, 投入另一名云顶集团40011官网资源是昂贵的，并且增加了已经很高的程序开销. 为了最小化这个, 以及少数需要程序性TEE的案件, 有些项目利用心脏麻醉师来完成这个角色.

类似的, 其余需要经胸超声心动图(TTE)的病例, 通常，回声超声仪能够获取图像, 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.

健康的计划性成长

一旦收入捕获优化和间接费用的调整, 计划应侧重于TAVR和结构性心脏容积的增长. 继续计划性增长的最佳做法包括:

• 通过建立评估扩展机会 协作式护理网络.
• 避免不必要的术前检查延误. 门诊病人通常需要几周的时间来接受检查, 作为最佳实践, 组织的目标是将这个过程控制在四周以内. 检查清单和频繁的护理团队参与可以帮助确保流程的顺利和及时.
• 随着操作者经验的增加，可以考虑提供其他的导管入路.g.(颈动脉，腋窝/锁骨下，以及瓣中瓣手术).
• 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.
• 追求通过认证成为阀门卓越中心 美国心脏病学会.
• 继续投资资源以支持质量, 并定期监测所有公开报告的患者安全和质量数据.

最佳实践TAVR程序

考虑到许多组织目前面临的强劲的财务逆风, optimizing financial margins of all service lines and procedures is prudent; however, 应优先考虑诸如TAVR之类的资源密集型程序. 当我们展望未来, TAVR手术的持续增长, 以及二尖瓣和三尖瓣的经导管置换术, 似乎. 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.

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