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Site of Service Influence on Stent Utilization for Hemodialysis Access Interventions
Nicholas J. Madden, DO, Matthew J. Dougherty, MD, Keith D. Calligaro, MD, Douglas A. Troutman, DO, Krystal Maloni, M.D..
Pennsylvania Hospital, Philadelphia, PA, USA.

ObjectiveWith unsustainably rising health care spending in the US, the Center for Medicare and Medicaid Services has in recent years attempted to utilize reimbursement rates to influence utilization of less expensive care sites for covered patients, such as ambulatory surgery facilities and office based interventions in lieu of hospital service sites. It has been suggested that cost savings have not been realized due to an increase in procedure numbers performed by physicians with ownership interests in non-hospital facilities. CMS has proposed massive reimbursement changes for 2019 for office and ASC based procedures, which would reduce access angioplasty reimbursement in the ASC setting by 75.9%, while stenting would be increased by 12.1% over current levels. The clinical utility of adjunctive stenting in treating access stenosis remains controversial and highly discretionary. As a vascular group performing such procedures in both a hospital and non-hospital facility in which we have equity interest, we reviewed the prevalence of stent deployment in patients in both settings since 2014 to determine whether site of service affected stent utilitzation. Methods Between 2014 and 2018, 986 total angioplasty or angioplasty with stenting procedures were performed by our group. 599 were done in the hospital setting, while 387 were performed in an ambulatory facility, initially as a physician office site of service, and since 2018 as an ASC. Patient demographics and variables were compared. Results There was no difference in any clinical or demographic variable between the hospital and non-hospital groups, other than a higher incidence of Medicaid patients in the hospital setting (p <.001). In hospital treated patients, 190 of 599 procedures included adjunctive stenting (33.2%), while in the non-hospital treated patients 136 of 387 had stents (35.1%), despite financial incentives for both professional and facility reimbursement in favor of stenting (p=1.24) ConclusionWhile financial incentives have not yet had an appreciable influence in stent utilization within previous reimbursement paradigms, the dramatic changes proposed by CMS may well alter this dynamic and lead to substantially higher overall costs without proven clinical advantage. With very high failure and reintervention rates and increasingly expensive adjuncts (drug coated balloons and stents, covered stents), the cost implications of attempts to incentivize interventionalists toward a specific sites of care are substantial, and unintended negative consequences are likely to occur.


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