GAOs cardiac device trends: Moderating or shifting to outpatient?

Trends in the use of implantable orthopedic and cardiac devices in Medicare beneficiaries were mixed between 2003 and 2009, according to an analysis by the Government Accountability Office (GAO). For instance, admission rates for beneficiaries receiving implantable cardiac devices fluctuated between 2003 and 2009, but showed declines after 2007. In contrast, admission rates for orthopedic implantations rose steadily.

Implantation of orthopedic and cardiac medical devices is the most common procedure provided to Medicare patients and it accounts for the lion’s share of spending, the report outlined. Expenditures jumped from $16 billion in 2004 to $20 billion in 2009, or about 4.3 percent per year. But most of that increase was attributed to the orthopedic segment. Spending related to cardiac implantable devices nosed up 1.2 percent annually compared with an 8.1 percent yearly gain for orthopedic implantable devices.

Given those costs, the U.S. Senate Finance Committee asked the GAO to provide descriptive information on changes in implantable medical devices (IMDs), focusing on hospital admissions, duration of hospital stays and discharge of Medicare beneficiaries. The analysts defined cardiac devices as drug-eluting stents, automatic implantable cardiac defibrillators (ICDs) and dual-chamber pacemakers. They noted that procedures for these devices can be performed in inpatient and outpatient settings. For this analysis, they concentrated on inpatient trends.

Among trends they noted in inpatient admission for cardiac device implantation:

• Rates for drug-eluting stents increased rapidly from 2003 through 2006, declined sharply from 2006 through 2007 and then stayed flat. The authors attributed the trend to either preference for bare metal stents or an overall decrease in stent procedures.
• Rates for ICDs also increased from 2003 to 2006 and then declined, but more moderately than the rates seen with stents.
• The rate of dual-chamber pacemaker admissions declined slowly and steadily.

The authors attributed some of these patterns to a shift in surgeries to outpatient settings, noting a spurt in outpatient cardiac device procedures beginning in 2007 through 2009. “This trend coincided with Medicare Recovery Audit contractors collecting overpayments for certain inpatient cardiac IMD procedures that could have been performed in the outpatient setting, possibly prompting other hospitals to change their admission patterns,” the GAO authors wrote. “Generally, Medicare pays hospitals a relatively lower rate for the same procedure when it is delivered in the outpatient rather than the inpatient setting.”

They reported that the percentage of Medicare patients in poor health rose for every type of cardiac device procedure, particularly for stents and pacemakers after 2007. The proportion of patients admitted in very poor health rose between 2003 and 2009, with a similar bump after 2007. The increase was especially apparent with ICDs, with the share of Medicare beneficiaries doubling between 2007 and 2009. The authors suggested that healthier patients had chosen to have procedures done in the outpatient setting, “leaving a greater proportion of beneficiaries in the inpatient setting with poor or very poor health.”

For duration of stay and discharge among cardiac beneficiaries, the GAO reported:

• A general decline between 2003 and 2007 followed by an increase into 2009. They attributed the uptick after 2007 to patient mix, with healthier patients migrating to outpatient settings and patients in poor and very poor health receiving inpatient care.  
• Stays for patients in poor health were generally one to three days longer than for patients in good health.
• The share of beneficiaries discharged to rehabilitative facilities remained relatively stable.
• About 86 percent of beneficiaries were discharged to home or self-care between 2003 and 2007. After 2007, that percentage declined; the authors again attributed the change to a sicker patient population.

The report was presented to the Finance Committee May 14 and released to the public June 13. The full report is available here.