Why reimbursement lags for MR-conditional CRM devices, and what to do about it

Why reimbursement lags for MR-conditional CRM devices, and what to do about it

October 02, 2019
MRI
From the October 2019 issue of HealthCare Business News magazine

Adding to the challenge, with no “standard of care” for these CRM conditional devices, the choice was left to the physician whether it’s worth an extra $1,000 or $3,000 or more for an MRI-conditional implant. According to the Mayo Clinic, 75% of patients with a pacemaker will need an MRI at some point in their future. The physician determines which device type is appropriate through thorough examination and the patient’s health record, but no physician can predict the future with 100% accuracy. One patient may be well-suited for the non-conditional device, while the other, having multiple chronic conditions, may be more likely to need an MRI at some future date. Either way, for patients covered under Medicare, which again, is most of these patients, the reimbursement rate for the device is the same. So how can doctors be sure they’re providing the best patient care in the most cost-efficient way?

Physician’s formula: Develop and formalize criteria
Clear protocols and expectations need to be defined for staff to properly care for patients requiring an implantable cardiac device. Physicians and other caregivers should have a formal process in place to identity which patients are most likely to need MR-conditional CRMs and those who don’t. The process should include proper screening and treating patients in a manner that ensures safety and provides for good outcomes. Key personnel who should have a role in designing the program include physicians, nurses, and radiology staff. Even manufacturer representatives need to be involved, since they may be the ones that reprogram the devices for non-conditional MR patients before and after the procedure.

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Three steps hospitals should take to drive down costs
Until these newer CRM devices are recoded by CMS for total reimbursement — or all CRM devices are approved for MRs, which, as I mention below, is a likely possibility — below are three steps hospitals can take to mitigate the lagging reimbursements.

1. Evaluation: Supply chain should examine purchase histories, make projections, and then work with manufacturers to get market-relevant pricing for products used while considering new innovation that will or has recently affected the market.

2. Advocacy: Leverage medical societies and government officials when new technology reaches market that is revolutionary versus evolutionary to advocate for new reimbursement codes. For example, one manufacturer introduced a leadless pacemaker, a device which is placed directly in the heart without the need for a surgical pocket and insulated wires (leads), but the CMS reimbursement for this improved technology was the same as a single-chamber pacemaker. The American Heart Association, the Heart Rhythm Society and the American College of Cardiology teamed up to advocate for an adjustment in reimbursement and CMS came back with a separate APC code for the leadless device.

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