University of Chicago Medicine Mechanical Circulatory Support Program Issues Public Comment on Centers for Medicare & Medicaid Services Proposed Rule

WASHINGTON, July 18 -- The University of Chicago Medicine Mechanical Circulatory Support Program, Illinois, has issued a public comment on the Centers for Medicare and Medicaid Services' proposed rule entitled "Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Proposed Policy Changes and Fiscal Year 2021 Rates; Quality Reporting and Medicare and Medicaid Promoting Interoperability Programs Requirements for Eligible Hospitals and Critical Access Hospitals". The comment was written on July 10, 2020, and posted on July 14, 2020:

The comment was co-signed by Colleen LaBuhn, assistant director of clinical operations in the Heart and Vascular Center; Valluvan Jeevanandam, director of heart and vascular and chief of Cardiac Surgery Section; and Sean Pinney, assistant director for heart and vascular and chief of heart failure cardiology.

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The University of Chicago Medicine Mechanical Circulatory Support Program appreciates the opportunity to provide comments on and supports Medicare's consideration of a policy under sections 1886(d)(B) and (c) of the Act to maintain the FY 2021 relative weight equal to the FY 2020 relative weight for MS-DRG 215. In addition, we propose that over the course of this next year, Medicare review the documented Major Comorbidities and Complications (MCCs) that accompany patients in MS-DRG 215 to better understand the clinical populations and potential separation and differentiation of MS-DRG 215 based on the severity of the patient's diagnosis and related complications and comorbidities, such as cardiogenic shock.

Currently MS-DRG 215 encompasses multiple "other heart assist system implants" including percutaneous devices such as Impella or Tandem products as well as surgically implanted CentriMag or Rotaflow devices. These types of ventricular support devices (VADs) assist the failing heart at various degrees and are utilized by experienced centers based on the severity of the patient's condition. The University of Chicago Medicine is a leading academic medical center in the Midwest, serving the south side of Chicago in a primarily underprivileged community. We function as a critical tertiary care center for some of the sickest heart failure patients transferred to us from all over the Country. Advanced heart failure care is provided to these patients utilizing these life-saving devices based on the severity of the patient's heart failure.

In a review of our program data from the last 2 years, almost 100% of our patients who received these devices with MS-DRG 215 had associated cardiogenic shock. 80% of the patients had Medicare or Medicaid as their primary insurance. Compared with the below Medicare IPPS (Table 5.) geometric mean length of stay (LOS) of 4.9 days, our mean LOS for the percutaneous devices was 30 days and for the surgically implanted devices, 39 days.

Table 5. Final Rule 2020

Table omitted: LIST OF MEDICARE SEVERITY DIAGNOSIS-RELATED GROUPS (MS-DRGS), RELATIVE WEIGHTING FACTORS, AND GEOMETRIC AND ARITHMETIC MEAN LENGTH OF STAY - FY 2020 Correction Notice: https://www.regulations.gov/contentStreamer?documentId=CMS-2020-0052-0454&attachmentNumber=1&contentType=pdf

The significant differences between geometric LOS and our mean LOS could be related to how these devices are utilized across the country; everything from high risk stenting with brief, temporary support to more severe cardiogenic shock and longer-term recovery. Within our program, we tend to utilize these devices in the latter; extremely sick patients with associated cardiogenic shock, and other MCCs leading to much higher direct costs ranging from around $100,000 to $175,000 per case. Despite the significant illness in these patients and the higher costs associated with them, our overall survival and recovery of these patients remains similar to national published data on cardiogenic shock with device support: 75-80%.

In addition to the patients we have cared for over the past 2 years, we anticipate that we will continue to see a rise in these acute, severely sick patients during 2020 and into 2021 correlating with the increase in COVID-19 related cardiac disease. A rate cut during a public health emergency is not recommended for hospitals who are caring for these confirmed COVID-19 patients including the University of Chicago Medicine.

We maintain that decreasing the weight of MS-DRG 215 would have a substantial negative impact on all hospitals that implant these devices. This includes a majority of highly-experienced, large-volume, tertiary programs, such as the University of Chicago Medicine, offering critical access heart care for under-served populations.

Thank you for your consideration of maintaining the FY 2021 relative weight equal to the FY 2020 relative weight for MS-DRG 215 and reviewing this MS-DRG for future adjustments based on patient severity.

Sincerely,

Colleen LaBuhn, MSN, APN, CCRN, Assistant Director of Clinical Operations, Heart and Vascular Center

Valluvan Jeevanandam, MD, Director, Heart and Vascular, Chief, Section of Cardiac Surgery

Sean Pinney, MD, Assistant Director, Heart and Vascular, Chief, Heart Failure Cardiology

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The proposed rule can be viewed at: https://www.regulations.gov/document?D=CMS-2020-0052-0002

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