Drivers of Variation in 90-Day Episode Payments After Percutaneous Coronary Intervention

Abstract

Background: Percutaneous coronary intervention (PCI) is a common and expensive procedure that has become a target for bundled payment initiatives. We described the magnitude and determinants of variation in 90-day PCI episode payments across a diverse array of patients and hospitals.

Methods and results: We linked clinical registry data from PCIs performed at 33 Michigan hospitals to 90-day episodes of care constructed using Medicare fee-for-service and commercial insurance claims from January 2012 to October 2016. Payments were price standardized and risk adjusted using clinical and administrative variables in an observed-over-expected framework. Hospitals were stratified into quartiles based on average episode payments. Payment components between the highest and the lowest quartiles were compared with identified drivers of variation (ie, index hospitalization/procedure, readmissions, postacute care, and professional fees). Among 40 925 90-day PCI episodes, the average risk-adjusted 90-day episode payment by hospital ranged between $22 154 and $27 205 with a median of $24 696 (interquartile range, $24 190-$25 643). Hospitals in the lowest and the highest quartiles had average episode payments of $23 744 and $26 504, respectively (difference, $2760). Readmission payments were the primary driver of this variation (46.2%), followed by postacute care (22.6%). Readmissions remained the primary driver of variation in key subgroups, including inpatient and outpatient PCI, as well as PCI for acute myocardial infarction and nonacute myocardial infarction indications.

Conclusions: Substantial hospital-level variation exists in 90-day PCI episode payments. Over half the variation between high- and low-payment hospitals was related to care after the index procedure, primarily because of readmissions and postacute care. Hospitals and policymakers should consider targeting these components when developing initiatives to reduce PCI-related spending.

Keywords: episode of care; health expenditures; hospitals; myocardial infarction; patient readmission; percutaneous coronary intervention.

Figure 1.

Average 90-day percutaneous coronary intervention total episode payment by hospital. Hospitals ordered from lowest to highest mean risk-adjusted total episode payment. Error bars indicate 95% confidence intervals.

Figure 2.

Payment components and variation of average 90-day episode payments between high and low payment hospitals. Payment components contributing to the average 90-day episode payments among high and low payment hospitals (Panel A). The contribution of each payment category to total episode payment variation between high and low payment hospitals (Panel B).

Figure 3.

The relationship between hospital 90-day risk-adjusted readmission rates and average 90-day risk-adjusted episode payments. Correlation between average 90-day risk-adjusted episode payments and 90-day risk-adjusted readmission rates by hospital. The red line indicates the line of best fit with corresponding 95% confidence intervals (dashed line). Spearman’s correlation coefficient and p-value are noted in the top left corner.