The years ahead will see greater challenges in cardiovascular disease (CVD) care. To prepare for what’s coming, providers and payers will benefit from working together to optimize quality of care and patient outcomes and lower the total cost of patient care.
The relentless rise of cardiovascular disease
CVD is the costliest chronic disease in the U.S. It’s expected that CVD occurrences, death rates, infirmities and costs will keep rising. By 2035, direct medical costs related to the disease are expected to skyrocket to $1.1 trillion.1
Even now, when it comes to health care expenses related to CVD, about one in every six health care dollars is spent on the disease.2
Trends in cardiology health care practice
Nationally, cardiovascular care accounts for up to 60 percent of the operating margins for hospitals.3 At the same time, government payers are lowering reimbursement rates. And private payers are decreasing coverage and reimbursements for certain outpatient procedures and imaging.
These cost and reimbursement pressures will drive more cardiology practices to look for ways to maintain revenues. For instance, cardiology professionals will join larger cardiology practices or national health systems to improve their negotiating power for payer reimbursement.
Cardiologists will be on the lookout for medical technology solutions that offer both clinical and economic value. They’ll seek treatments for CVD that also support the new financial arrangements and incentives they’re facing now and in the future.
CVD treatments: Trading better care for worse reimbursement?
Transcatheter aortic valve replacement (TAVR) will likely surpass most open-heart procedures in the not-too-distant future. Patients with aortic valve disease have seen greatly improved outcomes with TAVR. Yet hospitals often make much more money from surgeries.
As more innovations in health care for cardiovascular disease move forward, one goal needs to be avoiding abrasion from “penalizing” providers who adopt new technology. These advances may be better for patients, but reimbursement could be worse.
It’s important that as CVD care advances, we create reimbursement structures that favor evidence-based innovation. That will help make sure these innovations aren’t stifled because of economic incentives.
The provider perspective on payers
In the near future, providers and payers will need to work more closely together to address CVD care. It’s instructive to review what providers view as things payers are doing well — and where there are opportunities for improvement.
Payers are doing well as they:
- Keep up with code changes. Payers are staying on top of code changes. They’re making sure that before they receive claims, they fix any potential medical coding
- Offer new payment models for value vs. volume. With the new value-based care strategy, payers are focused on developing new reimbursement contracts. They are also seeking to keep providers satisfied with their new requirements and responsibilities.
- Outsource to vendors for cardiology reviews. By using outsourcing partners, payers can provide thorough reviews despite tight schedules and volume variations. This accuracy helps providers in the long run.
Payers have opportunities for improvement when they:
- Strengthen policies. Vague policy language and a lack of reimbursement policies contribute to fraud and abuse.
- Maintain provider profiles and contracts. Cardiologists may have non-standard contracts that aren’t being monitored well by payers. Non-standard contracts require maintenance to make sure claims are paid accurately.
- Perform timely claims processing. When a payer doesn’t process in time, providers may balance bill a member. That escalates costs for the member and the payer. Payers may also be penalized for not promptly handling claims.
- Staff internal expertise for clinical oversight. Payers will benefit from a peer expert in their organization. It allows for a balanced discussion with a highly specialized provider when there’s a disagreement on policy or benefits.
How proactive payers can face the future of CVD care
As payers and providers increase their focus on CVD care, proactive payers will find ways to work more closely with providers. This can help bring down health care costs and smooth the way for a more effective reimbursement process today and in the future. A few things to consider:
- Educate providers about coding and claims. But not only providers. Target other key players such as managers and billers who are responsible for coding and implementing claim edits. Reach them in new ways besides mailings — use webinars, e-newsletters and other digital tools.
- Stay on top of emerging technologies. Proactive payers explore innovative ways to use technology (think blockchain technology for instance) to ensure timely and appropriate claims payments. Quick and efficient data transfer is a necessity now and in the future.
- Increase collaboration with providers. Providers respond better and abrasion is avoided when payers encourage conversation and collaboration. By communicating more effectively, payers can also create more efficiencies in their reimbursement cycle.
Learn more about the innovations Optum is making in payment integrity. Visit optum.com/paymentintegrity.
1American Heart Association. Cardiovascular disease: A costly burden for America — Projections through 2035. heart.org/wp-content/uploads/2017/10/Cardiovascular-Disease-A-Costly-Burden.pdf. Published 2017. Accessed March 1, 2019.
3Amit A, Crimmins-Reda P. Challenges and opportunities for cardiac cath labs: Focus on health economics of the cath lab. Becker’s Hospital Review. July 12, 2018. beckershospitalreview.com/quality/challenges-and-opportunities-for-cardiac-cath-labs-focus-on-health-economics-of-the-cath-lab.html. Accessed March 1, 2019.
About the author
Cardiology Ideation Leader, Optum Payment Integrity R&D
Cailen has more than 13 years of experience in revenue cycle management. She has worked in a variety of settings, including large, multi-specialty medical groups. She is a Certified Professional Coder by AAPC.