Long-Term Healthcare Spending Doesn’t Aid Heart Attack Survival

December 27, 2017 - Healthcare spending on 180 days of heart attack care grew 14.4 percent since 1999, but patient morality rates remained constant for heart attack patients after the 30-day discharge period when the bulk of spending growth occurred, a recent JAMA Cardiology study showed.

“Right now, there’s no disincentive to use cost-ineffective types of care,” stated lead author Donald Likosky, PhD of University of Michigan’s Department of Cardiac Surgery. “Providers are well-intentioned, but many of the current management and treatment strategies are both expensive and don’t appear to be effective at reducing mortality following heart attacks.”

The analysis of Medicare data on almost 480,000 beneficiaries who were hospitalized for acute myocardial infarction (AMI) at 1,200 hospitals between 1999 and 2014 revealed that overall inflation- and risk-adjusted healthcare spending during the 180 days after an admission for AMI increased by nearly 14 percent, or $4,486, per patient between 1999 and 2014, with the total spending increase occurring by 2008.

Healthcare spending on 180 days of heart attack care stabilized in the last six years of the study’s period.

While researchers observed overall healthcare spending growth on heart attack care, substantial costs variation emerged between high- and low-spending hospitals. Expenditures at the 61 hospitals with the slowest spending growth decreased costs by almost 19 percent, or $7,384, per patient during the study’s period.

On the other hand, the 61 hospitals with the fastest spending growth increased costs by 44.1 percent, or $12,828, per patient.

Despite dramatic spending increases at some hospitals, the highest spending organizations did not see large case fatality rate decreases, researchers noted.

Healthcare spending growth on AMI care primarily occurred a month after the initial heart attack admission. Total spending increased 31 percent between 31 to 365 days after the index admission.

In contrast, total healthcare spending rose just 6.1 percent on care up to 30 days.

Nursing home and home health expenditures doubled and spending on outpatient services tripled after the 30-day post-acute care period, contributing to significantly greater spending between 31 and 180 days following admission.

Heart attack fatality in the 180 days after an attack declined from almost 27 percent per patient in 1999 to 21.5 percent by 2014. However, most of the decline occurred in the 30 days after the index admission.

The findings suggest that healthcare spending growth after day 30 is not making a difference for patient mortality rates. Case fatality rates for days 31 to 180 remained relatively unchanged from 1999 to 2014.

Hospitals may want to consider using more cost-effective interventions, such as early percutaneous coronary interventions (PCI), shortly after a heart attack patient is admitted, the study indicated. Organizations that quickly diagnosed and performed angioplasty surgery within 24 hours after a patient’s first symptoms reported the largest survival gains and cost reductions.

Early PCI utilization grew by 102.9 percent by 2014. And hospitals that increased early PCI use the most also reported lower healthcare spending on post-acute care, including skilled nursing facility care ($700 decrease per patient) and home health, hospice, and durable medical equipment care ($298 decrease per patient).

“We also find that patients at high-volume hospitals benefit the most from early stenting treatments by interventional cardiologists,” said co-author Jessica Van Parys, PhD, of Hunter College. “This finding is most likely because physician and nursing staff learn over time what works best for their heart attack patients.”

Researchers stated that the study’s findings may spell trouble for Medicare bundled payment models that target AMI patients and cardiac rehabilitation. Historically, CMS incentivized hospitals to reduce spending and improve care quality by capping payments to hospitals under bundled payment models and publicly reporting their mortality rates.

Researchers pointed out that traditional 30-day bundled payment models may not impact overall heart attack spending since the greatest cost growth and variation occur after the first 30 days beyond an admission. Bundled payments should include services beyond 30 days to effectively decrease healthcare spending.

CMS attempted to extend cardiac bundled payments through the Episode Payment Models and Cardiac Rehabilitation Incentive Payment Models. The bundled payment models would have paid providers a single reimbursement for 90 days of care after discharge.

However, the federal agency canceled the mandatory bundled payment models last month and promised to develop similar models that will be voluntary.