EECP is economically, clinically sound strategy
New hope for patients with failed CABGs
Thousands of patients with failed angioplasties, unsuccessful bypass procedures, and dashed hopes can now look to enhanced external counterpulsation (EECP) for renewed promise. The outpatient cost-effective procedure can get blood to deprived areas of the heart without spilling a drop. Thirty-five EECP beds in 25 centers around the country are seeing excellent results.
John E. Strobeck, MD, PhD, director of The Heart-Lung Center of Hawthorne (NJ), says hundreds of thousands of patients could benefit from EECP especially once insurers recognize the procedure. "You need to see the obvious reality coming down the pike," Strobeck says. "For those hospital administrators whose headlights are turned on, it makes a lot of sense for them to get involved in this technology."
Depending upon geographic area, EECP is about one-third the cost of an uncomplicated angioplasty procedure and about one-sixth the cost of an uncomplicated coronary artery bypass graft (CABG). Those estimates include not just the surgical fees for the invasive procedures, but the whole hospitalization package. The average cost of EECP is $7,000 to $8,000. The entire package of balloon angioplasty can run $21,000 and CABG, $44,000. Because EECP carries almost no risks or complications, costs are kept down.
Who pays?
Third-party payers do not routinely accept EECP claims, although exceptions exist. "All of our patients have been self-paid so far," says Karen Manzo, RN, clinical director of HeartCare Centers of Ohio, part of Grant Riverside Methodist Hospital in Columbus. Her facility charges $7,000 for the treatment. "A CPT code has been applied for, but the procedure does not have its own code yet, so you can’t file a claim for the procedure as such."
But insurance companies will often pay for ancillaries of the treatment. Many of the components of EECP have existing codes that can be indicated on claim forms monitoring EKG, blood pressure, and oxygen saturation. In addition, some centers are getting reimbursed for the code called "outpatient monitoring by a nonphysician medical personnel person" one of the therapists or "physician supervising a procedure." Putting codes together strategically this way to get reimbursement should be done cautiously. Only time will will tell if such a practice warrants extra scrutiny from Medicare.
J. Michael Jones, president of HealthCorp of America in Atlanta, says reimbursement is handled on a case-by-case basis. "There’s no uniform reimbursement yet. It’s up to each individual insurance company." There have been a number of Medicare reimbursements around the country, generally on an appeal basis, but here’s no guarantee.
"It’s a tough road right now," continues Jones. "We’re amazed if a claim is paid initially. The best thing to do is submit the claim, and if it’s not paid the first time, see it through medical review. Send as much clinical information as possible along with the claim."
HealthCorp is focusing on the managed care arena where CPT codes aren’t necessary. "If we go to a managed care group," says Jones, "we have a referral at a predetermined negotiated price. We’ve met with some success following that route."
HealthCorp charges about $9,500 for managed care patients. "The manufacturer recommends a price between $7,000 and $9,000. Some centers structure themselves differently and charge $7,000 to $8,000. Considering the development costs we’ve had and continue to have, I can’t justify a lower cost for the procedure right now. Possibly in the future, our price will be lower." HealthCorp has been operating since September 1996.
As evidence mounts for the cost-effectiveness of EECP, insurers have more incentive to support the procedure. Robert Spina, a former catheterization laboratory manager who now works for Vasomedical in Westbury, NY, cites the case of a 55-year-old chronic coronary artery disease (CAD) patient who had a quadruple bypass in 1986 but developed anginal symptoms nine years later. After an angioplasty in January 1996, another in February, a stent in April, and a third angioplasty in June, his insurance company had paid more than $100,000 with nothing to show for it.
"The same vessel kept closing, and his relief from angina lasted only a month or so," says Spina. As he entered his last week of EECP treatment, the patient’s angina had not returned.
Vasomedical has been marketing its EECP therapy unit, the MC2, since March 1995, when the Rockville, MD-based U.S. Food and Drug Administration issued clearance. The list price of the system is $200,000. Systems are generally leased for three or five years.
Currently, The Heart-Lung Center of Hawthorne leases one setup for $3,000 a month as part of a three-year contract. Plans for four EECP beds in a new outpatient center there are in the works. Using another leasing company for the new beds, the center will make monthly payments of $1,800 in year one, $2,300 in year two, and $5,000 in year three, making start-up easier. The Heart-Lung Center of Hawthorne charges patients $5,000 for the 35-visit treatment.
If early success is an indication, the procedure may significantly reduce the number of repeat angioplasties and CABGs, predicts Strobeck, who is also co-director of interventional cardiology at The Valley Hospital in Ridgewood, NJ.
At Strobeck’s Heart-Lung Center, 80% of failed angioplasty patients show no chest pain three years after EECP. Ninety-five percent of single-vessel patients have no signs of reclogging, and more than 60% of multiple-vessel or multiple-blockage patients are symptom-free, the director says.
Patients with CAD are candidates for counterpulsation. (See contraindications for EECP, at left.) The majority of candidates have had some type of invasive intervention. "We look in their medical records for the most recent cardiac catheterization report so we can see the extent of their CAD," says Manzo. "Patients with disease or occlusion in one or two of their major coronary arteries typically benefit more from EECP than those with disease in all three arteries. You need one conduit or one opened vessel for collateral bridging to take place. That’s the nature of the treatment building more blood supply to the heart through collateral circulation. If a patient has triple-vessel disease, we will treat him, but the outcome won’t be as good." (See story on how EECP creates new channels to the heart, p. 88.)
Patient compliance is essential
Continuum of care and patient compliance are important when you’re looking at a five-day-a-week, seven-week procedure. Patients have been through a lot by the time they make it to this point, and quitting is an easy option.
Manzo is the first clinician patient candidates meet when they arrive to be evaluated for the EECP program. "Therapists administer the counterpulsation," says Manzo, "but I’m with patients throughout their treatment; they feel comfortable with that."
EECP is administered one hour a day, Monday through Friday, for a total of 35 hours. Some patients prefer to do two hours a day, shortening their course to 31¼2 weeks. Manzo’s center has three setups and treats between eight and 12 patients a day. To allow patients to continue their jobs, most centers accommodate them with convenient hours. The Heart-Lung Center of Hawthorne, for example, opens at 7 a.m. and remains open until 11 p.m.
"A patient once said to me," says Manzo, "My doctor says I have to choose between undergoing EECP or CABG. The same amount of time is involved either way because the CABG would require six weeks recuperation. With EECP, I don’t have to have my chest cut open.’" EECP is sometimes a choice for those who are running out of options.
Strobeck says The Heart-Lung Center of Hawthorne currently has 30 patients on a waiting list for the procedure. He sees a nearly limitless patient load. Approximately 450,000 angioplasties are performed every year in the United States, and between 25% and 50% of them fail. An estimated 6.7 million Americans suffer from angina, according to the American Heart Association in Dallas.
"Unless they come out with a drug that can grow new blood vessels, the hottest thing will continue to be enhanced counterpulsation, Strobeck notes."
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