Medicare's decision to increase payment for stroke patients who receive tissue plasminogen activator likely will result in more stroke centers, but experts are divided over whether it will mean better care for patients.
“It's a great step forward,” said William Barsan, M.D., professor and chair of emergency medicine at the University of Michigan, Ann Arbor. “This has been something in the works for a long time. We identified this as an issue that needed to be addressed soon after TPA was released.”
Currently, the Centers for Medicare and Medicaid Services (CMS) pays hospitals the same amount—about $5,700—under its diagnosis-related group (DRG) payment system for treating a stroke patient, regardless of whether TPA is used. But under a proposed regulation issued in August, CMS would develop a new DRG called “acute ischemic stroke with use of thrombolytic agents.”
Although TPA costs about $2,000 per dose, the new DRG would pay hospitals about $6,000 more for these patients. That's because patients who receive TPA generally are sicker overall than other stroke patients, and often require more intensive treatment and longer hospital stays, according to a CMS spokeswoman.
That logic is further explained in the proposed regulation. The regulation's authors wrote that when they reviewed average charges for stroke patients, “we noted that the average standardized charges for all patients in DRG 14 ['Intracranial Hemorrhage or Cerebral Infarction'] were $18,997, but that the subset of 2,085 cases in which TPA was used had average standardized charges of $35,128.” As a result, “we are changing the structure of stroke DRGs not to award higher payment for a specific drug, but to recognize the need for better overall care for this group of patients.”
In addition to getting TPA to more patients, this change also will save CMS money if it goes through, said Joseph Broderick, M.D., professor and chair of neurology at the University of Cincinnati. “If you can keep patients out of rehabilitation and nursing homes because you improve things on the front end, you save Medicare and the health system money,” Dr. Broderick said.
But Jerome Hoffman, M.D., professor of medicine and emergency medicine at the University of California, Los Angeles, is not so sure that giving more stroke patients TPA is a good idea. “There is not good evidence that TPA is beneficial in patients with stroke,” he said. “It probably helps a few people and hurts a few people, and the balance is really unclear.”
Aside from the issue of which patients should receive TPA, the increased payment will encourage hospitals to put more money into treating stroke patients, according to Dr. Broderick.
“A lot of hospitals have not seen a reason why they should put more resources into [treating] strokes when, in essence, these kinds of patients are going to cost them money.”
Now that they're being paid more for these patients, “more administrators will say, 'Why don't we have a stroke center? Why don't we have more patients who are treated with TPA?'” he said. “If they are going to get paid almost twice as much money, that's an incentive to see why the system is not working, why someone isn't taking the initiative.”
But new financial incentives for hospitals may have little impact on what some experts say is fundamentally a clinical obstacle.
It's not that hospitals don't want to provide patients with proper care, said Dr. Barsan, but it takes a lot of effort to make TPA treatment work efficiently, especially because there is only a 3-hour window for administration once the stroke has occurred.
The 3-hour window is a big issue, Dr. Hoffman concurred. “Many people who are having a stroke wake up with symptoms, so it's hard to tell when they were last normal,” he said.
“So most people are outside the 3-hour window.”
A survey Dr. Barsan and colleagues performed of more than 1,100 emergency physicians found that while 60% of respondents said they were “very likely” or “likely” to use TPA in an ideal setting with an appropriate patient and access to the proper equipment and personnel, another 24% of respondents said they would be unlikely to use the drug, and 16% said they were “uncertain” about the matter (Ann. Emerg. Med. 2005;46:56–60).
Of this combined group, nearly two-thirds said they were concerned about a possible brain hemorrhage, another 23% listed lack of benefit from the drug, and 12% said they would not use it for both reasons.
Then there are the practical issues. “Ideally, you would have a 'door-to-needle' time of 60 minutes,” Dr. Barsan said. This would require first rapidly identifying the patient when he or she arrives in the emergency department, then doing an exam and determining that the patient did have a stroke, and finally sending the patient for a CT scan to make sure it is not a hemorrhagic stroke, he said.