ACCA: How to know when disruptive CV technology adoption will result in ROI?
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While cardiovascular program revenues are dropping in hospitals across the U.S., they remain a leading source of organizational profits. However, the contemporary generation of technology, especially ones that require a new program or service line, require a strategic approach and widespread cultural change.
“Technology can be a program differentiator and be disruptive at the same time,” he said. He reviewed the history and of six cardiovascular technologies to elucidate this point:
- Intracoronary brachytherapy;
- Drug-eluting stents (DES);
- Magnetic catheter guide;
- Cardiac robotics;
- Transcatheter aortic valve replacements; and
- Hybrid operating room (OR).
Intracoronary brachytherapy was a short-lived, disruptive technology, whose era ended with the dawn of DES in 2004. This was an expensive technology to both implement and operate, according to Kramer. It was expensive to implement due to the need for ancillary departmental affiliations, such as radiation oncology and physics. It was expensive to operate due to access restrictions on procedure room(s) due to radiation exposure, and due to the need for additional supplies (cutting balloons).
While few facilities introduced brachytherapy, Kramer said that those facilities saw an increase in revenues because of the technology’s professed capability to prevent stenosis. Also, when DES came to the market, almost all intracoronary brachytherapy programs were shut down.
In April 2004, the Cordis DES was approved by the FDA. The prices of DES have come down, but the prices initially skyrocketed. “The average costs associated with stents went from $750-$900 to approximately $2,200 or higher for the same type of procedure, with the same stent type, and facilities used the same reimbursement due to their popularity as a better product,” Kramer said. “Initially, stent utilization ranged from 1.7 to 1.8 per case.”
Thus, he defined DES a disruptive technology that is “still around” at a lower price point. But it is not a novel technology, because it was a new iteration of products already on the market.
Comparatively, magnetic catheter guidance systems were a novelty item in the realm of electrophysiology, which was aimed at making targeted mapping and ablation therapy easier and more efficacious; however, it hasn’t truly proved its worth and adoption remains low, according to Kramer.
Early adopters were able to promote on the basis of "pinpoint" precision, but the systems are extremely expensive to implement, due to actual equipment, facility modifications and associated catheters. While the adoption has been generally low, it may gain acceptance with new generations of physicians who grew up through childhood playing video games. However, to gain great adoption rates and demonstrate that a $2.5 million investment is worthwhile, he suggested that it will require “a significant evolution.”
As for cardiac robotics, the early models were clumsy and difficult to use. But the Da Vinci Robot (Intuitive) launched as a system with foot controls and hand petals that were easier to maneuver for the cardiac surgical setting. Initially, the launch failed due to difficulties overcoming the learning curve, as the standard system had technical challenges such as short arms, making its cardiac application more challenging than traditional surgery, Kramer explained. Also, the system was extremely expensive to operationalize due to the actual equipment, cost of reposables and increased operating room time per case.
However, he made a case for cardiac robotics for the “very few programs” with surgeons and surgical teams that have culturally embraced the technology. It has created a market niche in minimally invasive cardiac surgery with a smaller incision, less pain, shorter recovery and length of stay.
“Significant rate of return if there is a super user of the technology, and teamed with staff of equal proficiency,” said Kramer, who acknowledged that it requires a commitment and cultural change of both the patients and medical personal, including general practitioners.
“At Main Line, which has utilized DaVinci for more than 800 surgeries, we’re able to discharge the patient in three days, and sending patients with telemetry monitors to avoid unnecessary readmissions,” Kramer said.
More recently, transcatheter aortic valve replacement (TAVR) has represented the “next true frontier of disruptive technology,” he said. TAVR will have limited availability at present due to restrictions from the FDA and the Centers for Medicare & Medicaid Services (CMS) about facility volume, registry participation and technological requirements. Currently, only 150 sites in the U.S. will have access to the Sapien valve. TAVR is an expensive technology, and is not simple to learn or use, especially because surgical/interventional team decision-making and procedural approach.
Also, he pointed out that traditional aortic surgery is still a very viable procedure for many aortic stenosis patients. “For every one patient that underwent TAVR in PARTNER, five patients were directed to another therapy,” said Kramer. “Also, practitioners will become more proficient in identifying aortic stenosis patients earlier in their disease state onset.” Thus, time will tell if this investment will be a value proposition.
Even though providers can convert a cath lab to accommodate valve procedures, the hybrid OR is optimal for valve procedures in case anything goes wrong with the procedure. Staff needs to be properly trained in both interventional and operating procedures. However, hospitals could benefit from performing diagnostic catheterizations, coronary stenting, valve procedures, operations and endovascular repair of abdominal aortic aneurysm procedures. These procedures require more imaging, but “if a provider is looking to reap an ROI purely based on imaging procedures in the hybrid OR, it is unlikely due to their $2 million to $3 million price tag,” Kramer added.
Considering this review, Kramer concluded that facilities need to approach disruptive technologies with a strategic, holistic approach, because while the revenues are diminishing, there are still areas of growth that allow facilities to differentiate themselves.