Testimony of a failed reimbursement change: why it went wrong

Device implantation in Sweden

Frieder Braunschweig MD PhD FESC FACC

Professor of Cardiology, Director of Arrhythmia

Heart and Vascular Theme

Past president Swedish Society of Cardiology

Karolinska University Hospital, Stockholm, Sweden

Health care organization in Sweden

Speaker

• Ca: 10 000 000 inhabitants

• Public health care

• 20 county councils

• Health care expenditure 9.6% of GDP

• 2.7 hospital beds per 1000

• Cardiology outpatient clinics

largely linked to hospitals

• Large GP centers

Device implantation: precondition in Sweden

• Proud history in pacing

• Active research on devices in HF

• Rich country

• High tech nation

• High standards and quality in health care

• Implanting centers:• Pacemaker: 44 (4/mio; Europe 3.9/mio)

• ICD: 30 (3/mio; Europe 2.4/mio)

• CRT: 25 (2.5/mio; Europe 1.7/mio)

Speaker

Eucomed 2014

ICD implantation in Europe 2007-2012

National guidelines 2015(Swedish board of health and welfare)

Priority: 1-10 Do notFurther research encouraged

CRT: HF, NYHA III-IV, LVEF ≤35%, LBBB, SR prio 1

ICD: Primary prophylactic indication (IHD) prio 2

Moss et al, N Engl J Med 2009;361:1329-38

CRT utilization in Sweden

Lund LH, Braunschweig F et al EJHF (2014) 16, 1073–1081

Swedish HF register, RiksSvikt (n=14.713)

CRT indication based on ESC 2013 guidelines

CRT in EHRA countries

0

50

100

150

200

250

0 2 4 6 8 10 12 14

r=0.68

Health care expenditure as % of GDP

CRT implant per mio (2014)

CRT implantation in relation to health care expenditure

Crash course in Swedish health economics

Frieder Braunschweig

StockholmCounty council

2017 budget

HospitalA

HospitalB

HospitalC

PrimaryCare

etc

DevicesAblation

ValveTAVI

MitraclipStents

HF

Budget: Heart and Vascular

etc

CancerPediatricsTrauma

“No revenue -only costs…”

Low device implantation in Sweden:possibly linked to high cost and budget limits

Action plan:

- increase device implantation by reducing costs- establish lowest device costs in Europe- countywise tender

2007 2017

PacemakerICD

CRT, CRT-D

4 000to

15 000Euro

<3000Euro

Braunschweig F et al, Cardiostim 2014

Cost per Life year gained [Swedish Crowns]

Cost per QALY[Swedish Crowns]

2008 2008 20132013

251.000 301.000146.000 174.000

-42%-42%

ICD cost effectiveness in Sweden

Device implantation in Sweden: CRT

Frieder BraunschweigEHRA Whitebook 2016, Raatikainen et al, Europace (2016) 18, iii1–iii79

Frieder BraunschweigEHRA Whitebook 2016, Raatikainen et al, Europace (2016) 18, iii1–iii79

Device implantation in Sweden: CRT-D

Frieder Braunschweig

151

EHRA Whitebook 2016, Raatikainen et al, Europace (2016) 18, iii1–iii79

Device implantation in Sweden: ICD

Moss et al, N Engl J Med 2009;361:1329-38

Reasons for device under-utilization

Hübinette et al Europace 2014 16, 1580–1586

Unawareness, lack of knowledge

Lund LH, Braunschweig F, Linde C et al, EJHF 2017, ahead of print

Reasons for device under-utilization

Lund LH, Braunschweig F, Linde C et al, EJHF 2017, ahead of print

Reasons for device under-utilization

The cost of low cost devices

• Service by Industry↓

• Education↓

• Information to physicians and the public

• Education of physicians about selection, implantation, folllow-up

• Device programming

• Research, sponsoring↓

• New indications

• Revised indications

• Innovation↓

• New devices

• New features and algorithms

• No appropriate reimbursement of remote monitoring

Speaker

Reimbursement change: lowest device costs

• In the public health cares setting of Sweden significant lowering of device costs had no dramatic effect on implantation rates

• Other factors more important for under-utilization

• Education

• Access to specialized care

• Other reimbursement models?

• Upfront reimbursement model still a handicap??

• “Value based care”

• Better networking EP/HF/GP required

• Informed patients

• “Get what you pay for”

• Fewer devices, worse outcome

• Lower breaking point for reimbursement?

• Service and education also needs to be funded…

Speaker

• Thank you

Speaker

Speaker

Hospital beds per 1 000 population, 2010

CRT (all) in EHRA countries

R² = 0,346

0

50

100

150

200

250

0 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000

Health care expenditure per capita (Euro)

CRT implant per mio (2014)

CRT implantation in relation to health care expenditure