Proposed changes to National Tariffs for EP and CIEDs

As you may be aware, there is a “National Tariff” for EP and device procedures, which is a pricing structure for activity under Payment by Results.

This pricing structure is currently based on Healthcare Resource Group (HRG) 4 codes e.g. “EA12Z: implantation of Cardioverter; Defibrillator only”.  For such procedures, where the overall cost of the procedure is dominated by a disposable item e.g. the ICD itself, the cost is divided into a tariff, which is a fixed price paid to the Trust for the procedure based on the national average costs of hospital services.  The current tariff for an elective ICD is £4,637.  In addition, the Trust can also claim the cost of the ICD as an “excluded” device.  How much a Trust can claim is negotiated locally between the Trust and the Specialised Commissioners.  Costs that are excluded in 2015/16 are 3D mapping system disposables, ablation catheters, ICD and CRT-D devices.  In 2014/15, the average cost of an ICD according to NICE TA 314 was £11,630, therefore a Trust will receive on average £16,267 reimbursement for the procedure.

The proposal from Monitor and NHS England for 2016/17 is that there will be a change from HRG4 to HRG4+ codes; the difference being that a Complexity and Comorbidity (CC) score is applied to the procedures, which has a large influence on reimbursement.  Although I do not know the details of this scoring, it is likely to include comorbidities such as diabetes, renal impairment etc.  The result is that, as an example, there are now 4 HRG4+ codes for ICDs (EA12A-D) based on CC scores 0-2, 3-5, 6-8 & 9+.  However, of greater importance, the so-called “excluded” device costs (3D mapping, ICDs and CRT-Ds) are now included in the new tariff structure.  The overall calculated tariff (procedure + device) is drastically reduced compared to current tariff. 

The following table gives some examples of how this will work in practice:
For ablation procedures, as an example, the proposed tariff for an AF ablation with CC score 0-1, including 3D mapping disposables will be £2,573.

What this means is that EP and device procedures will make a significant loss to Trusts.  Devices will be increasingly commoditised with stifling of innovation, cessation of industry support.  Treatment for our patients will be seriously damaged: quality and features will be ignored e.g. size, MRI compatibility, battery-saving features; Trusts will be reduced to treating as few patients as possible when we are already underperforming compared to NICE and European guidelines; new centres and expansion of services will be virtually impossible.

What can you do?

Ensure your Trust appeals to Monitor by 14th September 2015
The draft prices were published on 20th August 2015 and can be viewed here.  This link contains information on the proposed tariff and how to feedback to Monitor.  It is important that as many Trusts and other organisations as possible (such as Strategic Clinical Networks) feedback.  Be aware that the appeal rules have been changed to make rejection of the Tariff difficult; furthermore, the proposals lack transparency and validity from independent costing sources.

Prepare your department for better Clinical Coding
Make sure that the procedure is correctly identified and coded.  Understand elective versus urgent versus emergency (technical meanings not obvious; emergency is poorly reimbursed).  Complexity and Comorbidity scores will be important.

Prof Nick Linker - President, British Heart Rhythm Society