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