OBJECTIVES:

In 2020, Chile implemented a DRG payment reform. However, the system imported internationally sources DRG weights instead of using local costs. Thus, there is a need to understand if the current DRG weights accurately represent the local costs of Chilean public providers. This is particularly evident in procedures requiring high-cost medical devices. The Transcatheter Aortic Valve Replacement (TARV) for Aortic Stenosis (AS) has been described as a critical case. We aim to estimate the gap between the current TAVR reimbursement rate and the local provider costs from the public providers' perspective.

METHODS:

The reimbursement rate was estimated using open-access DRG databases from public providers. Data on: DRG coding, DRG weights, basal reimbursement, and add-on payment amounts were collected. To estimate local provider costs, an activity-based costing approach and bottom-up strategy was used. Costs were categorized in order to explore principal cost drivers. Estimations were made a per-patient (PP) without complications basis and expressed in 2022 Chilean pesos (CLP).

RESULTS:

The average DRG TAVR payment (irrespective of AE severity and severity distribution) was CLP$23,138,514 (a baseline of CLP$4,602,504 + an additional add-on payment of CLP$18,536,010 when code 35.05 was approved). The average local cost to providers PP without complications were estimated at CLP$20,353,312. Costs were sorted by lab work and scans (0.30%), bed-days (0.86%), drugs and post-procedure care (0.97%), medical team costs (1.54%), OR supplies (9.22%), and the TAVR device (87.12%). When complications are not considered, the gap between full reimbursement and costs for the intraoperative period was CLP$2,785,202 (12.04%) (positive margin for providers).

CONCLUSIONS:

With the inclusion of an add-on payment for TAVR in AE, the gap between DRG average reimbursement and procedure costs diminished in non-complicated patients. However, the reimbursement rate versus true costs balance is delicate as it relies on best-case scenarios.