OBJECTIVES:

Given the recent DRG payment reform in Chile, there is a need to understand the balance between the current reimbursement rate and real provider cost. The case of Aortic Stenosis treated with Surgical Aortic Valve Replacement (SAVR) and Transcatheter Aortic Valve Replacement (TARV) has been described as critical. We aim to estimate the reimbursement rate and real provider costs for SAVR and TAVR from the public providers' perspective.

METHODS:

The analysis considers the current DRG reimbursement and a real cost estimation. Reimbursement estimation: Open-access DRG databases from public providers were explored. Data on: DRG coding, DRG weights, basal reimbursement, and add-on payment amounts were gathered. DRGs are utilized in surgery reimbursement only but excludes pre and postoperative care. Cost estimation: Real costs were estimated using an activity-based costing approach and bottom-up strategy for pre-operative, intra-operative, and post-operative periods. Among the explored cost drivers were lab work, bed days, drugs, and medical devices. Estimations were made a per-patient (PP) without complications basis and expressed in 2022 Chilean pesos (CLP).

RESULTS:

Pre-operative costs: costs were estimated at CLP$372,714 and CLP$576,563 for SAVR and TAVR respectively. Intra-operative reimbursement: SAVR CLP$11,107,026, and TAVR CLP$23,138,514 (including add-on payment for TAVR). Intra-operative costs for non-complicated patients: SAVR costs CLP$12,753,730 and TAVR CLP$20,353,312. Post-operative costs for SAVR are CLP$205,240 and CLP$76,410 for years 1 and 2, respectively. For the case of anticoagulants in mechanical valves (0.4 ratio), an annual cost of CLP$87,274 is summed. Post-operative costs for TAVR are CLP$235,000 and CLP$114,170 for years 1 and 2, respectively. The total comprehensive cost for SAVR was CLP$13,477,913, and for TAVR, CLP$ $21.280.830 (including a 0.25 ratio of aspirin intake), in a 2 years horizon.

CONCLUSIONS:

Significant efforts need to be made to estimate local costs for high-cost procedures and adjust accordingly the current DRG reimbursement rate.