To evaluate the current impact of tPA cost on inpatient reimbursement at a large, integrated health system of stroke care. 

In 2016, the University Hospitals System Stroke Program initiated a high reliability medicine initiative to improve the value of stroke care by optimizing quality and reducing cost.  That year, Kleindorfer et al reported the relative increase in alteplase (tPA) cost outpaced the increase in Medicare reimbursement.  Since then, the FDA physician’s labelling rule and national guideline updates have expanded eligibility for IV-tPA use in acute stroke.  

All stroke hospital discharges for DRGs 61-63, 64-66, 69 from 1q2016-2q2018 at 11 University Hospitals Health System facilities were analyzed for volume, pharmacy, and financial data using Premier™ and EPSi™.

For all medically-managed stroke (DRGs 61-63, 64-66, 69), average total direct costs (TDC) were 56% of total costs and consistently declined from 59% to 54%.  Room and board comprised 55% and pharmacy 14% of TDC of which 55% was due to tPA cost. Overall, direct and total contribution margins (DCM, TCM) were positive and steadily increased.

For tPA “drip and keep” (DRGs 61-63), average TDC were higher at 68% and did not significantly change from 71% to 68%.  At the current average wholesale price of $10,560.43 /100mg, tPA accounted for most of the TDC.  For tPA-managed stroke, contribution margins have steadily declined; the DCM remains positive but the TCM became substantially negative after 3q2016.

Our HRM-Stroke initiative resulted in an improved contribution margin for stroke overall but saw hospital losses for tPA-managed patients.  The current price of tPA has increased 64% since 2014 and 246% since 2005.  Although tPA may be cost-effective from a payors perspective by reducing post-acute care costs, its use now exceeds reimbursement for inpatient care. These losses would likely be greater for tpa-managed stroke mimics captured to non-stroke DRGs.