US budget impact of increased payer adoption of the Flexitouch advanced pneumatic compression device in lymphedema patients with advanced chronic venous insufficiency and multiple infections

Figures & data

Table 1. Status quo and alternate payer policy patient treatment distributions^a.

Treatment groups	CONS	CONS + SPCD	CONS + other APCD	CONS + FLX
Status quo patient distribution	86.6%	1.7%	5.0%	6.6%
Alternate payer policy patient distribution
SPCD failure removal scenario	86.6%	0.0%	5.0%	8.3%^b
Exclusive APCD scenario	86.6%	1.7%	0.0%	11.6%^c
Expanded access scenario	77.9%	1.7%	5.0%	15.3%^d

^a Patient distributions between treatment groups were derived from all patients who qualified for the BHI analysis (i.e. not restricted to patients included in case-matched cohorts).

^b In the SPCD failure removal scenario, the 1.7% of patients using CONS + SPCD are shifted to the CONS + FLX treatment group. These patients are added to the 6.6% using CONS + FLX in the status quo scenario.

^c In the exclusive APCD scenario, the 5.0% of patients using CONS + Other APCD are shifted to the CONS + FLX treatment group. These patients are added to the 6.6% using CONS + FLX in the status quo scenario.

^d In the expanded access scenario, 10% of the 86.6% of patients using CONS only are shifted to the CONS + FLX treatment group. These patients are added to the 6.6% using CONS + FLX in the status quo scenario.

Table 2. Description of status quo and alternate payer policy scenarios.

Status quo scenario	Criteria requiring failure of an SPCD prior to initiation of APCD therapy
Alternate payer policy scenarios
SPCD failure removal scenario	Criteria requiring failure of an SPCD prior to initiation of APCD therapy are removed, allowing all patients prescribed a PCD access to Flexitouch
Exclusive APCD scenario	Flexitouch is selected as the exclusive APCD offered to plan members
Expanded access scenario	Criteria restricting access to PCDs are relaxed, allowing patients treated conservatively access to Flexitouch

Table 3. Status quo inputs.

Epidemiology and treatment					Sources
LE prevalence	0.1%				Moffatt et al.^27 Williams et al.^28
LE treatment rate^a	63.5%				2012–2016 BHI Claims Analysis
CVI prevalence^b	6.0%
Frequent infections prevalence^c	10.2%
Lympedema and sequelae-related costs by treatment group
	CONS	CONS + SPCD	CONS + other APCD	CONS + FLX
One-time PCD acquisition^d	N/A	$946	$5,459		2017 Medicare DMEPOS Fee Schedule^26
Medical cost inputs (mean per patient per year)
CVI sub-population
Home health	$370	$522	$511	$334	2012–2016 BHI Claims Analysis
Emergency	$11	$7	$45	$33
Inpatient	$8,715	$4,215	$4,186	$1,560
Physical therapy	$81	$34	$37	$39
Outpatient	$2,453	$2,313	$3,026	$1,090
Office	$584	$397	$705	$652
Lab	$1	$2	$3	$5
Other service location	$39	$0	$8	$126
Frequent infections sub-population
Home health	$649	$2,214	$921	$827	2012–2016 BHI Claims Analysis
Emergency	$71	$83	$116	$173
Inpatient	$16,382	$14,584	$13,308	$8,810
Physical therapy	$92	$92	$44	$87
Outpatient	$3,709	$5,329	$3,294	$3,026
Office	$826	$872	$1,039	$542
Lab	$2	$22	$4	$1
Other service location	$40	$31	$6	$121

^a Within the BHI claims database, patients diagnosed with non-filarial LE were identified by >1 inpatient claim or ≥2 outpatient claims within a 30 day period with the first or second ICD-9: 457.0, 457.1, 757.0, ICD-10: I97.2, I89.0, Q82.0. Treatment was identified by >1 claim for active LE treatment, including MLD [97124, 97140] AND/OR Education [97535] AND/OR PT/OT [97001, 97002, 97003, 97004, 97110, 97112, 97161, 97162, 97163, 97165, 97166, 97167, 97530]. Costs were identified from claims processed in 2012–2016. Costs associated with each qualifying patient were annualized.

^b CVI was identified by ≥1 inpatient claim or ≥2 outpatient claims within a 30 day period with the first or second claim for CVI [ICD-9: 459.3x, 459.8x, ICD-10: I87.2].

^c Infections were identified by the following codes: Cellulitis [ICD-9: 681.xx, 682.xx; ICD-10: L03.01x, L03.03x, L03.11x, L03.211, L03.213, L03.221, L03.31x, L03.81x, L03.90], Septic shock [ICD-9: 785.52, ICD-10: R65.21], Lymphangitis [ICD-9: 457.2, ICD-10: L03.02x, L03.04x, L03.12x, L03.212, L03.222, L03.32x, L03.89x, L03.91], Erysipelas [ICD-9: 035, ICD-10: A46], other local infections of skin and subcutaneous tissue [ICD-9: 686.xx, ICD-10: L08.xx].

^d PCD acquisition costs estimated as the midpoint of the published floor and ceiling rates in 2017 Medicare DMEPOS fee schedule. SPCD (HCPCS E0651) floor = $869, ceiling = $1,022; APCD (FLX and other APCDs, HCPCS E0652) floor = $5,017, ceiling = $5,902.

LE and sequelae-related costs were identified as any claims with LE as the first or second diagnosis (codes above), inpatient or outpatient claims with cellulitis diagnosis in any position (codes above), claims with septic shock diagnosis in any position (codes above), claims with lymphagitis diagnosis in any position (codes above), claims with erysipelas diagnosis in any position (codes above), claims with other local infections of skin and subcutaneous tissue diagnosis in any position (codes above) and inpatient claims or recurrent (>1) non-inpatient claims with ulcer diagnosis in any position [ICD-9: 707.x; ICD-10: I70.23x, I70.24x, I70.25, I70.33x, I70.34x, I70.35, I70.43x, I70,44x, I70.45, I70.53x, I70.54x, I70.55, I70.63x, I70.64x, I70.65, I70.73x, I70.74x, I70.75, L89.x, L97.x, L98.4x].

Table 4. Alternate payer policy medical cost inputs (mean per patient per year).

	Patients shifted from CONS to CONS + FLX	Patients shifted from CONS + SPCD to CONS + FLX	Patients shifted from CONS + Other APCD to CONS + FLX
CVI sub-population
Home health	$334	$408	$380
Emergency	$33	$6	$36
Inpatient	$1,560	$297	$1,468
Physical therapy	$39	$16	$36
Outpatient	$1,090	$353	$1,283
Office	$652	$74	$600
Lab	$5	$0	$6
Other service location	$126	$0	$163
Frequent infections sub-population
Home health	$827	$845	$798
Emergency	$173	$200	$192
Inpatient	$8,810	$6,620	$9,355
Physical therapy	$87	$42	$88
Outpatient	$3,026	$4,130	$3,617
Office	$542	$389	$505
Lab	$1	$1	$1
Other service location	$121	$0	$175

Table 5. Cumulative total 2-year budget impact.

Status quo	Alternate payer policy		Budget impact^a	Breakeven point^b
CVI sub-population
$8,957,911	SPCD failure removal	$8,905,070	–$52,841	0.71 years
	Exclusive APCD	$8,784,594	–$173,317	N/A
	Expanded access	$8,582,310	–$375,601	0.65 years
Frequent infections sub-population
$27,785,492	SPCD failure removal	$27,592,761	–$192,729	0.41 years
	Exclusive APCD	$27,526,091	–$259,399	N/A
	Expanded access	$27,172,311	–$613,179	0.67 years

^a Budget impact is calculated as Alternate – Status quo; therefore, a negative budget impact reflects cost savings.

^b Breakeven point is the time required for payers to recoup PCD costs, which are incurred, in full, at the beginning of year 1.

Figure 1. One-way sensitivity analysis, sensitivity multiplier = ±20%. Sensitivities were tested for inpatient and outpatient costs for patients shifted to CONS + FLX from other treatment groups.

Moffatt CJ, Franks PJ, Doherty DC, et al. Lymphoedema: an underestimated health problem. QJM : monthly journal of the Association of Physicians. 2003 Oct;96(10):731-8. PubMed PMID: 14500859; eng.

 Google Scholar

Williams AF, Franks PJ, Moffatt CJ, et al. Lymphoedema: estimating the size of the problem. Palliative medicine 2005 Jun;19(4):300-13. doi:10.1191/0269216305pm1020oa. PubMed PMID: 15984502; eng.

 PubMed Web of Science ®Google Scholar

Data availability statement

The claims data that support the findings of this study are available via purchase from Blue Health Intelligence. The methodology section contains description of the specific claims data utilized. Medicare fee schedule data is openly available from the Centers for Medicare and Medicaid Services at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule-Items/DME17-D.html.