The Reimbursement Gap between Acute and Chronic Limb-Threatening Ischemia: Same Drg Different Reality

Document Type

Conference Proceeding

Publication Date

7-1-2026

Publication Title

J Vasc Surg

Keywords

acute disease, acute limb ischemia, aged, cohort analysis, conference abstract, controlled study, critical limb ischemia, diagnosis related group, disease management, female, hospital cost, hospitalization, human, length of stay, major clinical study, male, medicaid, medicare, operating room, outpatient, pharmacoeconomics, reimbursement, retrospective study, surgery, very elderly

Abstract

Objectives: Acute limb ischemia (ALI) and chronic limb-threatening ischemia (CLTI) are reimbursed under the same diagnosis-related groups (DRGs) despite important differences in clinical complexity and resource utilization. The adequacy of current DRG reimbursement in covering hospital costs for ALI compared with CLTI remains unclear. This study compares hospital costs and profit margins for patients treated for ALI vs CLTI. Methods: All patients undergoing inpatient treatment for ALI or CLTI at a quaternary medical center between 2016 and 2024 were reviewed. Patients were identified using International Classification of Diseases, 10th edition, codes and stratified by presentation (ALI vs CLTI) and treatment modality (open vs endovascular). Exclusion criteria included outpatient cases, those treated with only medical management, and incomplete financial data. Costs were a combination of the professional and technical charges for the entire hospitalization, while profit was defined as reimbursement minus cost. Analyses were stratified by payer type. Results: A total of 2712 patients were included (ALI: 656; CLTI: 2,056). The payer mix was predominantly government insured (59% Medicare, 14% Medicaid), while the remaining 27% were commercially insured. Among Medicare beneficiaries, ALI admissions were associated with substantially higher costs compared to CLTI ($50,894 vs $29,183; P < .001) (Table I) with significantly worse losses (−$12,673 vs −$6,343; P < .001) (Table II). When restricted to open surgical interventions, costs and profit margins were similar between ALI and CLTI (Tables I and II). In contrast, among Medicare endovascular interventions, ALI admissions were more than twice as expensive as CLTI admissions ($50,894 vs $23,884; P < .001) and resulted in greater than double the losses (−$13,716 vs −$4,613; P < .001). Major contributors were the costs of implantable devices ($5997 vs $3745; P < .001), the operating room ($7891 vs $4903; P < .001), and increased length of stay (9 days vs 7 days; P = .004) in endovascular ALI cases. Conclusions: In an era of endovascular management, within a real-world payer mix in which Medicare predominates, ALI care is associated with markedly higher resource utilization and substantial hospital losses. Current reimbursement structures inadequately account for the intensity of acute disease management, particularly for Medicare-funded endovascular interventions. Policy adjustments, including refinement of DRG weights or targeted Centers for Medicare and Medicaid add-on payments for high-cost services, warrant consideration to more accurately align reimbursement with the clinical realities of ALI care. [Formula presented] [Formula presented]

Volume

84

Issue

1

First Page

e294

Last Page

e295

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