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JAMA Intern Med. 2019 Oct 14. doi: 10.1001/jamainternmed.2019.4269. [Epub ahead of print]

Trends in Medicare Payment Rates for Noninvasive Cardiac Tests and Association With Testing Location.

Author information

Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora.
School of Education and Social Policy, Northwestern University, Evanston, Illinois.
Colorado Permanente Medical Group, Denver.
School of Public Health, University of Colorado, Aurora.
George Washington University School of Medicine and Health Sciences, Washington, DC.
School of Law, University of Texas at Austin.
Institute for Health Research, Kaiser Permanente Colorado, Aurora.
Kaiser Permanente Washington Health Research Institute, Seattle.
Kaiser Permanente Northwest, Portland, Oregon.
Pritzker School of Law, Institute for Policy Research, Kellogg School of Management, Northwestern University, Chicago, Illinois.



To control spending, the Centers for Medicare & Medicaid Services reduced Medicare fee-for-service (FFS) payments for noninvasive cardiac tests (NCTs) performed in provider-based office settings (ambulatory offices not administratively affiliated with hospitals) starting in 2005. Contemporaneously, payments for hospital-based outpatient testing increased. The association between differential payments by site and test location is unknown.


To quantify trends in differential Medicare FFS payments for NCTs performed in hospital-based and provider-based settings, determine the association between the hospital-based outpatient testing to provider-based office testing payment ratio and the proportion of hospital-based NCTs, and to examine trends in test location between Medicare FFS and 3 Medicare Advantage health maintenance organizations for which Centers for Medicare & Medicaid Services payments do not depend on testing location.

Design, Setting, and Participants:

This observational claims-based study used Medicare FFS claims from 1999 to 2015 (5% random sample) and Medicare Advantage claims from 3 large health maintenance organizations (2005-2015) among Medicare FFS beneficiaries aged 65 years or older and a health maintenance organization control group. Statistical analysis was performed from May 1, 2017, to July 15, 2019.


The weighted mean payment ratio of Medicare FFS hospital-based outpatient testing to provider-based office testing for outpatient NCTs.

Main Outcomes and Measures:

Proportion of outpatient NCTs performed in the hospital-based setting and Medicare FFS costs.


The data included a mean of 1.72 million patient-years annually in Medicare FFS (mean age, 75.2 years; 57.3% female in 2015) and a mean of 142 230 patient-years annually in the managed care control group (mean age, 74.8 years; 56.2% female in 2015). The Medicare payment ratio of FFS hospital-based outpatient testing to provider-based office testing increased from 1.05 in 2005 to 2.32 in 2015. The FFS hospital-based outpatient testing proportion increased from 21.1% in 2008 to 43.2% in 2015 and was correlated with the payment ratio (correlation coefficient with a 1-year lag, 0.767; P < .001). In contrast, the hospital-based outpatient testing proportion for the control group declined from 16.6% in 2008 to 15.2% in 2015 (correlation coefficient, -0.024, P = .95). The estimated extra costs owing to tests shifting to the hospital-based outpatient setting in the Medicare FFS group was $661 million in 2015, including $161 million in patient out-of-pocket costs.

Conclusions and Relevance:

In settings in which reimbursement depends on test location, increasing hospital-based payments correlated with greater proportions of outpatient NCTs performed in the hospital-based outpatient setting. Site-neutral payments may offer an incentive for testing to be performed in the more efficient location.

[Available on 2020-10-14]

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