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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

1
Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora.
2
School of Education and Social Policy, Northwestern University, Evanston, Illinois.
3
Colorado Permanente Medical Group, Denver.
4
School of Public Health, University of Colorado, Aurora.
5
George Washington University School of Medicine and Health Sciences, Washington, DC.
6
School of Law, University of Texas at Austin.
7
Institute for Health Research, Kaiser Permanente Colorado, Aurora.
8
Kaiser Permanente Washington Health Research Institute, Seattle.
9
Kaiser Permanente Northwest, Portland, Oregon.
10
Pritzker School of Law, Institute for Policy Research, Kellogg School of Management, Northwestern University, Chicago, Illinois.

Abstract

Importance:

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.

Objectives:

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.

Exposures:

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.

Results:

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.

PMID:
31609397
PMCID:
PMC6802070
[Available on 2020-10-14]
DOI:
10.1001/jamainternmed.2019.4269

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