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

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.

Trends in High- and Low-Value Cardiovascular Diagnostic Testing in Fee-for-Service Medicare, 2000-2016.

Importance: Owing to a rapid increase in rates of diagnostic cardiovascular testing in the 1990s and early 2000s, the Centers for Medicare & Medicaid Services implemented a series of payment changes intended to reduce overall spending on fee-for-service testing. Whether guideline-concordant testing has been subsequently affected is unknown to date. Objective: To determine whether changes in overall rates of use of diagnostic cardiovascular tests were associated with changes in high-value testing recommended by guidelines and low-value testing that is expected to provide minimal benefits. Design, Setting, and Participants: This retrospective cohort study assessed a national 5% random sample of Medicare fee-for-service beneficiaries aged 65 to 95 years from January 1, 1999, through December 31, 2016. Data were analyzed from February 15, 2018, through August 15, 2019. Exposures: Eligibility to receive high-value testing (assessment of left ventricular systolic function among patients hospitalized with acute myocardial infarction or heart failure) and low-value testing (stress testing before low-risk noncardiac surgery and routine stress testing within 2 years of coronary revascularization not associated with acute care visits). Main Outcomes and Measures: Age- and sex-adjusted annual rates of overall, high-value, and low-value diagnostic cardiovascular testing. Results: Mean (SD) age was similar over time (75.57 [7.32] years in 2000-2003; 74.82 [7.79] years in 2012-2016); the proportion of women slightly declined over time (63.23% in 2000 to 2003; 57.27% in 2012 to 2016). The rate of overall diagnostic cardiovascular testing per 1000 patient-years among the 5% sample of Medicare beneficiaries increased from 275 in 2000 to 359 in 2008 (P < .001) and then declined to 316 in 2016 (P < .001). High-value testing increased steadily over the entire study period for patients with acute myocardial infarction (85.7% to 89.5%; P < .001) and heart failure (72.6% to 80.1%; P < .001). Low-value testing among patients undergoing low-risk surgery increased from 2.4% in 2000 to 3.8% in 2008 (P < .001) but then declined to 2.5% in 2016 (P < .001). Low-value testing within 2 years of coronary revascularization slightly increased from 47.4% in 2000 to 49.2% in 2003 (P = .03) but then declined to 30.8% in 2014 (P < .001). Conclusions and Relevance: Rates of overall and low-value diagnostic cardiovascular testing appear to have declined considerably and rates of high-value testing have increased slightly. Payment changes intended to reduce spending on overall testing may not have adversely affected testing recommended by guidelines.