Claims Variability in Charges and Payments for Common Open and Endovascular Procedures.

BACKGROUND: Cost-effectiveness in healthcare is being increasingly scrutinized. Data regarding claims variability for vascular operations are lacking. Herein, we aim to describe variability in charges and payments for aortoiliac (AI) and infrainguinal (II) revascularizations. METHODS: We analyzed 2012-2014 claims data from a statewide claims database for procedures grouped by Current Procedural Terminology codes into II-open (II-O), II-endovascular (II-E), AI-open (AI-O), and AI-endovascular interventions (AI-E). We compared charges and payments in urban (≥50,000 people, UAs) versus rural areas (<50,000 people, RAs). Amounts are reported in $US as median with interquartile range. Cost-to-charge ratios (CCRs) as a measure of reimbursement were calculated as the percentage of the charges covered by the payments. Wilcoxon rank-sum tests were performed to determine significant differences. RESULTS: A total of 5,239 persons had complete claims data. There were 7,239 UA and 6,891 RA claims, and 1,057 AI claims (AI-E = 879, AI-O = 178) and 4,182 II claims (II-E = 3,012, II-0 = 1,170). Median charges were $5,357 for AI [$1,846-$27,107] and $2,955 for II [$1,484-$9,338.5] (P < 0.0001). Median plan payment was $454 for AI [$0-$1,380] and $454 for II [$54-$1,060] (P = 0.67). For AI and II, charges were significantly higher for UA than RA (AI: UA $9,875 [$2,489-$34,427], RA $3,732 [$1,450-$20,595], P < 0.0001; II: UA $3,596 [$1,700-$21,664], RA $2,534 [$1,298-$6,169], P < 0.0001). AI-E charges were higher than AI-O (AI-E $7,960 [$1,699-$32,507], AI-O $4,774 [$2,636-$7,147], P < 0.0001), but AI-O payments were higher (AI-E $424 [$0-$1,270], AI-O $869 [$164-$1,435], P = 0.0067). II-E charges were higher (II-E $2,994 [$1,552-$22,164], II-O $2,873 [$1,108-$5,345], P < 0.0001), but II-O payments were higher (II-E $427 [$50-$907], II-O $596 [$73-$1,299], P < 0.0001). CCRs were highest for II operations and UAs. CONCLUSIONS: Wide variability in claim charges and payments exists for vascular operations. AI procedures had higher charges than II, without any difference in payments. UA charged more than RA for both AI and II operations, but RA had higher payments and CCRs. Endovascular procedures had higher charges, while open procedures had higher payments. Charge differences may be related to endovascular device costs, and further research is necessary to determine the reasons behind consistent claims variability between UA and RA.

Evaluating Two Measures of Lumbar Spine MRI Overuse: Administrative Data Versus Chart Review.

PURPOSE: Lumbar spine (LS) MRI overuse may be identified in administrative data, but these data may lack the detailed clinical information needed to correctly assess overuse. The aim of this study was to compare chart review with analysis of administrative data to determine the appropriateness of LS MRI. METHODS: The sensitivity and specificity of the administrative method were determined, with inappropriateness regarded as the positive result, as if chart review determined the true state. Patients were the first 146 veterans who underwent LS MRI in the outpatient setting in fiscal year 2012 at the Veterans Affairs Palo Alto Health Care System. The InterQual criteria for chart review and the method of evaluating administrative data developed by CMS and endorsed by the National Quality Forum were used. Slight modifications were made to each measure to ensure completeness and comparability. RESULTS: Of the 146 scans reviewed, 23% were considered inappropriate by the administrative measure, whereas 59% were considered inappropriate by chart review. Compared with chart review, the administrative measure had specificity of 82% for identifying inappropriate scans and sensitivity of 27% for identifying appropriate scans. CONCLUSIONS: Compared with chart review, analysis of administrative data identified scans that were appropriate but underestimated inappropriate ordering. Contrary to expectations, chart review resulted in more scans being classified as inappropriate. The administrative method is economically feasible for identifying the overuse of LS MRI, but it underestimates the true extent of inappropriate ordering.