Rates of Major Cardiovascular Procedures Differ for
Medicare Advantage, Fee-For-Service Patients
Large study of seniors finds Medicare Advantage
patients had lower age, sex, race, and income-adjusted procedure rates
for angiography and PCI; wide geographic variation, too – See Video
July 11, 2013 - In a study that included nearly 6
million senior citizens from 12 states in Medicare Advantage or Medicare
fee-for-service plans, rates of angiography and percutaneous coronary
interventions were significantly lower among Medicare Advantage
beneficiaries and geographic variation in procedure rates was
substantial for both payment types, according to a study in the July 10
issue of JAMA.
“Treatment of cardiovascular disease is one of the
largest drivers of health care cost in the United States, accounting for
$273 billion annually. Cardiovascular procedures are major contributors
to this high cost,” according to background information in the article.
“Little is known about how different financial incentives between
Medicare Advantage and Medicare fee-for-service (FFS) reimbursement
structures influence use of cardiovascular procedures.”
“Under the Medicare FFS reimbursement structure,
physicians are paid more for doing more procedures. In contrast,
integrated delivery systems that provide care for Medicare Advantage
beneficiaries receive a capitated payment, and physicians working in
these settings are not paid more for doing more procedures,” the authors
Daniel D. Matlock, M.D., M.P.H., of the University
of Colorado School of Medicine, Aurora, and colleagues conducted a study
to compare the overall rates and local area rates of coronary
angiography, percutaneous coronary intervention (PCI; procedures such as
balloon angioplasty or stent placement used to open narrowed coronary
arteries), and coronary artery bypass graft (CABG) surgery between
Medicare Advantage and Medicare FFS beneficiaries living in the same
The study, which included 878,339 Medicare
Advantage patients and 5,013,650 Medicare FFS patients older than 65
years of age, compared rates of these procedures between 2003-2007
across 32 hospital referral regions (HHRs) in 12 states.
The researchers found that compared with Medicare
FFS patients, Medicare Advantage patients had lower age-, sex-, race-,
and income-adjusted procedure rates for angiography and PCI but similar
rates for CABG surgery. There were no differences between Medicare
Advantage and Medicare FFS patients in the rates of urgent angiography.
When examining procedure rates across HRRs, there was wide geographic
variation among Medicare Advantage patients and Medicare FFS patients.
Across regions, the authors found no statistically
significant correlation between Medicare Advantage and Medicare FFS
beneficiary utilization for angiography and modest correlations for PCI
and CABG surgery. Among Medicare Advantage beneficiaries, adjustment for
additional cardiac risk factors had little influence on procedure rates.
“The finding that Medicare Advantage patients have
lower rates of angiography and PCI underscores the need for additional
research to determine the extent to which this is attributable to
differences in population characteristics, more efficient utilization of
procedures among Medicare Advantage patients (i.e., overutilization in
Medicare FFS), or harmfully restrictive management of utilization among
Medicare Advantage patients (i.e., underutilization in Medicare
Advantage). One explanation for the differences in rates seen in this
report could be that Medicare Advantage beneficiaries are healthier and
require fewer cardiovascular procedures than Medicare FFS
beneficiaries,” the authors write.
“Geographic variation in health services in the
Medicare FFS population has fueled the perception of an inefficient,
ineffective U.S. health care system. Until the causes of geographic
variation are understood, shedding light on the sources of variability
remains an important research and quality improvement endeavor. Indeed,
comparing ‘the effectiveness of accountable care systems and usual care
on costs, processes of care, and outcomes for geographically defined
populations of patients’ is one of the Institute of Medicine’s 100
priorities for comparative effectiveness research.
“Capitation in various forms is anticipated to be
an effective means of reducing future health care cost growth,
particularly cost growth resulting from unnecessary care. Although in
this study capitation was associated with lower procedure rates for
angiography and PCI, the substantial geographic variation that remained
despite the reimbursement structure suggests that capitation alone may
not lead to reductions in the wide variations seen in use of
Editorial: Variations in Health Care, Patient
Preferences, and High-Quality Decision Making
“Scientists have documented variation in health
care and have identified nonpatient factors that influence practice,”
writes Harlan M. Krumholz, M.D., S.M., of the Yale University School of
Medicine, New Haven, Conn., in an accompanying editorial.
“However, too little attention, for too long, has
been directed toward ensuring the quality of preference-sensitive
patient decisions. Moreover, if high-quality decisions, under the wide
range of circumstances in medicine, are a worthy goal, investment is
necessary to advance the science of clinical decision making, including
increasing the understanding of the vulnerabilities of current
approaches and developing ways to improve performance and ensure that
the patient’s interests are best served. Ultimately, the goal is not to
eliminate variation but to guarantee that its presence throughout health
care systems derives from the needs and preferences of patients.”
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