Cardiovascular Procedures Driven More by Geography Than Reimbursement Type

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Use of coronary angiography and percutaneous coronary intervention (PCI) is higher among Medicare patients enrolled in the program’s fee-for-service (FFS) vs. capitated plans, reports a paper published in the July 10, 2013, issue of the Journal of the American Medical Association. But geography had even greater influence on utilization.

Daniel D. Matlock, MD, MPH, of the University of Colorado School of Medicine (Aurora, CO), evaluated patterns in the rates of coronary angiography, PCI, and CABG use across 32 hospital referral regions in 12 states between 2003 and 2007. Among the nearly 6 million patients over age 65 years who were included, 878,339 were enrolled in Medicare Advantage and over 5 million in Medicare FFS. In Medicare Advantage, a capitated plan, reimbursement is paid based on the number of patients being served over a certain time period rather than the number of services being performed.

The 2 groups were demographically similar, though Medicare Advantage patients had lower rates of diabetes (21% vs. 24%), hyperlipidemia (44% vs. 50%), and prior CAD (13% vs. 19%; P < 0.01 for all comparisons).

Adjusted for age, sex, race, and income, overall rates of both angiography and PCI per 1,000 person-years were higher for Medicare FFS patients than Medicare Advantage patients, while CABG use was similar between the 2 groups. But the differences for angiography and PCI appeared restricted to elective cases, with urgent procedures occurring at similar rates for both (table 1).

Table 1. Procedure Use by Medicare Plan

In addition, procedure rates varied across hospital referral regions, with similar degrees of variation for both plans. The geographic differences for angiography and PCI were driven mainly by elective procedures (table 2).

Table 2. Geographic Variation by Medicare Plan

Further adjustment for other cardiac risk factors did not change the findings.

Not Necessarily a Sign of Overuse

Gregory J. Dehmer, MD, of Texas A&M University Health Science Center College of Medicine (Temple, TX), told TCTMD in an e-mail communication that it would be wrong to assume that the higher usage among FFR beneficiaries does in fact represent overuse. “It is not necessarily a bad thing,” he said, adding that Medicare Advantage patients could possibly be undertreated.

Moreover, the fact that angiography and PCI—but not CABG—were affected by plan type could relate simply to the relative complexities of the procedures, Dr. Dehmer proposed. “As one goes from angiography to PCI to CABG, the procedure becomes more technical, more complex and has more risk,” he said. “Thus, it's fairly easy for the physician and patient to decide to move forward on an angiogram, but the decision to have CABG is always more difficult and causes one to pause.”

In another e-mail communication, Hitinder S. Gurm, MD, of the University of Michigan (Ann Arbor, MI), commented to TCTMD that “PCI and angiography are probably more impacted by patient and physician preference and thus more prone to be influenced by cultural factors.”

For example, PCI in stable CAD patients “is more likely to be influenced by the perceived impact on quality of life and the desire to have a mechanical fix, or to accept the limitations associated with it,” he said. “CABG is usually performed for more extensive disease, and this is less likely to be impacted upon by patient or physician preference.”

Dr. Matlock agreed. In an e-mail communication, he noted that indications for CABG tend to be “much clearer” than for angiography and PCI in general, an idea bolstered by the finding that differences for catheter-based procedures were seen only in elective cases.

Geographic Variation Likely Driven by ‘Nonclinical Factors’

Identifying the reason for geographic disparities is “extremely tough, Dr. Matlock said. “One of the problems with regional variation studies is that no one really knows what the ‘right rate’ is.  My opinion is that there is not a benign reason—the only truly benign reason being variation explained by patient characteristics or preferences,” he noted. “Rather, I think this could definitely represent overuse, underuse, or both depending on the region.”

Dr. Dehmer similarly noted: “It is certainly possible that the increase in PCIs in some regions was entirely appropriate, but in a study that examined almost 6 million patient records one would expect many of the variables that could affect the decision to perform angiography or PCI to equalize between groups.”

Since physicians are theoretically all following the same clinical practice guidelines and appropriate use criteria, geographic variation should be minimal, Dr. Dehmer continued. “These data suggest that nonclinical factors may be driving decisions about the utilization of these procedures in some settings,” he said.

Dr. Gurm suggested that geographic differences could “probably partly be explained by differences in risk factor prevalence, risk factor control, poverty, other environmental factors, and both overuse and underuse of procedures.”

In addition, Dr. Dehmer noted that the study did not assess factors such as “level of education, availability of other health insurances offered in retirement benefits, availability of invasive cardiology services (urban vs. rural), etc,” that might have differed between the Medicare FFS and Advantage populations.

Looking Forward

As to whether the goal should be to reduce differences, Dr. Gurm was circumspect. “[W]e need to understand [variation] and not necessarily abolish it.”

Capitation “is not the way to reduce inappropriate utilization,” he commented.

Instead, Dr. Gurm said that reimbursement should be more nuanced and perhaps tied to expected benefit, with the highest payments reserved for lifesaving procedures and possibly related to the number needed to treat. Procedures that improve quality of life would fall in the middle, with the lowest reimbursement for those with uncertain benefit.

Dr. Dehmer, meanwhile, emphasized that because “[s]everal experts in healthcare finance have estimated that treatment variation is costing the healthcare system about 10 billion dollars annually,” reducing variation is a worthy goal.

“Professional organizations have collaborated to develop clinical practice guidelines, expert consensus documents, and appropriate use criteria,” he pointed out. “We all recognize these documents don’t cover every possible situation. . . . However, it is clear that often these thoughtful recommendations are not being followed in routine practice.”

Ultimately, he said, “[p]hysicians need to understand that the fee-for-service model is going to disappear and, in the future, you will not be paid for how much you do but rather how well you do the things you are supposed to do in patient care.”

In an accompanying editorial, Harlan M. Krumholz, MD, SM, of the Yale University School of Medicine (New Haven, CT), said that change will not be easy and should be patient-centered.

“[T]oo little attention, for too long, has been directed toward ensuring the quality of preference-sensitive patient decisions. Moreover, if high-quality decisions . . . 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,” he concluded. “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.”

1. Matlock DD, Groeneveld PW, Sidney S, et al. Geographic variation in cardiovascular procedure use among Medicare Fee-for-service vs. Medicare Advantage beneficiaries. JAMA. 2013;310:155-162.
2. Krumholz HM. Variations in health care, patient preferences, and high-quality decision making [editorial]. JAMA. 2013;310:151-152.

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