Surge in Outpatient PAD Procedures Linked to Change in Medicare Reimbursement

During the years 2006 through 2011—a period encompassing the 2008 shift in Medicare reimbursement policy to favor outpatient treatment—the rate of inpatient peripheral vascular interventions decreased in the United States as that of outpatient and office-based procedures rose, according to a study published in the March 10, 2015, issue of the Journal of the American College of Cardiology.

In particular, use of atherectomy increased sharply along with more generous payment for the procedure, blunting the intended cost saving.

Using a 5% national sample of Medicare fee-for-service beneficiaries, researchers led by W. Schuyler Jones, MD, of Duke University Medical Center (Durham, NC), identified 39,339 patients who underwent lower-extremity revascularization between 2006 and 2011, with 79.4% receiving percutaneous intervention, 18.6% surgery, and 2.0% hybrid procedures.

Of those who received intervention, 27.3% had angioplasty alone, 22.4% atherectomy (with or without angioplasty or stenting), and 50.3% stent implantation (with or without angioplasty but without atherectomy).

Compared with stented patients, those who underwent atherectomy or angioplasty alone were older and more likely to be male or black and more often had renal failure, diabetes, heart failure, and stroke. Patients in the atherectomy group were more likely to have ischemic heart disease, to be treated by a cardiologist, and to reside in the Midwest or South compared with those who had angioplasty alone or stenting.

The overall rate of intervention increased slightly over the study period, from 401.4 to 419.6 per 100,000 beneficiaries. This was offset by a marked decline in surgical revascularization from 115.5 to 77.8 (P < .001). The rate of hybrid procedures remained stable. Angioplasty alone and atherectomy alone both increased over the study period (from 97.7 to 109.4 and 96.4 to 125.9, respectively), while the use of stents decreased modestly (from 207.4 to 184.3).

In addition, a 25% reduction between 2006 and 2011 in interventions performed in inpatient hospital settings was matched by a similar increase in procedures done in outpatient hospital settings and office-based clinics. The rate of atherectomy in the latter settings accelerated after the 2008 Medicare payment modification (table 1).

The majority of interventions were performed by surgeons or cardiologists. Although surgeons initially did fewer cases than cardiologists (140.1 vs 154.9 per 100,000 beneficiaries in 2006), by 2011 the pattern had reversed (177.5 vs 166.9). Meanwhile, the proportion of interventional procedures performed by radiologists continued to decline from 81.0 in 2006 to 50.8 in 2011.

Mean payments for all inpatient interventions were higher than for interventions performed in outpatient settings or office-based clinics. Although payments for angioplasty and stenting increased steadily between 2006 and 2011, costs for outpatient atherectomies more than doubled between 2006 and 2008—the year Medicare reimbursement changed—with an additional 50% increase over the following 3 years.

Few office-based atherectomies were performed between 2006 and 2010. However, in 2011, the mean cost of these procedures ($13,478) paralleled that of inpatient atherectomy and surpassed the cost of outpatient procedures ($8,680) as well as office-based stenting ($6,379) and office-based angioplasty ($4,800). Mean costs for office-based atherectomy alone ($11,893) were lower than for atherectomy plus stenting ($16,445).

Policy Change Boosts Atherectomy

The aim of the 2008 changes in Medicare reimbursement was “to provide incentives for outpatient procedures, encourage greater efficiency, and ultimately, lower the overall costs of [peripheral vascular intervention] to the Medicare program,” the authors say. At least in the first goal—shifting procedures to the outpatient setting—it succeeded.

But “a striking finding,” they note, is the fivefold increase in interventions at office-based clinics, especially in light of the growing ownership of such clinics by physicians rather than hospital or healthcare systems. “A major reason for physicians to perform procedures in office-based clinics is to capture the entire bundled fee, rather than just the professional fees for inpatient (and outpatient) facility services,” Dr. Jones and colleagues assert.

Throughout the study period, expenditures for angioplasty with or without stenting were significantly higher in inpatient settings than in outpatient settings and office-based clinics, the investigators observe. After the changes in reimbursement, payments for outpatient and office-based atherectomies were the highest and mirrored those for inpatient atherectomies.

Between 2003 and 2011, performance of atherectomy rose sharply despite a lack of randomized data to support its use, the authors continue. Indeed, more than half of all office-based clinic procedures in 2011 were atherectomies, and payments for such procedures were higher than for angioplasty.

“In sum, reimbursement rates likely contributed to the more frequent use of atherectomy during the study period, and this increased use likely neutralized some of the cost savings to Medicare after changes to the [Outpatient Prospective Payment System],” Dr. Jones and colleagues conclude.

Financial Incentive Often Fills ‘Data Vacuum’

In an accompanying editorial, Paul Heidenreich, MD, of the VA Palo Alto Health Care System (Palo Alto, CA), writes that due to the high prevalence of PAD and the high use and cost of intervention, the condition has been a focus of Medicare policy makers.

However, clinical practice guidelines are silent on which form of peripheral intervention to use, he notes, and financial incentive has a tendency to “fill any outcome data vacuum.” While noting that facility fees for atherectomy are “significantly greater” than for angioplasty, Dr. Heidenreich suggests that the desire to be at the forefront of one’s specialty may be an alternative explanation for the procedure’s growth.

Regardless of the motive, in the absence of outcomes data, Medicare should require participation in a registry, he recommends.

CMS Proceeded Without Considering ‘Value’

“When a payer—here the largest one in  the country—puts financial incentives in place, it’s not surprising that hospitals and physicians adapt,” said Christopher J. White, MD, of the Ochsner Heart and Vascular Institute (New Orleans, LA), in a telephone interview with TCTMD.

Moreover, higher reimbursement for atherectomy compared with balloon angioplasty or stenting is appropriate because the newer procedure requires more time and skill and the devices are expensive, he noted.

It is important to remember that during the study period, balloon angioplasty and stenting, though procedurally successful, did not show durable results, Dr. White said. “Operators didn’t have any real comparative data, but they were trying to push the envelope to get better outcomes by doing atherectomy,” he said, adding, “I don’t believe they were motivated by [the small extra income].

“Today atherectomy use is not anywhere close to what it was then,” he continued, noting that the recent Society for Cardiac Angiography and Interventions expert consensus statement underlines the lack of evidence.

In 2008, “CMS was premature—it didn’t have enough information about [the state of peripheral intervention] to make an intelligent rule about how to save money,” Dr. White said. The current study provides “a historical lesson that unless you can assess value—a therapy’s benefit to patients compared with its cost, with complications factored in—changing payment models doesn’t make a lot of sense,” he concluded.

Dr. White added that the American College of Cardiology’s National Cardiovascular Data Registry already has a division dedicated to peripheral intervention to help do just that.





1. Jones WS, Mi X, Qualls LG, et al. Trends in settings for peripheral vascular intervention and the effect of changes in the outpatient prospective payment system. J Am Coll Cardiol. 2015;65:920-927.


2. Heidenreich P. Incentives for clinical decisions where evidence is lacking [editorial]. J Am Coll Cardiol. 2015;65:928-930.




  • The project was funded by an American Heart Association Clinical and Mentored Population Science Research grant.
  • Dr. Jones reports receiving research grants from the American Heart Association, AstraZeneca, Boston Scientific, Bristol-Myers Squibb, and Daiichi Sankyo.
  • Drs. Heidenreich and White report no relevant conflicts of interest.