Division of General Internal Medicine, University of Colorado Denver School of Medicine, Aurora, CO 80045, USA.
JAMA. 2013 Jul 10;310(2):155-62. doi: 10.1001/jama.2013.7837.
Little is known about how different financial incentives between Medicare Advantage and Medicare fee-for-service (FFS) reimbursement structures influence use of cardiovascular procedures.
To compare regional cardiovascular procedure rates between Medicare Advantage and Medicare FFS beneficiaries.
DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional study of Medicare beneficiaries older than 65 years between 2003-2007 comparing rates of coronary angiography, percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG) surgery across 32 hospital referral regions in 12 states.
Rates of coronary angiography, PCI, and CABG surgery.
We evaluated a total of 878,339 Medicare Advantage patients and 5,013,650 Medicare FFS patients. Compared with Medicare FFS patients, Medicare Advantage patients had lower age-, sex-, race-, and income-adjusted procedure rates per 1000 person-years for angiography (16.5 [95% CI, 14.8-18.2] vs 25.9 [95% CI, 24.0-27.9]; P < .001) and PCI (6.8 [95% CI, 6.0-7.6] vs 9.8 [95% CI, 9.0-10.6]; P < .001) but similar rates for CABG surgery (3.1 [95% CI, 2.8-3.5] vs 3.4 [95% CI, 3.1-3.7]; P = .33). There were no significant differences between Medicare Advantage and Medicare FFS patients in the rates per 1000 person-years of urgent angiography (3.9 [95% CI, 3.6-4.2] vs 4.3 [95% CI, 4.0-4.6]; P = .24) or PCI (2.4 [95% CI, 2.2-2.7] vs 2.7 [95% CI, 2.5-2.9]; P = .16). Procedure rates varied widely across hospital referral regions among Medicare Advantage and Medicare FFS patients. For angiography, the rates per 1000 person-years ranged from 9.8 to 40.6 for Medicare Advantage beneficiaries and from 15.7 to 44.3 for Medicare FFS beneficiaries. For PCI, the rates ranged from 3.5 to 16.8 for Medicare Advantage and from 4.7 to 16.1 for Medicare FFS. The rates for CABG surgery ranged from 1.5 to 6.1 for Medicare Advantage and from 2.5 to 6.0 for Medicare FFS. Across regions, we found no statistically significant correlation between Medicare Advantage and Medicare FFS beneficiary utilization for angiography (Spearman r = 0.19, P = .29) and modest correlations for PCI (Spearman r = 0.33, P = .06) and CABG surgery (Spearman r = 0.35, P = .05). Among Medicare Advantage beneficiaries, adjustment for additional cardiac risk factors had little influence on procedure rates.
Although Medicare beneficiaries enrolled in capitated Medicare Advantage programs had lower angiography and PCI procedure rates than those enrolled in Medicare FFS, the degree of geographic variation in procedure rates was substantial among Medicare Advantage beneficiaries and was similar in magnitude to that observed among Medicare FFS beneficiaries.
关于医疗保险优势计划和医疗保险按服务收费（FFS）报销结构之间的不同财务激励如何影响心血管程序的使用，知之甚少。
比较医疗保险优势计划和医疗保险 FFS 受益人的区域心血管程序率。
设计、地点和参与者：对 2003-2007 年间年龄在 65 岁以上的 Medicare 受益人的横断面研究，比较了 12 个州的 32 个医院转诊区的冠状动脉造影、经皮冠状动脉介入治疗（PCI）和冠状动脉旁路移植术（CABG）手术的比率。
冠状动脉造影、PCI 和 CABG 手术的比率。
我们共评估了 878339 名 Medicare 优势计划患者和 5013650 名 Medicare FFS 患者。与 Medicare FFS 患者相比，医疗保险优势计划患者每 1000 人年的经年龄、性别、种族和收入调整后的程序比率更低，包括血管造影（16.5 [95% CI，14.8-18.2] 与 25.9 [95% CI，24.0-27.9]；P <.001）和 PCI（6.8 [95% CI，6.0-7.6] 与 9.8 [95% CI，9.0-10.6]；P <.001），但 CABG 手术的比率相似（3.1 [95% CI，2.8-3.5] 与 3.4 [95% CI，3.1-3.7]；P =.33）。在紧急血管造影（3.9 [95% CI，3.6-4.2] 与 4.3 [95% CI，4.0-4.6]；P =.24）或 PCI（2.4 [95% CI，2.2-2.7] 与 2.7 [95% CI，2.5-2.9]；P =.16）的每 1000 人年比率方面，医疗保险优势计划和 Medicare FFS 患者之间没有显著差异。
程序率在医疗保险优势计划和 Medicare FFS 患者之间的医院转诊区之间差异很大。对于血管造影，医疗保险优势计划受益人的每 1000 人年比率范围为 9.8 至 40.6，而 Medicare FFS 受益人的比率范围为 15.7 至 44.3。对于 PCI，医疗保险优势计划的比率范围为 3.5 至 16.8，而 Medicare FFS 的比率范围为 4.7 至 16.1。CABG 手术的比率范围为 1.5 至 6.1，而 Medicare FFS 的比率范围为 2.5 至 6.0。在各个地区，我们没有发现医疗保险优势计划和 Medicare FFS 受益人的血管造影利用率之间存在统计学显著相关性（Spearman r = 0.19，P =.29），而 PCI（Spearman r = 0.33，P =.06）和 CABG 手术（Spearman r = 0.35，P =.05）的相关性适中。在医疗保险优势计划的受益人群中，对其他心脏风险因素的调整对程序率的影响很小。
尽管参加有资金上限的医疗保险优势计划的 Medicare 受益人的血管造影和 PCI 程序率低于参加医疗保险 FFS 的受益人群，但医疗保险优势计划受益人的程序率在地理上存在很大差异，其程度与医疗保险 FFS 受益人群的程序率相似。
