Masoudi Frederick A, Viragh Timea, Magid David J, Moghtaderi Ali, Schilsky Samantha, Sage William M, Goodrich Glenn, Newton Katherine M, Smith David H, Black Bernard
Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora.
School of Education and Social Policy, Northwestern University, Evanston, Illinois.
JAMA Intern Med. 2019 Dec 1;179(12):1699-1706. doi: 10.1001/jamainternmed.2019.4269.
To control spending, the Centers for Medicare & Medicaid Services reduced Medicare fee-for-service (FFS) payments for noninvasive cardiac tests (NCTs) performed in provider-based office settings (ambulatory offices not administratively affiliated with hospitals) starting in 2005. Contemporaneously, payments for hospital-based outpatient testing increased. The association between differential payments by site and test location is unknown.
To quantify trends in differential Medicare FFS payments for NCTs performed in hospital-based and provider-based settings, determine the association between the hospital-based outpatient testing to provider-based office testing payment ratio and the proportion of hospital-based NCTs, and to examine trends in test location between Medicare FFS and 3 Medicare Advantage health maintenance organizations for which Centers for Medicare & Medicaid Services payments do not depend on testing location.
DESIGN, SETTING, AND PARTICIPANTS: This observational claims-based study used Medicare FFS claims from 1999 to 2015 (5% random sample) and Medicare Advantage claims from 3 large health maintenance organizations (2005-2015) among Medicare FFS beneficiaries aged 65 years or older and a health maintenance organization control group. Statistical analysis was performed from May 1, 2017, to July 15, 2019.
The weighted mean payment ratio of Medicare FFS hospital-based outpatient testing to provider-based office testing for outpatient NCTs.
Proportion of outpatient NCTs performed in the hospital-based setting and Medicare FFS costs.
The data included a mean of 1.72 million patient-years annually in Medicare FFS (mean age, 75.2 years; 57.3% female in 2015) and a mean of 142 230 patient-years annually in the managed care control group (mean age, 74.8 years; 56.2% female in 2015). The Medicare payment ratio of FFS hospital-based outpatient testing to provider-based office testing increased from 1.05 in 2005 to 2.32 in 2015. The FFS hospital-based outpatient testing proportion increased from 21.1% in 2008 to 43.2% in 2015 and was correlated with the payment ratio (correlation coefficient with a 1-year lag, 0.767; P < .001). In contrast, the hospital-based outpatient testing proportion for the control group declined from 16.6% in 2008 to 15.2% in 2015 (correlation coefficient, -0.024, P = .95). The estimated extra costs owing to tests shifting to the hospital-based outpatient setting in the Medicare FFS group was $661 million in 2015, including $161 million in patient out-of-pocket costs.
In settings in which reimbursement depends on test location, increasing hospital-based payments correlated with greater proportions of outpatient NCTs performed in the hospital-based outpatient setting. Site-neutral payments may offer an incentive for testing to be performed in the more efficient location.
为控制支出，医疗保险和医疗补助服务中心自2005年起降低了在基于医疗机构的办公室环境（与医院无行政隶属关系的门诊办公室）中进行的非侵入性心脏检查（NCTs）的医疗保险按服务收费（FFS）支付。与此同时，基于医院的门诊检查支付增加。不同地点和检查地点之间的支付差异关联尚不清楚。
量化在基于医院和基于医疗机构的环境中进行的NCTs的医疗保险FFS差异支付趋势，确定基于医院的门诊检查与基于医疗机构的办公室检查支付比率与基于医院的NCTs比例之间的关联，并研究医疗保险FFS和3个医疗保险优势健康维护组织（医疗保险和医疗补助服务中心的支付不依赖于检查地点）之间的检查地点趋势。
设计、设置和参与者：这项基于观察性索赔的研究使用了1999年至2015年（5%随机样本）的医疗保险FFS索赔以及3个大型健康维护组织（2005 - 2015年）中65岁及以上医疗保险FFS受益人的医疗保险优势索赔和一个健康维护组织对照组。统计分析于2017年5月1日至2019年7月15日进行。
医疗保险FFS基于医院的门诊检查与基于医疗机构的办公室检查的加权平均支付比率，用于门诊NCTs。
在基于医院的环境中进行的门诊NCTs比例和医疗保险FFS成本。
数据包括医疗保险FFS每年平均172万患者年（平均年龄75.2岁；2015年女性占57.3%）以及管理式医疗对照组每年平均1
