Research published in the Journal of the American Medical Association finds itself at the intersection of two controversies–geographic variation in utilization and spending and the relative value of Medicare Advantage plans versus traditional Medicare. (JAMA Article) The researchers looked at common cardiovascular procedures to ascertain the relative rates of use both in various locales and between the fee-for-service and Medicare Advantage programs. Angiography, bypass surgery and stenting were the procedures and hospital referral regions were the geographic unit. In general, Medicare Advantage beneficiaries had substantially lower rates per thousand person-years for angiography–16.5 vs. 25.9 for fee-for-service; PCI–6.8 vs.9.8; but more similar rates for bypass surgery–3.1 vs. 3.5. Interestingly urgent angiography and stenting rates were very similar; indicating that the reductions in use for MA patients was due to more cautious elective use of the procedures. However, Medicare Advantage showed equally great geographic variation in the rates of use of the procedures as did fee-for-service. The range of variation is three to four-fold for each procedure, which is simply astounding. The reasons for the variation are unclear, but other research is zeroing in on both population health differences and regional practice pattern preferences by providers. To the extent that population health characteristics are the driver, the variation is acceptable; to the extent that it merely reflects provider practice preferences, there is a clear opportunity to encourage the providers with high procedure rates to reexamine the appropriateness of their utilization.
