Trends in Cardiac Testing in Medicare

Testing has been identified as an area in which numerous unnecessary and inappropriate services are delivered.  Savings would obviously occur if testing could be constrained within more precise guidelines for use.  Medicare has attempted to create new reimbursement policies designed to limit low-value testing and encourage higher-value tests.  Research in the Journal of the American Medical Association Network Open examines the impact of these policy changes on cardiovascular testing.   (JAMA Article)   Some cardiovascular tests, like stress tests and echocardiography, had been widely used and are expensive.  CMS reduced payments for these tests and heightened scrutiny, which did reduce use, but it is unclear whether both low-value and high-value test rates declined or more one or the other.  Reducing appropriate tests would not be good for overall quality.  The researchers looked at what they deemed to be high-value cardiovascular testing and low-value testing for the period from 1999 to 2016.  The high-value testing was generally for patients actually hospitalized with heart attacks or heart failure.  Much of the low-value testing related to low-risk non-cardiac surgeries and to percutaneous interventions or coronary artery bypass surgery.

The overall rate of diagnostic testing first increased from 200 per 1000 person years in 2000 to 359 in 2008 and then declined to 316 in 2016.  The proportion of patients who received high-value testing increased from 85.7% in 2000 to 89.5% in 2016.  Heart attack patients were somewhat more likely than heart failure ones to receive high-value testing.  The proportion of patients undergoing low-risk surgeries who received low-value testing increased from 2.4% in 2000 to 3.8% in 2008 but then declined to 2.5% in 2016.  Low value testing in connection with PCI or CABG increased slightly from 47.4% in 2000 to 49.2% in 2003 and then declined to 30.8% in 2014.  So this study suggests that general reductions in reimbursement did not appear to impact high-value testing to a significant extent.  This may be due to specialty societies during the study period creating and widely disseminating practice guidelines regarding cardiovascular testing.  I would also note that in regard to the discussion about “waste” in the US health system, this study supports the idea that there is both underuse and overuse, which may largely offset each other.  Also note the large administrative costs that would be involved if you took the most accurate approach–evaluate each proposed use of testing for appropriateness.  Do you think that would actually reduce total spending?