In 2010 the Centers for Medicare and Medicaid Services significantly reduced fees for cardiology services, focusing on those delivered in the office setting such as myocardial perfusion imaging (MPI) and echocardiograms and electrocardiograms. At the time of the cuts, the ACC predicted a surge in the number of private practices integrating with hospitals. Now, new research published in JAMA: Internal Medicine shows these cuts did result in increased hospital integration.

Data from 806,266 Medicare beneficiaries from all 50 state, as well as 12,567,069 commercially insured individuals, indicate prices across all services after 2010 favored the hospital outpatient department (HOPD) setting. The shares of volume in the HOPD setting also increased after 2010, according to the researchers. Specifically, growth in the HOPD share was 5.9, 3.9, and 2.7 percentage points per year (P < .001) faster after 2010 compared with before 2010 for MPI, echocardiograms, and electrocardiograms, respectively.

Researchers also highlighted a continued increase in the overall volume of echocardiograms and electrocardiograms per beneficiary after the fee cut, while the volume of MPI decreased slightly. Aggregate analyses of all cardiovascular imaging and cardiovascular medicine services produced qualitatively similar results. Results were also similar in the commercial patient population, "suggesting that integration was associated with comparable effects across payers," they said.

With growing discussions around policies aimed at equalizing payments across settings as a means of reducing variations in care, the researchers suggest that "narrowing the payment gap may lead to less physician-hospital integration, which might in turn limit price increases from market power."

In a related commentary, Ralph Brindis, MD, MACC, and Eugene Sherman, MD, FACC, note that these finding demonstrate the "unintended consequences" associated with the in-office payment reduction policies, namely a "shifting [of] the performance of these procedures to the hospital environment, with the associated hospital outpatient department payment formula, at a substantial increase in cost to the CMS." They write that "addressing the problem of overuse of unnecessary tests and procedures by implementing payment models that encourage appropriate testing while discouraging inappropriate testing is a more rational approach for controlling Medicare costs than across-the-board decreases in reimbursement. Physicians will need to assume leadership in new delivery systems and health care policy to encourage all specialties to practice cost-effective medicine."

Keywords: Centers for Medicare and Medicaid Services, U.S., Electrocardiography, Fees and Charges, Health Policy, Medicaid, Medicare, Myocardial Perfusion Imaging

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