New research published in JAMA Internal Medicine explores whether testing location impacted payment rates for outpatient noninvasive cardiovascular tests.

In 2005, the Centers for Medicare and Medicaid Services decreased Medicare fee-for-service (FFS) payments for noninvasive cardiac tests performed in provider-based office settings. At the same time, payments for hospital-based outpatient testing increased. In an effort to determine a correlation between differential payments by site and test location, Frederick A. Masoudi, MD, MSPH, FACC, et al., analyzed Medicare claims from 1999 to 2015 and compared the payment ratio by site and location.

The findings: "In settings in which reimbursement depends on test location, higher hospital-based vs. practice-based payments were associated with greater proportions of outpatient noninvasive cardiac tests performed in hospital-based locations," the authors said.

Specifically, office testing increased from 1.05 in 2005 to 2.32 in 2015. The Fee for Service (FFS) hospital-based outpatient testing proportion increased from 21.1 percent in 2008 to 43.2 percent in 2015 and was correlated with the payment ratio compared with the hospital-based outpatient testing proportion for the managed care control group, which declined from 16.6 percent in 2008 to 15.2 percent in 2015. Masoudi and colleague noted that the estimated extra costs associated with tests shifting to the hospital-based outpatient setting among Medicare FFS patients was $661 million in 2015, including $161 million in patient out-of-pocket costs.

Based on the finding, the authors suggest that site-neutral payments may offer an incentive for testing to be performed in the more efficient location – a topic of much debated discussion in the cardiovascular space.

To more effectively engage in this debate, the ACC, under the guidance of the Health Affairs Committee recently updated its site neutral payment principles in order to proactively engage in policy discussions on the best path forward. The principles urge discussion around approaches to remove unnecessary and/or unexpected cost to patients and the health care system, including equity across outpatient ambulatory settings. These new principles also highlight that any changes to Medicare payment should prioritize patient access, quality and value of care. Additionally, the College recommends that significant changes to address payment disparities between sites of service be phased in over time to safeguard the stability of the health care system, particularly for settings providing care for potentially underserved populations.

Also of note, the principles call on site-of-service payment policies to be aligned with programmatic and systemic changes to avoid unnecessary complexity and promote the successful transition to a value-based payment system. Lastly, the College suggests any payment differences across sites be related to documented differences in the resources needed to ensure patient access and high-quality care. Medicare payments for all sites of care should account for costs related to emergency capacity, compliance with regulatory requirements, geographic differences, quality improvement activities, higher need populations, or other factors relevant to a site of service, the ACC says.

Clinical Topics: Cardiovascular Care Team

Keywords: ACC Advocacy, Health Expenditures, Quality Improvement, Centers for Medicare and Medicaid Services, U.S., Medicare, Medicaid, Managed Care Programs, Quality of Health Care

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