Geographic Variation in Cardiovascular Procedure Use Among Medicare Fee-for-Service vs Medicare Advantage Beneficiaries
Geographic Variation in Cardiovascular Procedure Use Among Medicare Fee-for-Service vs Medicare Advantage Beneficiaries
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DOI：
10.1001/jama.2013.7837
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发表时间：
2013-07-10
影响因子：
120.7
通讯作者：
Magid, David J.
中科院分区：
文献类型：
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作者：
Matlock, Daniel D.;Groeneveld, Peter W.;Magid, David J.
重要性人们对Medicare Advantage和Medicare按服务收费（FFS）报销结构之间不同的财务激励措施如何影响心血管手术的使用知之甚少。目的比较Medicare Advantage和Medicare FFS受益人之间的地区心血管手术率。设计、设置、和参与者2003-2007年65岁以上的医疗保险受益人的横断面研究，比较了冠状动脉造影，经皮冠状动脉介入治疗（PCI），和冠状动脉旁路移植术（CABG）手术在32家医院转诊地区在12个states.Main Outcomes AND Measures率冠状动脉造影，PCI，和CABG surgery.Results我们评估了878 339名Medicare Advantage患者和5 013 650名Medicare FFS患者。与Medicare FFS患者相比，Medicare Advantage患者的年龄、性别、种族和收入调整后的每1000人年血管造影手术率较低（16.5 [95% CI，14.8-18.2] vs 25.9 [95% CI，24.0-27.9]; P < .001）和PCI（6.8 [95% CI，6.0-7.6] vs 9.8 [95% CI，9.0-10.6]; P < .001），但CABG手术的发生率相似（3.1 [95% CI，2.8-3.5] vs 3.4 [95% CI，3.1-3.7]; P = .33）。在每1000人年的紧急血管造影率方面，Medicare Advantage和Medicare FFS患者之间没有显著差异（3.9 [95% CI，3.6-4.2] vs 4.3 [95% CI，4.0-4.6]; P = .24）或PCI（2.4 [95% CI，2.2-2.7] vs 2.7 [95% CI，2.5-2.9]; P = .16）。在Medicare Advantage和Medicare FFS患者中，各医院转诊地区的手术率差异很大。对于血管造影术，Medicare Advantage受益人的比率范围为每1000人-年9.8至40.6，Medicare FFS受益人的比率范围为每1000人-年15.7至44.3。对于PCI，Medicare Advantage的比率范围为3.5至16.8，Medicare FFS为4.7至16.1。CABG手术的发生率范围为1.5 - 6.1，Medicare Advantage为2.5 - 6.0。在不同地区，我们发现医疗保险优势和医疗保险FFS受益人利用血管造影术（斯皮尔曼r = 0.19，P = 0.29）之间没有统计学显著相关性，PCI（斯皮尔曼r = 0.33，P = 0.06）和CABG手术（斯皮尔曼r = 0.35，P = 0.05）之间存在适度相关性。在医疗保险优势受益人中，调整额外的心脏风险因素对手术率的影响很小。结论和相关性虽然参加资本医疗保险优势计划的医疗保险受益人的血管造影和PCI手术率低于参加医疗保险FFS的人，在医疗保险优势受益人中，手术率的地理差异程度很大，与在医疗保险受益人中观察到的差异程度相似FFS受益人。
IMPORTANCE Little is known about how different financial incentives between Medicare Advantage and Medicare fee-for-service (FFS) reimbursement structures influence use of cardiovascular procedures.OBJECTIVE To compare regional cardiovascular procedure rates between Medicare Advantage and Medicare FFS beneficiaries.DESIGN, SETTING, AND PARTICIPANTS Cross-sectional study of Medicare beneficiaries older than 65 years between 2003-2007 comparing rates of coronary angiography, percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG) surgery across 32 hospital referral regions in 12 states.MAIN OUTCOMES AND MEASURES Rates of coronary angiography, PCI, and CABG surgery.RESULTS We evaluated a total of 878 339 Medicare Advantage patients and 5 013 650 Medicare FFS patients. Compared with Medicare FFS patients, Medicare Advantage patients had lower age-, sex-, race-, and income-adjusted procedure rates per 1000 person-years for angiography (16.5 [95% CI, 14.8-18.2] vs 25.9 [95% CI, 24.0-27.9]; P < .001) and PCI (6.8 [95% CI, 6.0-7.6] vs 9.8 [95% CI, 9.0-10.6]; P < .001) but similar rates for CABG surgery (3.1 [95% CI, 2.8-3.5] vs 3.4 [95% CI, 3.1-3.7]; P = .33). There were no significant differences between Medicare Advantage and Medicare FFS patients in the rates per 1000 person-years of urgent angiography (3.9 [95% CI, 3.6-4.2] vs 4.3 [95% CI, 4.0-4.6]; P = .24) or PCI (2.4 [95% CI, 2.2-2.7] vs 2.7 [95% CI, 2.5-2.9]; P = .16). Procedure rates varied widely across hospital referral regions among Medicare Advantage and Medicare FFS patients. For angiography, the rates per 1000 person-years ranged from 9.8 to 40.6 for Medicare Advantage beneficiaries and from 15.7 to 44.3 for Medicare FFS beneficiaries. For PCI, the rates ranged from 3.5 to 16.8 for Medicare Advantage and from 4.7 to 16.1 for Medicare FFS. The rates for CABG surgery ranged from 1.5 to 6.1 for Medicare Advantage and from 2.5 to 6.0 for Medicare FFS. Across regions, we found no statistically significant correlation between Medicare Advantage and Medicare FFS beneficiary utilization for angiography (Spearman r = 0.19, P = .29) and modest correlations for PCI (Spearman r = 0.33, P = .06) and CABG surgery (Spearman r = 0.35, P = .05). Among Medicare Advantage beneficiaries, adjustment for additional cardiac risk factors had little influence on procedure rates.CONCLUSIONS AND RELEVANCE Although Medicare beneficiaries enrolled in capitated Medicare Advantage programs had lower angiography and PCI procedure rates than those enrolled in Medicare FFS, the degree of geographic variation in procedure rates was substantial among Medicare Advantage beneficiaries and was similar in magnitude to that observed among Medicare FFS beneficiaries.