Low-value cardiac services take bite from Medicare

Between 25 percent and 42 percent of Medicare beneficiaries received a low-value service in 2009, with cardiovascular testing and procedures accounting for much of the spending. The results were published online May 12 in JAMA Internal Medicine.

The U.S. Preventive Services Task Force, the American Board of Internal Medicine Foundation’s Choosing Wisely program, the National Institute for Health and Care Excellence and the Canadian Agency for Drugs and Technology each have identified services that they consider to be of little to no clinical value. Senior author J. Michael McWilliams, MD, PhD, of the Department of Health Care Policy at Harvard Medical School in Boston, and colleagues culled their evidence-based lists plus peer-reviewed medical journal articles to find low-value service measures that could be detected through Medicare claims data with reasonable certainty of the accuracy of the classification.  

They selected 26 measures. Each measure had two versions, one with a higher sensitivity but lower specificity and another with higher specificity but lower sensitivity. The measures covered five different categories: cardiovascular testing and procedures; cancer screening; diagnostic and preventive testing; imaging; and other surgery. The specific cardiovascular measures were:

• Stress testing for stable coronary disease
• PCI with balloon angioplasty or stent placement for stable coronary disease
• Renal artery angioplasty or stenting
• Carotid endarterectomy in asymptomatic patients
• Inferior vena cava filters to prevent pulmonary embolism

Using a 5 percent random sample of Medicare claims data from 2008-2009 and files from the Chronic Conditions Data Warehouse, they applied the measures to more than 1.6 million beneficiaries.

With the more sensitive measures, McWilliams et al found that 42 percent of the Medicare beneficiaries had at least one low-value service, for 21.9 million instances. Spending on low-value services totaled $8.5 billion for the entire Medicare population, or $310 per beneficiary, for 2.7 percent of total annual spending in 2009.

The more specific measures showed 25 percent of beneficiaries getting at least one service, for 9.1 million instances. Spending was $1.9 million, or $71 per beneficiary, for 0.6 percent of total annual spending.

In the more sensitive measures, cardiovascular testing and procedures accounted for about 10 percent of utilization and almost 2 percent of overall Medicare spending. Stress testing and PCI/stenting accounted for more than half of the total spending among low-value services, at $2.07 billion and $2.81 billion, respectively.

Under the more specific measures, cardiovascular testing and procedures had the smallest count per beneficiary yet it still accounted for the most spending. Stress testing fell to 0.8 counts per 100 beneficiaries for $212 million. PCI/stenting dropped to 0.1 counts per 100 beneficiaries and $212 million. In this analysis, only carotid artery disease screening for asymptomatic patients—placed in the imaging category—was higher, at 5.6 counts per 100 beneficiaries and $274 million.

Their findings give grist to the argument that the U.S. healthcare system is burdened by excessive waste, but they urged caution. “Despite their imperfections, claims-based measures of low-value care could be useful for tracking overuse and evaluating programs to reduce it. However, many direct claims-based measures of overuse may be insufficiently accurate to support targeted coverage or payment policies that have a meaningful effect on use without resulting in unintended consequences.”