CMS policies to reduce low-value cardio testing are working, researchers find

Overall rates of low-value diagnostic cardiovascular testing—including imaging—have dropped over the past 10 years, validating payment reform policies enacted by CMS to curb fee-for-service testing.

The findings, published Oct. 11 in JAMA Network Open, also revealed that payment changes did not adversely affect high-value, guideline-recommended testing, said first author Vinay Kini, MD, MSHP, and colleagues.

“Our findings suggest that during a period of Medicare reimbursement changes intended to reduce spending on overall testing, rates of low-value testing declined considerably while guideline-concordant testing among patients with (acute myocardial infarction) AMI and (heart failure) HF was not adversely affected,” added Kini, with the University of Colorado Anschutz Medical Campus in Aurora, and colleagues.

From the 1990s and up until the early 2000s, diagnostic cardio testing like echocardiography and stress-test utilization rose “substantially” among Medicare fee-for-service beneficiaries, the researchers explained. In the wake of overutilization concerns in 2004, CMS reduced physician fees for inpatient and outpatient testing along with the facility fees for office-based testing.

There have been few studies, however, evaluating the policy change's impact on guideline-recommended, high-value testing nor on potential changes in low-value testing.

Kini and colleagues retrospectively analyzed a national 5% random sample of Medicare fee-for-service beneficiaries ages 65 to 95 years from January 1999 through December 2016. The most common tests analyzed were echocardiography and nuclear SPECT. Among the others reviewed were: stress ECG, left heart catheterization with left ventriculography, nuclear PET, coronary CT with angiography and cardiac MRI.

Diagnostic testing rates jumped from 275 per 1,000 patient-years in 2000 to 359 per 1,000 patient-years in 2008. That rate dropped to 316 per 1,000 patient-years in 2016. 

Low-value testing before low-risk surgery increased from 2000 to 2008 (2.4% to 3.8%), but dropped back down by 2016 (2.5%). And low-value testing within two years of coronary revascularization jumped slightly between 2000 and 2003 (47.4% to 49.2%), but fell to 30.8% in 2014.

High-value testing, meanwhile, increased incrementally for acute MI cases (85.7% in 2000 to 89.5% in 2016) and HF (72.6% to 80.1%).

“Rates of overall and low-value diagnostic cardiovascular testing appear to have declined considerably, and rates of high-value testing appear to have increased slightly. Payment changes intended to reduce spending on overall testing may not have adversely affected testing recommended by guidelines,” the team wrote.

The researchers explained that other changes during the study period, such as public hospital outcomes reporting, “vertical integration” of cardiology practices into health systems, value-based incentives or other clinical tweaks could have also impacted the changes in testing rates. However, the results eliminate the concerns that CMS-enacted payment changes might have led to an unintended reduction in high-value, guideline-recommended cardio testing.