Differences in High- and Low-Value Cardiovascular Testing by Health Insurance Provider

Abstract

Background Quality of care incentives and reimbursements for cardiovascular testing differ between insurance providers. We hypothesized that there are differences in the use of guideline-concordant testing between Medicaid versus commercial insurance patients <65 years, and between Medicare Advantage versus Medicare fee-for-service patients ≥65 years. Methods and Results Using data from the Colorado All-Payer Claims Database from 2015 to 2018, we identified patients eligible to receive a high-value test recommended by guidelines: assessment of left ventricular function among patients hospitalized with acute myocardial infarction or incident heart failure, or a low-value test that provides minimal patient benefit: stress testing prior to low-risk surgery or routine stress testing within 2 years of percutaneous coronary intervention or coronary artery bypass graft surgery. Among 145 616 eligible patients, 37% had fee-for-service Medicare, 18% Medicare Advantage, 22% Medicaid, and 23% commercial insurance. Using multilevel logistic regression models adjusted for patient characteristics, Medicaid patients were less likely to receive high-value testing for acute myocardial infarction (odds ratio [OR], 0.84 [0.73-0.98]; P=0.03) and heart failure (OR, 0.59 [0.51-0.70]; P<0.01) compared with commercially insured patients. Medicare Advantage patients were more likely to receive high-value testing for acute myocardial infarction (OR, 1.35 [1.15-1.59]; P<0.01) and less likely to receive low-value testing after percutaneous coronary intervention/ coronary artery bypass graft (OR, 0.63 [0.55-0.72]; P<0.01) compared with Medicare fee-for-service patients. Conclusions Guideline-concordant testing was less likely to occur among patients with Medicaid compared with commercial insurance, and more likely to occur among patients with Medicare Advantage compared with fee-for-service Medicare. Insurance plan features may provide valuable targets to improve guideline-concordant testing.

Keywords: health policy; imaging; quality of care.

Figure 1. Flow diagrams for creation of high‐value testing cohorts.

Patients hospitalized with acute myocardial infarction (AMI) (A) and heart failure (HF) (B). CTA indicates computed tomography angiography; LVEF, left ventricular ejection fraction; MRI, magnetic resonance imaging; PET, positron emission tomography; and SPECT, single photon emission computed tomography).

Figure 2. Flow diagrams for creation of low‐value testing cohorts.

Patients undergoing low‐risk surgery (A) and coronary revascularization (B). CABG indicates coronary artery bypass graft surgery; CTA, computed tomography angiography; ECG, electrocardiography; PCI, percutaneous coronary intervention; PET, positron emission tomography; and SPECT, single photon emission computed tomography. *Tests related to acute care (emergency department visits or hospital admissions) were not considered low value. ^#Tests related to acute care (emergency department visits or hospital admissions) or that were followed by repeat coronary revascularization were not considered low value.

Figure 3. Rates of high‐value testing by health insurance provider.

The proportion of patients receiving high‐value testing to assess left ventricular ejection fraction after hospitalization for acute myocardial infarction (AMI) or incident heart failure (HF) by insurance provider. FFS indicates fee‐for‐service.

Figure 4. Rates of low‐value testing by health insurance provider.

The proportion of patients receiving low‐value stress testing prior to low‐risk surgery and after percutaneous coronary intervention (PCI)/coronary artery bypass graft surgery (CABG) by health insurance provider. FFS indicates fee‐for‐service.