Initial financial impact of office-based laboratories on Medicare payments for percutaneous interventions for peripheral artery disease

Abstract

ObjectivePercutaneous interventions for peripheral artery disease (PAD) are transitioning away from hospital-based settings to office-based laboratories (OBLs). Those in favor of OBL use reference lower hospitalization rates and high efficiency; however, critics claim financial incentives may lead to multiple procedures and higher atherectomy use. We sought to determine how Medicare payments are affected by OBL use. MethodsWe identified physicians performing percutaneous interventions for PAD from 2006 to 2013 in a 20% Medicare sample. Physicians performing a majority of interventions at OBLs were classified as high OBL users; control physicians performed interventions at hospital-based settings. The primary outcomes were total Medicare payments at 30 days and 1 year. Generalized log-gamma regression models were used to evaluate factors influencing payments reported as a percentage change and 95% confidence interval (95% CI). A secondary analysis was performed of physicians who transitioned from hospital-based settings to OBLs, “switch physicians.” A multivariate model with difference-in-differences regression was used to evaluate the effects of transitioning to OBLs. ResultsA total of 89 high OBL users performed percutaneous interventions on 887 patients, and 3715 control physicians treated 54,213 patients during the time period. Payments for patients treated by high OBL users were significantly higher compared with control physicians at 30 days ($4465), 90 days ($8925), and 1 year ($27,436). Major factors increasing payments at 1 year were treatment by a high OBL user (49%; 95% CI, 42%-56%), hospital admissions (127%; 95% CI, 123%-131%), repeated lower extremity procedures (41%; 95% CI, 39%-43%), and lower extremity wound (20%; 95% CI,18%-22%). Factors decreasing payments at 1 year were living in a rural setting (8%; 95% CI, 7%-9%) and dementia (5%; 95% CI, 3%-7%). Analysis of 292 switch physicians identified 3888 patients treated before OBLs (pre-switch) and 3246 after OBLs (post-switch). Transitioning to OBLs was associated with higher payments at 30 days and 90 days, and this increase was higher compared with control physicians. ConclusionsThese findings highlight that OBL use for PAD interventions significantly influences Medicare payments, and its widespread adaptation should be made with caution. The main factors driving payments were hospitalization admissions, repeated lower extremity procedures, and wound status. Further work is needed to evaluate the appropriate use of OBLs to optimize patient outcomes and resource allocations.