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

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.