Invited Commentary

Do Geographic Variations Signify Overuse? Christine G. Gourin, MD, MPH1

No sponsorships or competing interests have been disclosed for this article.

Keywords Medicare, variation, geographic, regional, reimbursement, incentives, practice patterns, utilization Received March 18, 2015; accepted March 24, 2015.

n this issue, Cracchiolo et al1 present Medicare Part B physician reimbursement data that show significant variation in practice patterns among otolaryngologists within a single geographic area in Medicare fee-for-service recipients. Using a single metropolitan statistical area, they found that physicians employed at 1 of 3 academic hospitals had a significant 2-fold increase in Medicare payment and work relative value units (RVUs) compared with physicians working at the other 2 academic hospitals or in private practices. This difference persisted after controlling for Medicare patient volume, gender, subspecialty, or institutional complexity of care and appeared to be associated with differences in the type of services provided rather than differences in reimbursement rates. Specifically, physicians affiliated with the academic hospital with significantly higher payments were associated with a greater utilization of procedures over evaluation and management services. The unspoken question raised by these data is, are these geographic variations a marker for overuse of services? The Dartmouth Atlas Research Project has reported large geographic variations in Medicare spending that are independent of beneficiaries’ health or socioeconomic status. Among hospitalized patients, they found that regional differences in Medicare spending were largely explained by a more specialist-oriented pattern of practice observed in high-spending regions.2 Neither quality of care nor access to care appeared to be better for Medicare enrollees in higher-spending regions. While Medicare enrollees in higher-spending regions received more care than those in lower-spending regions, they did not have better health outcomes or higher satisfaction with care.3 Patients moving from lower-care-intensity regions to higher-care-intensity regions underwent more diagnostic tests and services and received more diagnoses, with no apparent survival benefit.4 The issue of regional variation in practice patterns received popular attention when Gawande5 published ‘‘The Cost Conundrum’’ in the New Yorker, comparing geographic

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Otolaryngology– Head and Neck Surgery 2015, Vol. 152(6) 991–992 Ó American Academy of Otolaryngology—Head and Neck Surgery Foundation 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599815583477 http://otojournal.org

variations in Medicare spending in McAllen with neighboring El Paso, Texas, notable for a 2-fold difference in per capita Medicare spending. He suggested this difference was due to overuse of services in McAllen, driven by financial incentives in the fee-for-service model resulting in more care and more specialist visits. The differences in spending in McAllen compared with El Paso and the remainder of the United States appear to hold true only for the Medicare population, leading researchers to conclude that providers respond differently to incentives in Medicare compared with those in private insurance programs with better reimbursement.6 Geographic variations in oncologist practice patterns have been shown to follow decreases in Medicare reimbursement.7 The implication of these data is that reimbursement drives variations in care. Thus Cracchiolo’s data raise interesting questions, but it is important to remember that specific instances of overuse are challenging to measure directly, particularly with claims data. While Cracchiolo et al1 found no difference between hospitals and private practices in the distribution of subspecialists, they did find that rhinologists and physicians associated with one academic medical center had significantly higher payments and work RVUs per physician, primarily related to the increased use of office endoscopies. Unmeasured differences in clinical characteristics between patients seen by different providers could contribute to differences in utilization. There may be differences in the composition of patients seen by these outliers that are condition specific. Differences in the primary complaint, associated symptomatology, and referral patterns may underlie differences in procedural use that are not reflected in claims. Risk adjustment was performed using the Medicare Case Mix Index and Hospital Care Intensity Index, which are markers of inpatient disease severity and care by institution. These may not provide accurate risk adjustment for patients reflected in Medicare Part B claims, particularly for care provided in the outpatient setting, where care and patients may differ significantly from the inpatient setting. In addition,

1 Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, USA

Corresponding Author: Christine G. Gourin, MD, MPH, Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins Outpatient Center, 601 N Caroline Street, Suite 6260, Baltimore, MD 21287, USA. Email: [email protected]

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the observed differences in care may be driven by how other services are used: for example, there may be more diagnostic testing by providers who perform fewer diagnostic procedures. Identification of overuse requires a standard to clearly measure it. Both nasal endoscopy and fiber-optic laryngoscopy for sinusitis have been identified by the Blue Cross Blue Shield of Massachusetts Alternative Quality Contract (AQC) as procedures with unexplained practice variations.8 The AQC is an Accountable Care Organization (ACO) model that ‘‘combines a per-patient global budget with significant performance incentives based on quality measures.’’8(p1) Segal et al9 reported significant overuse of both procedures in Medicare recipients, which varied markedly among hospital referral regions. However, they did not review the process by which these procedures were designated as overused, such as the presence or absence of symptomatology not measurable in claims data. The American Academy of Otolaryngology—Head and Neck Surgery Foundation (AAO-HNS/F) has published clinical indicators for nasal endoscopy10 that require 1 or more symptoms of sinonasal disease including obstruction and abnormal or limited anterior rhinoscopy. The AAO-HNS/F clinical indicators for fiber-optic laryngoscopy10 include symptoms that may be associated with sinusitis such as nasal obstruction, congestion, and chronic rhinorrhea. The AAO-HNS/F has identified routine imaging for acute sinusitis and frequent imaging for chronic sinusitis as low value in the ‘‘Choosing Wisely’’ campaign,11 but imaging for sinusitis was not targeted by the AQC. This is one example of a discrepancy between cliniciandeveloped clinical practice guidelines and measures adopted by an ACO that can lead to very different incentives and conclusions. Cracchiolo et al1 are to be commended for bringing attention to an important issue. What we cannot know from this study is what the driving force is behind the observed variations in practice. The Institute of Medicine has concluded that even after controlling for all measurable factors, a large amount of variation in spending is unexplained.12 But explain we must, in order to put these results in context for patients and payers. We must clearly articulate, publish, adopt, and defend evidence-based practices and develop systems that capture the data that support diagnostic practices, care, and outcomes. Physicians have an opportunity and an obligation to lead in these efforts by defining true meaningful use, in an era in which the care we provide is under increasing scrutiny and oversight. Author Contributions Christine G. Gourin, substantial contributions to the conception or design of the work or the acquisition, analysis, or interpretation of data for the work; drafting the work or revising it critically for important intellectual content; final approval of the version to be

published; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Disclosures Competing interests: None. Sponsorships: None. Funding source: None.

References 1. Cracchiolo J, Ridge JA, Egleston B, Lango M. Practice arrangement and Medicare physician payment in otolaryngology. Otolaryngol Head Neck Surg. 2015;6:979-987. 2. Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 1: the content, quality, and accessibility of care. Ann Intern Med. 2003;138:273-287. 3. Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care. Ann Intern Med. 2003;138:288-298. 4. Song Y, Skinner J, Bynum J, et al. Regional variations in diagnostic practices. N Engl J Med. 2010;363:45-53. 5. Gawande A. The cost conundrum. New Yorker. June 1, 2009. http://www.newyorker.com/magazine/2009/06/01/the-cost-conun drum. Accessed March 16, 2015. 6. Franzini L, Mikhail OI, Skinner JS. McAllen and El Paso revisited: Medicare variations not always reflected in the under-sixty-five population. Health Aff. 2010;29:2302-2309. 7. Jacobson M, Earle CC, Newhouse JP. Geographic variation in physician’s responses to a reimbursement change. N Engl J Med. 2011;265:2049-2052. 8. Blue Cross Blue Shield of Massachusetts. The Alternative QUALITY Contract. http://www.bluecrossma.com/visitor/pdf/ alternative-quality-contract.pdf. Accessed March 16, 2015. 9. Segal JB, Bridges JF, Change HY, et al. Identifying possible indicators of systematic overuse of health care procedures with claims data. Med Care. 2014;52:157-163. 10. American Academy of Otolaryngology—Head and Neck Surgery, Inc. and Foundation. Clinical indicators. http://www.entnet.org/con tent/clinical-indicators. Accessed March 16, 2015. 11. The AAO-HNSF releases list of common tests and treatments to question as part of the Choosing WiselyÒ campaign. http:// www.choosingwisely.org/the-aao-hnsf-releases-list-of-commontests-and-treatments-to-question-as-part-of-the-choosing-wiselycampaign/. Accessed March 16, 2015. 12. Institute of Medicine. Variation in Health Care Spending: Target Decision Making, Not Geography. Washington, DC: National Academies Press; 2013.

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Do geographic variations signify overuse?

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