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Figure.  Trends in Annual Mean Percutaneous Coronary Intervention (PCI) Volume in Patients Without Acute Myocardial Infarction (AMI), Investigated Hospitals, and Matched Noninvestigated Hospitals
Trends in Annual Mean Percutaneous Coronary Intervention (PCI) Volume in Patients Without Acute Myocardial Infarction (AMI), Investigated Hospitals, and Matched Noninvestigated Hospitals

The 8 investigated hospitals were matched without replacement to another hospital in the same state on the basis of 2006 PCI volume (in patients with and without AMI).

aDate at which the investigation of 1 hospital went public.

bDate at which the investigation of 2 hospitals went public.

cDate at which the investigation of 3 hospitals went public.

Table.  Hospitals and Cardiologists Accused of Billing Medicare for Unnecessary PCIsa
Hospitals and Cardiologists Accused of Billing Medicare for Unnecessary PCIsa
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    Research Letter
    Less Is More
    September 21, 2020

    US False Claims Act Investigations of Unnecessary Percutaneous Coronary Interventions

    Author Affiliations
    • 1Department of Health Policy and Management, Emory University, Atlanta, Georgia
    • 2Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut
    JAMA Intern Med. 2020;180(11):1534-1536. doi:10.1001/jamainternmed.2020.2812

    The US False Claims Act allows individuals to sue government contractors if they have private knowledge that the contractors defrauded the government. The act was originally intended to combat fraud by defense contractors. Recently, several physicians, hospitals, and other health care clinicians have been penalized under the act for billing Medicare for unnecessary care.1 In this study, we sought to identify US False Claims Act investigations of the overuse of percutaneous coronary interventions and assess their association with percutaneous coronary intervention (PCI) volumes.

    Methods

    We identified PCI-related US False Claims Act cases by searching US Department of Justice press releases for announcements with the terms stent, cardiovascular, angioplasty, or percutaneous coronary intervention. Additionally, we searched the NewsBank news database (NewsBank, Inc) to identify unresolved cases. This study was deemed exempt from human participants review by the Emory University institutional review board.

    We identified 16 hospitals that were investigated for performing unnecessary PCIs. We measured PCI volumes at the 8 hospitals located in states for which we had inpatient and ambulatory surgery data (Florida, Kentucky, Maryland, and New Jersey). Cases against these hospitals became public in 2007, 2008 (2 hospitals [12.5%]), 2010 (3 [18.8%]), 2011, and 2015. We measured PCIs using all-payer outpatient and inpatient hospital data for the period from January 2006 to December 2017.2

    We identified PCIs using Current Procedural Terminology codes on outpatient records and International Classification of Diseases, Ninth Revision (ICD-9 ) and ICD Tenth Revision (ICD-10) codes on inpatient records. We excluded patients with a diagnosis code for acute myocardial infarction (AMI). We matched each investigated hospital without replacement to another hospital in the same state on the basis of 2006 non-AMI PCI volumes. We used t tests to assess the significance of differences between 2006 and 2017. We used a linear regression with robust standard errors on aggregate data to test the equivalence of time trends between investigated and matched, noninvestigated hospitals. Analyses were performed using Stata, version 16 (StataCorp), and an α of 5% was used for significance testing.

    Results

    We identified 16 cases in which hospitals were investigated under the False Claims Act for billing Medicare for unnecessary PCIs (Table). Fourteen (87.5%) have been resolved with a settlement. In 3 of the 16 cases (18.8%), the US Department of Justice also successfully sought prison terms for individual cardiologists. Most of the investigated hospitals were in the Midwest, South, or mid-Atlantic regions.

    There were 676 729 PCIs in patients without an AMI in Florida, Kentucky, Maryland, and New Jersey during the study period. There were 234 hospitals in these 4 states that performed at least 25 PCIs in patients without AMI over the study period. Of these, 8 (3.4%) had cases that became public during the study period. In 2006, investigated hospitals accounted for 11 520 of 85 454 PCIs (13.5%) in patients without an AMI in these states.

    The Figure shows trends in mean hospital-level PCI volumes. In the 8 investigated hospitals, the mean (SD) annual PCI volume of patients without an AMI declined from 1440 (686) procedures in 2006 to 271 (120) procedures in 2017 (81.2%; P < .001). The total number of procedures in these hospitals declined from 11 520 to 2172. Among matched, noninvestigated hospitals, the mean (SD) volume declined from 1168 (620) to 369 (235) procedures (68.4%; P = .003). An F test eliminated the null hypothesis of equal trends between groups (F = 20.73; P < .001).

    Conclusions

    Physicians and hospitals that bill Medicare for unnecessary PCIs risk investigation under the US False Claims Act, especially if potential penalties are large based on high procedure volumes. When prosecuting individual cardiologists, the US Department of Justice often introduced evidence that cardiologists overstated the degree of stenosis in patients to show that they knowingly delivered unnecessary care. Depending on how common this practice is, estimates of the share of PCIs that are rarely appropriate based on appropriate use criteria3 are likely underestimated.

    It is difficult to precisely identify the association of the investigations with PCI use. Declines in procedure volumes at each hospital that was investigated generally coincide with the initiation of the investigations. However, volumes probably would have declined in the absence of the investigations as a result of the 2007 COURAGE trial.4 The investigations may have led physicians at noninvestigated hospitals to adopt more conservative practice styles, as was the case with the US Department of Justice’s investigation into implantable cardioverter defibrillators placed outside of Medicare coverage guidelines.5

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    Article Information

    Accepted for Publication: May 23, 2020.

    Corresponding Author: David H. Howard, PhD, Department of Health Policy and Management, Emory University, 1518 Clifton Rd NE, Atlanta, GA 30322 (david.howard@emory.edu).

    Published Online: September 21, 2020. doi:10.1001/jamainternmed.2020.2812

    Author Contributions: Dr Howard had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: All authors.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: All authors.

    Critical revision of the manuscript for important intellectual content: Desai.

    Statistical analysis: Howard.

    Administrative, technical, or material support: Desai.

    Conflict of Interest Disclosures: Dr Desai works under contract with the Centers for Medicare and Medicaid Services to develop and maintain performance measures used for public reporting and pay for performance programs. He reports consulting for Amgen, Boehringer Ingelheim, Cytokinetics, Relypsa, SC Pharmaceuticals, and Novartis. Dr Howard previously worked as a statistical consultant on a US False Claims Act case unrelated to PCI and reports personal fees from Brian Vroon, LLC outside the submitted work.

    References
    1.
    Howard  D.  False Claims Act liability for overtreatment.   J Health Polit Policy Law. 2020;45(3):419-437. doi:10.1215/03616878-8161036PubMedGoogle ScholarCrossref
    2.
    Agency for Healthcare Research and Quality. State-specific HCUP databases. Accessed December 10, 2019. https://www.hcup-us.ahrq.gov/databases.jsp
    3.
    Patel  MR, Calhoon  JH, Dehmer  GJ,  et al.  AAA/AATS/AHA/ASE/ASNC/SCAI/ SCCT/STS appropriate use criteria for coronary revascularization in patients with stable ischemic heart disease: a report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society of Thoracic Surgeons.   J Am Coll Cardiol. 2017;69(17):2212-2241. doi:10.1016/j.jacc.2017.02.001PubMedGoogle ScholarCrossref
    4.
    Boden  WE, O’Rourke  RA, Teo  KK,  et al; COURAGE Trial Research Group.  Optimal medical therapy with or without PCI for stable coronary disease.   N Engl J Med. 2007;356(15):1503-1516. doi:10.1056/NEJMoa070829PubMedGoogle ScholarCrossref
    5.
    Desai  NR, Bourdillon  PM, Parzynski  CS,  et al.  Association of the US Department of Justice Investigation of implantable cardioverter-defibrillators and devices not meeting the Medicare National Coverage Determination, 2007-2015.   JAMA. 2018;320(1):63-71. doi:10.1001/jama.2018.8151PubMedGoogle ScholarCrossref
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