Financial Incentives May Be a Key Driver of Atherectomy Utilization for Peripheral Arterial Disease in the Office-Based Lab

Purpose: Angioplasty (AP), stenting (ST), and atherectomy (AT) are common revascularization procedures used in the treatment of lower extremity peripheral arterial disease (PAD). AT in particular has seen a larger increase in utilization compared to other modalities, despite inconclusive evidence regarding benefits over stenting. The higher reimbursement of AT leading to potential overuse has been characterized among vascular surgeons in the outpatient setting, which has been recently highlighted in the press. We aim to characterize and understand Medicare trends in PAD treatment usage and payments across different sites of service among physicians from 2011-2022.

Methods/Materials: Data were gathered from the 2011-2022 Physician/Supplier Procedure Summary files and tallied per 100,000 Medicare beneficiaries. Procedure rates were subcategorized across all major sites of service, with an emphasis on office-based labs (OBLs) and hospital outpatient departments (HOPDs).

Results: In 2022, the average and total annual Medicare payments for AT were $9610 ($320M, 66%), AT with ST $9710 ($133M, 27%), ST $6475 ($15.7M, 3%), and AP $3461 ($18.5M, 4%). Average payment for AT performed in the OBL is $1675 higher than when performed in the HOPD. From 2011-2022, OBL PAD treatments grew for AT (+1074%), AT with ST (+610%), AP (+220%), and ST (+60%). In HOPDs, the procedure rates decreased for all PAD procedures (-51%, -58%, -73%, and -35%, respectively). Over this period, the aggregate OBL Medicare payments surged for AT (+905%) and modestly rose for ST (+30%) while HOPD payments for these procedures dwindled (-55% and -73%, respectively).

Conclusions: AT rates have grown exponentially over other PAD treatments, and overall PAD work is shifting from the HOPD to the OBL. With clear financial incentive to perform AT over other competing modalities, and the sometimes questionable clinical benefit of AT vs ST, reimbursement may be a driving force behind these trends, especially given that PAD incidence has remained stable. AT has thus resulted in considerable Medicare costs compared to alternatives. These trends are noteworthy to payors, regulators, physicians, and patients.