Shifting Sites of Care in Electrophysiology: Trends and Cost Differences in Device Implantation Procedures Across Ambulatory and Hospital Settings in the Medicare Population.

Abstract

Background: Cardiac electrophysiology (EP) procedures, such as pacemaker and implantable cardioverter-defibrillator (ICD) implantations, are increasingly shifting from inpatient hospitals to outpatient settings. Ambulatory surgery centers (ASCs) may offer cost advantages over hospital outpatient departments (HOPDs), but national trends and payment differences in the Medicare population remain under characterized.

Objective: To evaluate trends in site-of-service utilization and Medicare payment differences for EP device implantation procedures between 2016 and 2023.

Methods: This cross-sectional study analyzed 100% Medicare fee-for-service claims data from 2016-2023 using the Physician/Supplier Procedure Summary files and 2023 payment data from the Medicare Procedure Price Lookup Tool. Pacemaker and ICD implantations were identified via CPT codes and categorized by site of service: inpatient, HOPD, or ASC. Annual procedure volumes were normalized per 10,000 Medicare Part B beneficiaries. Linear regression was used to assess volume trends and ASC uptake. Payment comparisons between ASC and HOPD settings were performed for five representative procedures.

Results: From 2016 to 2023, pacemaker volumes declined from 47.2 to 44.2 per 10,000 beneficiaries, and ICD volumes declined from 22.8 to 16.6 per 10,000. Concurrently, ASC utilization rose from 1.5% to 7.2% for pacemakers and from 1.4% to 6.9% for ICDs (p < 0.001 for both trends). In 2023, Medicare reimbursed 15-26% less for device implantations performed in ASCs compared to HOPDs. For example, dual-chamber pacemaker implantation (CPT 33208) cost $8,131 in ASCs versus $10,673 in HOPDs. Aggregate Medicare savings from shifting five EP procedures to ASCs totaled $59.3 million in 2023.

Conclusion: The use of ASCs for EP device implantation is increasing and is associated with substantially lower Medicare payments without affecting physician reimbursement. These findings highlight opportunities for cost savings and support the case for expanded ASC utilization and site-neutral payment reform.