Background There is pressure in the U.S. system to move away from fee‐for‐service models to a more pre‐paid system, which may result in decreased costs, but the impact on evidence‐based care is unclear. We examined a large pre‐paid Health Maintenance Organizations (HMO) in Israel to see if evidence‐based guidelines are followed for prostate specific antigen (PSA) testing. Methods A retrospective cohort of ambulatory visits from 2002 to 2011 of patients age >75 receiving care from Clalit Health Services was conducted. Historically reported U.S. cohorts were used for comparison. The main measure was the percent of patients who had at least one PSA after age 75. Results In each of the 10 years of follow‐up, 22% of the yearly Israeli cohort, with no known malignancy or benign prostatic hyperplasia, had at least one PSA, while for the total 10 years, 30% of the men had at least one PSA. These rates are considerably lower than previously reported U.S. rates. Conclusions In a pre‐paid system in which physicians have no incentive to order tests, they appear to order PSA tests at a lower rate than has been observed in the U.S. system. Additional quality of measures should continue to be examined as the U.S. shifts away from a fee‐for‐service model. Copyright © 2016 John Wiley & Sons, Ltd.