Changes in coverage among non-elderly adults with chronic diseases following Affordable Care Act implementation.

IMPORTANCE: Changes in insurance coverage after the Affordable Care Act (ACA) among non-elderly adults with self-reported chronic conditions across income categories have not been described. OBJECTIVE: To examine changes in insurance coverage after the ACA among non-elderly adults with chronic conditions across income categories, by geographic region. DESIGN: We compared self-reported access to health insurance pre-ACA (2010-2013) and post-ACA (2014-2017) for individuals 18-64 years of age with ≥ 2 chronic conditions, including hypertension, heart disease/stroke, emphysema, diabetes, asthma, cancer, and arthritis, across regions using a logistic regression approach, adjusted for covariates. We also assessed U.S. Census regional differences in insurance coverage post-ACA using modified Poisson regression models with robust variance and calculated the risk ratio (RR) of being uninsured by region, with the Northeast as the reference category. Within each region, we then examined changes in insurance coverage by income level among non-elderly individuals with any chronic condition. SETTING: 2010-2017 household component of the nationally representative Medical Expenditure Panel Survey (MEPS). PARTICIPANTS: All members of surveyed households during five interviews over a two-year period. INTERVENTION: Start of insurance coverage expansion under the ACA. MAIN OUTCOMES: Health insurance status. RESULTS: On average nationwide, non-elderly adults with self-reported chronic conditions experienced increased insurance coverage associated with the ACA (diabetes: +6.41%, high-blood pressure: +6.09%, heart disease: +6.50%, asthma: +6.37%, arthritis: +6.77%, and ≥ 2 chronic conditions: +6.39%). Individuals in the West region reported the largest increases (diabetes +9.71%, high blood pressure +8.10%, and heart disease/stroke +8.83 %, asthma +9.10%, arthritis +8.39%, and ≥ 2 chronic conditions +8.58). In contrast, individuals in the South region reported smaller increases in insurance coverage post-ACA among those with diabetes, heart disease/stroke, and asthma compared to the Midwest and West. The Northeast region, which had the highest levels of insurance coverage pre-ACA, exhibited the smallest increase in reported coverage post-ACA. Reported insurance coverage improved across all regions for adults with any chronic condition across income levels, most notably for very low- and low-income individuals. A further cross-sectional comparison after the ACA demonstrated important residual differences in insurance coverage, despite the gains in all regions. When compared to the Northeast, adults with any self-reported chronic conditions living in the South were more likely to report no insurance coverage (diabetes: RR 1.99, p-value <0.001, high blood pressure: RR 2.02, p-value <0.001, heart diseases/stroke: RR 2.55, p-value <0.001, asthma RR 2.21, p-value <0.001, arthritis: RR 2.25, p-value <0.001), and ≥ 2 chronic condition (RR 2.29, p-value <0.001). CONCLUSION AND RELEVANCE: The ACA was associated with meaningful increases in insurance coverage for adults with any self-reported chronic condition in all US regions, most notably in the West region and among those with lower incomes, suggesting a nation-wide trend to improved access to health insurance following implementation. However, intra-regional comparisons after ACA implementation showed important differences. Individuals with ≥2 chronic conditions in the South were 2.29 times less likely to have insurance coverage in comparison to their peers in the Northeast. Though the post-ACA improvements in reported access to health insurance coverage affected all US regions, the reported experience of those with multiple chronic conditions in the South point to continued barriers for those most likely to benefit from access to health insurance coverage. Medicaid expansion in the South would likely result in increased insurance coverage for individuals with chronic conditions and improve health care outcomes.

Geographic variations in specialty distribution and specialty-related mortality.

Using data from the Centers for Disease Control and Centers for Medicare and Medicaid Services, we analyzed the relationship between specialty physician location and specialty-specific mortality rates for diagnoses where access to specialty expertise could plausibly reduce death rates. After adjustment for demographic and health indicators, counties with the highest quartile specialty physician density had lower mortality rates compared to counties with the lowest quartile. The observed association in endocrinology, infectious disease, and neurology was 10.7, 2.9 and 7.2 fewer deaths per 100,000 residents, respectively. There is an inverse correlation between the distribution of select specialties and population-level mortality.

Differences in the Complexity of Office Visits by Physician Specialty: NAMCS 2013-2016.

BACKGROUND: Specialty-to-specialty variation in use of outpatient evaluation and management service codes could lead to important differences in reimbursement among specialties. OBJECTIVE: To compare the complexity of visits to physicians whose incomes are largely dependent on evaluation and management services to the complexity of visits to physicians whose incomes are largely dependent on procedures. DESIGN, SETTING, AND PARTICIPANTS: We analyzed 53,670 established patient outpatient visits reported by physicians in the National Ambulatory Medical Care Survey (NAMCS) from 2013 to 2016. We defined high complexity visits as those with an above average number of diagnoses (> 2) and/or medications (> 3) listed We based our comparison on time intervals corresponding to typical outpatient evaluation and management times as defined by the Current Procedural Terminology Manual and specialty utilization of evaluation and management codes based on 2015 Medicare payments. MAIN OUTCOME AND MEASURES: Proportion of complex visits by specialty category. KEY RESULTS: We found significant differences in the content of similar-length office visits provided by different specialties. For level 4 established outpatient visits (99214), the percentage involving high diagnostic complexity ranged from 62% for internal medicine, 52% for family medicine/general practice, and 41% for neurology (specialties whose incomes are largely dependent on evaluation and management codes), to 34% for dermatology, 42% for ophthalmology, and 25% for orthopedic surgery (specialties whose incomes are more dependent on procedure codes) (p value of the difference < 0.001). High medication complexity was found in the following proportions of visits: internal medicine 56%, family medicine/general practice 49%, and neurology 43%, as compared with dermatology 33%, ophthalmology 30%, and orthopedic surgery 30% (p value of the difference < 0.001). CONCLUSION: Within the same duration visits, specialties whose incomes depend more on evaluation and management codes on average addressed more clinical issues and managed more medications than specialties whose incomes are more dependent on procedures.

The undervaluation of evaluation and management professional services: the lasting impact of current procedural terminology code deficiencies on physician payment.

The Resource-Based Relative Value Scale (RBRVS) is fundamentally undermined by the following foundational errors: (1) The full range of office-based evaluation and management (E/M) activities are not captured by the Current Procedural Terminology (CPT) code choices, (2) it places relatively high values on procedural services, (3) there is no measure of intensity for complex outpatient E/M care, and (4) its maintenance and update have been delegated to select professional societies. Limitations imposed on the development of the RBRVS dating back to the early 1980s have not been corrected. The repertoire of codes for physician office-based E/M work must be expanded to create a new topology of choices with new outpatient code families with discrete service code levels, such as comprehensive outpatient consultation care, comprehensive outpatient primary care, and limited outpatient consultation care. Service code relative values must be based on representative samples and reliable survey data, draw from the broader literature on work intensity, and be developed with accountable and representative professional engagement.

Patient Protection and Affordable Care Act: promise and peril for primary care.

The Patient Protection and Affordable Care Act (PPACA) of 2010 brings both promise and peril for primary care. This Act has the potential to reestablish primary care as the foundation of U.S. health care delivery. The legislation authorizes specific programs to stabilize and expand the primary care physician workforce, provides an immediate 10% increase in primary care physician payment, creates an opportunity to correct the skewed resource-based relative value scale, and supports innovation in primary care practice. Nevertheless, the peril is that the PPACA initiatives may not alter the current trend toward an increasingly specialized physician workforce. To realize the potential for the PPACA to achieve a more equitable balance between generalist and specialist physicians, all primary care advocates must actively engage in the long rebuilding process.