Search Results for: "american academy"

Background: Efforts to better support primary care include the addition of primary care–focused billing codes to the Medicare Physician Fee Schedule (MPFS). Objective: To examine potential and actual use by primary care physicians (PCPs) of the prevention and coordination codes that have been added to the MPFS. Design: Cross-sectional and modeling study. Setting: Nationally representative claims and survey data. Participants: Medicare patients. Measurements: Frequency of use and estimated Medicare revenue involving 34 billing codes representing prevention and coordination services for which PCPs could but do not necessarily bill. Results: Eligibility among Medicare patients for each service ranged from 8.8% to 100%. Among eligible patients, the median use of billing codes was 2.3%, even though PCPs provided code-appropriate services to more patients, for example, to 5.0% to 60.6% of patients eligible for prevention services. If a PCP provided and billed all prevention and coordination services to half of all eligible patients, the PCP could add to the practice's annual revenue $124 435 (interquartile range [IQR], $30 654 to $226 813) for prevention services and $86 082 (IQR, $18 011 to $154 152) for coordination services. Limitation: Service provision based on survey questions may not reflect all billing requirements; revenues do not incorporate the compliance, billing, and opportunity costs that may be incurred when using these codes. Conclusion: Primary care physicians forego considerable amounts of revenue because they infrequently use billing codes for prevention and coordination services despite having eligible patients and providing code-appropriate services to some of those patients. Therefore, creating additional billing codes for distinct activities in the MPFS may not be an effective strategy for supporting primary care. Primary Funding Source: National Institute on Aging.

The Imperfect Science of Evaluating Performance: How Bad and Who Cares?

Evolving Practice Choices by Newly Certified and More Senior General Internists: A Cross-Sectional and Panel Comparison: Annals of Internal Medicine: Vol 175, No 7

Background: Hospital medicine has grown as a field. However, no study has examined trends in career choices by internists over the past decade. Objective: To measure changes in practice setting for general internists. Design: Using Medicare fee-for-service claims (2008 to 2018) and data from the American Board of Internal Medicine, practice setting types were measured annually for general internists initially certifying between 1990 and 2017. Setting: General internists (non-subspecializing) treating Medicare fee-for-service beneficiaries. Patients: Medicare fee-for-service beneficiaries aged 65 years and older with at least 20 evaluation and management (E&M) visits annually. Measurements: Practice setting types were defined as hospitalist (>95% inpatient E&M), outpatient only (100% outpatient E&M), or mixed. Results: 67 902 general internists, comprising 80% of all general internists initially certified from 1990 to 2017 (n = 84 581), were studied. From 2008 to 2018, both hospitalists and outpatient-only physicians increased as percentages of general internists (25% to 40% and 23% to 38%, respectively). This was accompanied by a 56% decline in the percentage of mixed-practice physicians (52% to 23%) as these physicians largely migrated to outpatient-only practice. By 2018, 71% of newly certified general internists practiced as hospitalists compared with only 8% practicing as outpatient-only physicians. Most (86% of hospitalists in 2013) had the same practice type 5 years later. This retention rate was similar across early career and more senior physicians (86% and 85% for the 1999 and 2012 initial certification cohorts, respectively) and for the outpatient-only practice type (95%) but was only 57% for the mixed practice type. Limitation: Practice setting measurement relied only on Medicare fee-for-service claims. Conclusion: Newly certified general internists are largely choosing hospital medicine as their career choice whereas more senior physicians increasingly see patients only in the outpatient setting. Primary Funding Source: This study did not receive direct funding.

Early Changes in Billing and Notes After Evaluation and Management Guideline Change

Background: The American Medical Association updated guidance in 2021 for frequently used billing codes for outpatient evaluation and management (E/M) visits. The intent was to account for provider time outside of face-to-face encounters and to reduce onerous documentation requirements. Objective: To analyze E/M visit use, documentation length, and time spent in the electronic health record (EHR) before and after the guideline change. Design: Observational, retrospective, pre–post study. Setting: U.S.-based ambulatory practices using the Epic Systems EHR. Participants: 303 547 advanced practice providers and physicians across 389 organizations. Measurements: Data from September 2020 through April 2021 containing weekly provider-level E/M code and EHR use metadata were extracted from the Epic Signal database. We descriptively analyzed overall and specialty-specific changes in E/M visit use, note length, and time spent in the EHR before and after the new guidelines using provider-level paired t tests. Results: Following the new guidelines, level 3 visits decreased by 2.41 percentage points (95% CI, −2.48 to −2.34 percentage points) to 38.5% of all E/M visits, a 5.9% relative decrease from fall 2020. Level 4 visits increased by 0.89 percentage points (CI, 0.82 to 0.96 percentage points) to 40.9% of E/M visits, a 2.2% relative increase. Level 5 visits (the highest acuity level) increased by 1.85 percentage points (CI, 1.81 to 1.89 percentage points) to 10.1% of E/M visits, a 22.6% relative increase. These changes varied by specialty. We found no meaningful changes in measures of note length or time spent in the EHR. Limitation: The Epic ambulatory client base may underrepresent smaller and independent practices. Conclusion: Immediate changes in E/M coding contrast with null findings for changes in both note length and EHR time. Provider organizations are positioned to respond more rapidly to billing process changes than to changes in care delivery and associated EHR use behaviors. Fully realizing the intended benefits of this guideline change will require more time, facilitation, and scaling of best practices that more directly address EHR documentation practices and associated burden. Primary Funding Source: None.

Affirmative Action Bans and Enrollment of Students From Underrepresented Racial and Ethnic Groups in U.S. Public Medical Schools

Background: The percentage of U.S. physicians who identify as being from an underrepresented racial or ethnic group remains low relative to their proportion in the U.S. population. How this percentage may have been affected by state bans on affirmative action in public postsecondary institutions has received relatively little attention. Objective: To examine the association between state affirmative action bans and percentage of enrollment in U.S. public medical schools from underrepresented racial and ethnic groups. Design: Event study comparing public medical schools in states that implemented affirmative action bans with those in states without bans. Setting: U.S. public medical schools. Participants: 21 public medical schools in 8 states with affirmative action bans matched to 32 public medical schools in 24 states without bans from 1985 to 2019. Measurements: Percentage of total enrollment from racial and ethnic groups underrepresented in medicine (Black, Hispanic, American Indian or Alaska Native, and Native Hawaiian or other Pacific Islander). Results: The percentage of enrollment from underrepresented racial and ethnic groups was 14.8% in U.S. public medical schools in the year before ban implementation in states with bans. The adjusted percentage of underrepresented students in ban schools decreased by 4.8 percentage points (95% CI, −6.3 to −3.2 percentage points) 5 years after ban implementation relative to the year before implementation, whereas the adjusted percentage in control schools increased by 0.7 percentage point (CI, −0.1 to 1.6 percentage points), for a relative difference, or difference-in-differences estimate, of −5.5 percentage points (CI, −7.1 to −3.9 percentage points). Limitation: Inability to account for the effect of these bans on undergraduate enrollment. Conclusion: State affirmative action bans were associated with significant reductions in the percentage of students in U.S. public medical schools from underrepresented racial and ethnic groups. Primary Funding Source: None.

The Emperor Has No Ganey

One of Many

Moving Beyond Race-Based Medicine

Human Papillomavirus Vaccine Impact and Effectiveness Through 12 Years After Vaccine Introduction in the United States, 2003 to 2018

Background: Human papillomavirus (HPV) vaccination was introduced in 2006 for females and in 2011 for males. Objective: To estimate vaccine impact and effectiveness against quadrivalent HPV vaccine (4vHPV)–type prevalent infection among sexually experienced U.S. females and vaccine effectiveness for sexually experienced U.S. males. Design: NHANES (National Health and Nutrition Examination Survey) conducted in 2003 to 2006 (prevaccine era) and in 2007 to 2010, 2011 to 2014, and 2015 to 2018 (vaccine eras). Setting: Nationally representative U.S. surveys. Participants: Sexually experienced participants aged 14 to 24 years. Intervention: U.S. HPV vaccination program. Measurements: Participant-collected cervicovaginal and penile specimens were tested for HPV DNA. The prevalences of 4vHPV and non-4vHPV types were estimated in each era for females and in 2013 to 2016 for males. Prevalences among the female population overall, vaccinated females, and unvaccinated females were compared in vaccine eras versus the prevaccine era (vaccine impact). Within each vaccine era, prevalence among vaccinated females was compared with that among unvaccinated females (vaccine effectiveness). Vaccine impact and effectiveness were estimated as (1 − prevalence ratio) · 100. Results: Among sexually experienced females aged 14 to 24 years, the impact on 4vHPV-type prevalence in 2015 to 2018 was 85% overall, 90% among vaccinated females, and 74% among unvaccinated females. No significant declines were found in non–4vHPV-type prevalence. Vaccine effectiveness ranged from 60% to 84% during vaccine eras for females and was 51% during 2013 to 2016 for males. Limitation: Self- or parent-reported vaccination history and small numbers in certain subgroups limited precision. Conclusion: Nationally representative data show increasing impact of the vaccination program and herd protection. Vaccine effectiveness estimates will be increasingly affected by herd effects. Primary Funding Source: Centers for Disease Control and Prevention.

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