Publications

2019
Suyoung Choi, Andrew D Wilcock, Alisa B Busch, Haiden A Huskamp, Lori Uscher-Pines, Zhuo Shi, and Ateev Mehrotra. 2019. “Association of Characteristics of Psychiatrists With Use of Telemental Health Visits in the Medicare Population.” JAMA Psychiatry, 76, 6, Pp. 654-657.Abstract
This observational study of Medicare fee-for-service claims data evaluates demographic characteristics of psychiatrists who deliver telemental health visits in the Medicare population.
Suyoung Choi, Andrew D Wilcock, Alisa B Busch, Haiden A Huskamp, Lori Uscher-Pines, Zhuo Shi, and Ateev Mehrotra. 2019. “Association of Characteristics of Psychiatrists With Use of Telemental Health Visits in the Medicare Population.” JAMA Psychiatry, 76, 6, Pp. 654-657.Abstract
This observational study of Medicare fee-for-service claims data evaluates demographic characteristics of psychiatrists who deliver telemental health visits in the Medicare population.
Ishani Ganguli, Jeffrey Souza, Michael J McWilliams, and Ateev Mehrotra. 2019. “Association Of Medicare's Annual Wellness Visit With Cancer Screening, Referrals, Utilization, And Spending.” Health Aff (Millwood), 38, 11, Pp. 1927-1935.Abstract
Medicare's annual wellness visit was introduced in 2011 to promote evidence-based preventive care and identify risk factors and undiagnosed conditions in aging adults. Use of the visit has risen steadily since then, yet its benefits remain unclear. Using national Medicare data for 2008-15, we examined claims from fee-for-service Medicare beneficiaries attributed to practices that did or did not adopt the visit. We performed difference-in-differences analysis to compare differential changes in appropriate and low-value cancer screening, functional and neuropsychiatric care, emergency department visits, hospitalizations, and total spending. Examining 17.8 million beneficiary-years, we found modest differential improvements in rates of evidence-based screening and declines in emergency department visits. However, when we accounted for trends that predated the introduction of the visit, none of these benefits persisted. In sum, we found no substantive association between annual wellness visits and improvements in care.
Kristin N Ray, Lori Uscher-Pines, and Ateev Mehrotra. 2019. “Authors' Response.” Pediatrics, 144, 2.
Nabeel Qureshi, Ateev Mehrotra, Robert S Rudin, and Shira H Fischer. 2019. “Common Laboratory Results Frequently Misunderstood by a Sample of Mechanical Turk Users.” Appl Clin Inform, 10, 2, Pp. 175-179.Abstract
OBJECTIVES: More patients are receiving their test results via patient portals. Given test results are written using medical jargon, there has been concern that patients may misinterpret these results. Using sample colonoscopy and Pap smear results, our objective was to assess how frequently people can identify the correct diagnosis and when a patient should follow up with a provider. METHODS: We used Mechanical Turk-a crowdsourcing tool run by Amazon that enables easy and fast gathering of users to perform tasks like answering questions or identifying objects-to survey individuals who were shown six sample test results (three colonoscopy, three Pap smear) ranging in complexity. For each case, respondents answered multiple choice questions on the correct diagnosis and recommended return time. RESULTS: Among the three colonoscopy cases (n = 642) and three Pap smear cases (n = 642), 63% (95% confidence interval [CI]: 60-67%) and 53% (95% CI: 49-57%) of the respondents chose the correct diagnosis, respectively. For the most complex colonoscopy and Pap smear cases, only 29% (95% CI: 23-35%) and 9% (95% CI: 5-13%) chose the correct diagnosis. CONCLUSION: People frequently misinterpret colonoscopy and Pap smear test results. Greater emphasis needs to be placed on assisting patients in interpretation.
Michael J McWilliams, Michael L Barnett, Eric T Roberts, Pasha Hamed, and Ateev Mehrotra. 2019. “Did Hospital Readmissions Fall Because Per Capita Admission Rates Fell?” Health Aff (Millwood), 38, 11, Pp. 1840-1844.Abstract
Recent reductions in hospital readmission rates have been attributed to the Hospital Readmissions Reduction Program. However, admission rates also declined during the same period. We found that because the probability of an admission occurring soon after another is lower when there are fewer admissions per patient, the reduction in admission rates may explain much of the reduction in readmission rates.
Rebecca A Gourevitch, Ateev Mehrotra, Grace Galvin, Avery C Plough, and Neel T Shah. 2019. “Does comparing cesarean delivery rates influence women's choice of obstetric hospital?” Am J Manag Care, 25, 2, Pp. e33-e38.Abstract
OBJECTIVES: Despite public reporting of wide variation in hospital cesarean delivery rates, few women access this information when deciding where to deliver. We hypothesized that making cesarean delivery rate data more easily accessible and understandable would increase the likelihood of women selecting a hospital with a low cesarean delivery rate. STUDY DESIGN: We conducted a randomized controlled trial of 18,293 users of the Ovia Health mobile apps in 2016-2017. All enrollees were given an explanation of cesarean delivery rate data, and those randomized to the intervention group were also given an interactive tool that presented those data for the 10 closest hospitals with obstetric services. Our outcome measures were enrollees' self-reported delivery hospital and views on cesarean delivery rates. METHODS: Intent-to-treat analysis using 2-sided Pearson's χ2 tests. RESULTS: There was no significant difference across the experimental groups in the proportion of women who selected hospitals with low cesarean delivery rates (7.0% control vs 6.8% intervention; P = .54). Women in the intervention group were more likely to believe that hospitals in their community had differing cesarean delivery rates (66.9% vs 55.9%; P <.001) and to report that they looked at cesarean delivery rates when choosing their hospital (44.5% vs 33.9%; P <.001). CONCLUSIONS: Providing women with an interactive tool to compare cesarean delivery rates across hospitals in their community improved women's familiarity with variation in cesarean delivery rates but did not increase their likelihood of selecting hospitals with lower rates.
Felippe O Marcondes, Paawan Punjabi, Lauren Doctoroff, Anjala Tess, Sarah O'Neill, Timothy Layton, Kramer Quist, and Ateev Mehrotra. 2019. “Does Scheduling a Postdischarge Visit with a Primary Care Physician Increase Rates of Follow-up and Decrease Readmissions?” J Hosp Med, 14, Pp. E37-E42.Abstract
BACKGROUND: Driven in part by Medicare's Hospital Readmissions Reduction Program, hospitals are focusing on improving the transition from inpatient to outpatient care with particular emphasis on early follow-up with a primary care physician (PCP). OBJECTIVE: To assess whether the implementation of a scheduling assistance program changes rates of PCP follow-up or readmissions. DESIGN: Retrospective cohort study. SETTING: An urban tertiary care center PATIENTS: A total of 20,918 adult patients hospitalized and discharged home between September 2008 and October 2015. INTERVENTION: A postdischarge appointment service to facilitate early PCP follow-up. MAIN MEASURES: Primary outcomes were rates of follow-up visits with a PCP within seven days of discharge and hospital readmission within 30 days of discharge. Our first analysis assessed differences in outcomes among patients with and without the use of the service. In a second analysis, we exploited the fact that the service was not available on weekends and conducted an instrumental variable analysis that used the interaction between the intervention and day of the week of admission. RESULTS: In our multivariable analysis, use of the appointment service was associated with much higher rates of PCP follow-up (+31.9 percentage points, 95% CI: 30.2, 33.6; P < .01) and a decrease in readmission (-3.8 percentage points, 95% CI: -5.2, -2.4; P < .01). In the instrumental variable analysis, use of the service also increased the likelihood of a PCP follow-up visit (33.4 percentage points, 95% CI: 7.9, 58.9; P = .01) but had no significant impact on readmissions (-2.5 percentage points, 95% CI: -22.0, 17.0; P = .80). CONCLUSIONS: The postdischarge appointment service resulted in a substantial increase in timely PCP followup, but its impact on the readmission rate was less clear.
Ishani Ganguli, Thomas H Lee, and Ateev Mehrotra. 2019. “Evidence and Implications Behind a National Decline in Primary Care Visits.” J Gen Intern Med, 34, 10, Pp. 2260-2263.Abstract
Primary care is the foundation of the health care system and the basis for new payment and delivery reforms in the USA. Yet since 2008, primary care visit rates dropped by 6-25% across a range of populations in five sources of national survey and administrative data. We hypothesize three likely mechanisms behind the decline: decreases in patients' ability, need, or desire to seek primary care; changes in primary care practice such as greater use of teams and non-face-to-face care; and replacement of in-person primary care visits with alternatives such as specialist, retail clinic, and commercial telemedicine visits. These mechanisms require further investigation. In the meantime, the trend prompts us to optimize the primary care visit and embrace the growth of alternatives while preserving the fundamental benefits of primary care.
Sabrina J Poon, Lan Vu, Leanne Metcalfe, Olesya Baker, Ateev Mehrotra, and Jeremiah D Schuur. 2019. “The Impact of Conversion From an Urgent Care Center to a Freestanding Emergency Department on Patient Population, Conditions Managed, and Reimbursement.” J Emerg Med, 56, 3, Pp. 352-358.Abstract
BACKGROUND: Freestanding emergency departments (FSEDs), EDs not attached to acute care hospitals, are expanding. One key question is whether FSEDs are more similar to higher-cost hospital-based EDs or to lower-cost urgent care centers (UCCs). OBJECTIVE: Our aim was to determine whether there was a change in patient population, conditions managed, and reimbursement among three facilities that converted from a UCC to an FSED. METHODS: Using insurance claims from Blue Cross Blue Shield of Texas, we compared outcomes of interest for three facilities that converted from a UCC to an FSED for 1 year before and after conversion. RESULTS: There was no significant change in age, sex, and comorbidities among patients treated after conversion. Conditions were similar after conversion, though there was a small increase in visits for potentially more severe conditions. For example, the most common diagnoses before and after conversion were upper respiratory infections (42.8% of UCC visits, 26.0% of FSED visits), while chest pain increased from rank 30 to 10 (0.5% of UCC visits, 2.3% of FSED visits). Yearly number of visits decreased after conversion, while median reimbursement per visit increased (facility A: $148 to $2,153; facility B: $137 to $1,466; and facility C: $131 to $1,925) and total revenue increased (facility A: $1,389,590 to $1,486,203; facility B: $896,591 to $4,294,636; and facility C: $637,585 to $8,429,828). CONCLUSIONS: After three UCCs converted to FSEDs, patient volume decreased and reimbursement per visit increased, despite no change in patient characteristics and little change in conditions managed. These case studies suggest that some FSEDs are similar to UCCs in patient mix and conditions treated.
Aarti Rao, Zhuo Shi, Kristin N Ray, Ateev Mehrotra, and Ishani Ganguli. 2019. “National Trends in Primary Care Visit Use and Practice Capabilities, 2008-2015.” Ann Fam Med, 17, 6, Pp. 538-544.Abstract
PURPOSE: Recent evidence shows a national decline in primary care visit rates over the last decade. It is unclear how changes in practice-including the use and content of primary care visits-may have contributed. METHODS: We analyzed nationally representative data of adult visits to primary care physicians (PCPs) and physician practice characteristics from 2007-2016 (National Ambulatory Medical Care Survey). United States census estimates were used to calculate visits per capita. Measures included visit rates per person year; visit duration; number of medications, diagnoses, and preventive services per visit; percentage of visits with scheduled follow-up; and percentage of physicians with practice capabilities including an electronic medical record (EMR). RESULTS: Our weighted sample represented 3.2 billion visits (83,368 visits, unweighted). Visits per capita declined by 20% (-0.25 visits per person, 95% CI, -0.32 to -0.19) during this time, while visit duration increased by 2.4 minutes per visit (95% CI, 1.1-3.8). Per visit, PCPs addressed 0.30 more diagnoses (95% CI, 0.16-0.43) and 0.82 more medications (95% CI, 0.59-1.1), and provided 0.24 more preventive services (95% CI, 0.12-0.36). Visits with scheduled PCP followup declined by 6.0% (95% CI, -12.4 to 0.46), while PCPs reporting use of EMR increased by 44.3% (95% CI, 39.1-49.5) and those reporting use of secure messaging increased by 60.9% (95% CI, 27.5-94.3). CONCLUSION: From 2008 to 2015, primary care visits were longer, addressed more issues per visit, and were less likely to have scheduled follow-up for certain patients and conditions. Meanwhile, more PCPs offered non-face-to-face care. The decline in primary care visit rates may be explained in part by PCPs offering more comprehensive in-person visits and using more non-face-to-face care.
Christopher M Whaley, Lan Vu, Neeraj Sood, Michael E Chernew, Leanne Metcalfe, and Ateev Mehrotra. 2019. “Paying Patients To Switch: Impact Of A Rewards Program On Choice Of Providers, Prices, And Utilization.” Health Aff (Millwood), 38, 3, Pp. 440-447.Abstract
Employers and insurers are experimenting with benefit strategies that encourage patients to switch to lower-price providers. One increasingly popular strategy is to financially reward patients who receive care from such providers. We evaluated the impact of a rewards program implemented in 2017 by twenty-nine employers with 269,875 eligible employees and dependents. For 131 elective services, patients who received care from a designated lower-price provider received a check ranging from $25 to $500, depending on the provider's price and service. In the first twelve months of the program we found a 2.1 percent reduction in prices paid for services targeted by the rewards program. The reductions in price resulted in savings of $2.3 million, or roughly $8 per person, per year. These effects were primarily seen in magnetic resonance imaging and ultrasounds, with no observed price reduction among surgical procedures.
Michael L Barnett, Ateev Mehrotra, and David C Grabowski. 2019. “Postacute Care - The Piggy Bank for Savings in Alternative Payment Models?” N Engl J Med, 381, 4, Pp. 302-303.
Tara Jain, Richard J Lu, and Ateev Mehrotra. 2019. “Prescriptions on Demand: The Growth of Direct-to-Consumer Telemedicine Companies.” JAMA, 322, 10, Pp. 925-926.
Ashley M Kranz, Andrew Mulcahy, and Ateev Mehrotra. 2019. “Response to: "Comment on Patterns of Postoperative Visits Among Medicare Fee-for-Service Beneficiaries'.” Ann Surg, 270, 6, Pp. e145.
Ashley M Kranz, Andrew Mulcahy, and Ateev Mehrotra. 2019. “Response to Comment on "Patterns of Postoperative Visits Among Medicare Fee-for-service Beneficiaries".” Ann Surg, 270, 6, Pp. e113.
Tara Jain, Eleanor B Schwarz, and Ateev Mehrotra. 2019. “A Study of Telecontraception.” N Engl J Med, 381, 13, Pp. 1287-1288.
Michael L Barnett, Andrew Wilcock, Michael J McWilliams, Arnold M Epstein, Karen E Joynt Maddox, John E Orav, David C Grabowski, and Ateev Mehrotra. 2019. “Two-Year Evaluation of Mandatory Bundled Payments for Joint Replacement.” N Engl J Med, 380, 3, Pp. 252-262.Abstract
BACKGROUND: In 2016, Medicare implemented Comprehensive Care for Joint Replacement (CJR), a national mandatory bundled-payment model for hip or knee replacement in randomly selected metropolitan statistical areas. Hospitals in such areas receive bonuses or pay penalties based on Medicare spending per hip- or knee-replacement episode (defined as the hospitalization plus 90 days after discharge). METHODS: We conducted difference-in-differences analyses using Medicare claims from 2015 through 2017, encompassing the first 2 years of bundled payments in the CJR program. We evaluated hip- or knee-replacement episodes in 75 metropolitan statistical areas randomly assigned to mandatory participation in the CJR program (bundled-payment metropolitan statistical areas, hereafter referred to as "treatment" areas) as compared with those in 121 control areas, before and after implementation of the CJR model. The primary outcomes were institutional spending per hip- or knee-replacement episode (i.e., Medicare payments to institutions, primarily to hospitals and post-acute care facilities), rates of postsurgical complications, and the percentage of "high-risk" patients (i.e., patients for whom there was an elevated risk of spending - a measure of patient selection). Analyses were adjusted for the hospital and characteristics of the patients and procedures. RESULTS: From 2015 through 2017, there were 280,161 hip- or knee-replacement procedures in 803 hospitals in treatment areas and 377,278 procedures in 962 hospitals in control areas. After the initiation of the CJR model, there were greater decreases in institutional spending per joint-replacement episode in treatment areas than in control areas (differential change [i.e., the between-group difference in the change from the period before the CJR model], -$812, or a -3.1% differential decrease relative to the treatment-group baseline; P<0.001). The differential reduction was driven largely by a 5.9% relative decrease in the percentage of episodes in which patients were discharged to post-acute care facilities. The CJR program did not have a significant differential effect on the composite rate of complications (P=0.67) or on the percentage of joint-replacement procedures performed in high-risk patients (P=0.81). CONCLUSIONS: In the first 2 years of the CJR program, there was a modest reduction in spending per hip- or knee-replacement episode, without an increase in rates of complications. (Funded by the Commonwealth Fund and the National Institute on Aging of the National Institutes of Health.).
Kristin N Ray, Zhuo Shi, Sabrina J Poon, Lori Uscher-Pines, and Ateev Mehrotra. 2019. “Use of Commercial Direct-to-Consumer Telemedicine by Children.” Acad Pediatr, 19, 6, Pp. 665-669.Abstract
OBJECTIVE: In commercial direct-to-consumer (DTC) telemedicine, physicians outside of the medical home treat common, acute complaints through real-time, audio-visual conferencing using telephones and personal computers. There has been little examination of the use of DTC telemedicine by children. We describe trends in DTC telemedicine use and DTC telemedicine visit characteristics. METHODS: Using 2011-2016 claims from a large national health plan, we identified pediatric acute visits to DTC telemedicine and to primary care providers (PCPs). We examined DTC telemedicine visit trends and compared DTC telemedicine and acute PCP visit diagnoses and patient characteristics. RESULTS: From 2011 through 2016, pediatric DTC telemedicine visits increased from 38 to 24,409 visits annually. In 2015 and 2016, the most common primary diagnoses for DTC telemedicine visits (n = 42,072) were infections of the nose/sinuses (24%), mouth/throat (16%), and ear (9%), which were also the most common diagnoses for acute PCP visits (n = 6,917,976). Odds of DTC telemedicine use were higher for children in non-metropolitan communities (odds ratio [OR], 1.45; 95% confidence interval [CI], 1.40-1.51) and children without preventive visits (OR, 1.08; 95% CI, 1.06-1.11). Compared to children receiving acute PCP care, children with DTC telemedicine visits were also more likely to have had urgent care (17% vs 10%; P < .001) and emergency department visits (21% vs 19%; P < .001) during the study period. CONCLUSIONS: The use of commercial DTC telemedicine visits for children is growing rapidly, primarily for acute respiratory infections. Compared to children who did not use DTC telemedicine for acute care, children using DTC telemedicine were also more likely to use other venues for acute care outside of the medical home.
Sunita M Desai, Laura A Hatfield, Andrew L Hicks, Michael E Chernew, Ateev Mehrotra, and Anna D Sinaiko. 2019. “What are the potential savings from steering patients to lower-priced providers? a static analysis.” Am J Manag Care, 25, 7, Pp. e204-e210.Abstract
OBJECTIVES: Healthcare payers are increasingly using price transparency and benefit design to encourage patients to choose lower-priced providers. We quantify potential savings from shifting patients to lower-priced providers. If there is limited price variation or if higher-priced providers command little market share, savings could be minimal. STUDY DESIGN: Using 2013-2014 commercial claims for 697,381 enrollees in California, we characterized within-market price variation and the relationship between providers' market shares and relative prices for 3 nonemergent, shoppable outpatient services: laboratory tests, imaging services, and durable medical equipment (DME). In a stylized policy simulation that holds provider price and utilization constant, we computed potential savings if patients who visited providers with prices above the median price shifted to the median-priced provider in their geographic market for the same service. METHODS: Observational analyses. RESULTS: Of the service categories examined, laboratory tests had greatest within-market price variation (median coefficient of variation of 100% vs 87% for imaging services and 43% for DME). Roughly half of services (53%, 47%, and 54% for laboratory tests, imaging services, and DME, respectively) were billed by providers with prices above their market median. Shifting these patients to the median-priced provider in their markets could save 42%, 45%, and 15% of spending on laboratory tests, imaging services, and DME, respectively, together representing savings of 11% of total outpatient spending and 7% of the sum of inpatient and outpatient spending. CONCLUSIONS: Steering patients from higher- to lower-priced providers within geographic markets in targeted service categories could generate substantial healthcare savings.

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