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Analytics & Research | Healthcare Policy & Reform

ACAView: Medicaid Gap Widening Between Expansion and Non-Expansion States


Iyue Sung, Director of Core AnalyticsIn measuring the effects of health insurance coverage expansion as part of our ACAView initiative with Robert Wood Johnson Foundation (RWJF), an important factor to consider is state policy towards Medicaid expansion.

The intention of the Affordable Care Act (ACA) was to expand coverage through two mechanisms: 1) People with moderate incomes could gain coverage through the exchanges, often encouraged by subsidies; and 2) those with lower incomes could gain coverage through an expansion of Medicaid eligibility to include groups that had not traditionally qualified for Medicaid.

For many years, states had widely varying Medicaid eligibility rules, with some states covering only women and their children in need of public aid and low-income people with disabilities. Other states had expanded eligibility to include people at income levels higher than the federal poverty level.

Given the differing Medicaid expansion decisions among states, we examined our data on visits to primary care physicians (PCPs) separately for states with and without Medicaid expansion.

Figure 1 shows proportions of visits between January 2012 and May 2014 for four groups of adults (18-64): uninsured individuals in Medicaid-expansion states; uninsured individuals in non-Medicaid expansion states; Medicaid beneficiaries in expansion states; and Medicaid beneficiaries in non-expansion states.



Two observations are worth noting:

  1. ACA coverage expansion appears to be widening a pre-existing gap between states that have elected to pursue Medicaid expansion and those that have not. Providers in the Medicaid-expansion states were already seeing higher proportions of Medicaid beneficiaries in 2013. For example, in December of 2013, 12.3% of 18-64 year- old visits to PCPs in expansion states were from Medicaid beneficiaries, compared with 5.9% in non-expansions states, a 6.4 percentage point differential. By May 2013, that difference had expanded to a 9.3 percentage point differential, as the percent of Medicaid visits increased in Medicaid expansion states but held constant in non-expansion states.
  2. The proportion of uninsured fell in both categories, from 4.5% to 3.3% in expansion states and 7.0% to 5.8% in non-expansion states (figures for January through May for both years, respectively).

Figure 2 expands the Medicaid payer mix analysis to other specialties.


In Medicaid expansion states, all four specialty types showed a substantial increase in the proportion of visits by Medicaid beneficiaries. In contrast, in non-Medicaid expansion states, the proportion of visits by Medicaid beneficiaries decreased for all four specialty groups.

As a result of these changes, by early 2014 PCPs, surgeons, and other specialists in expansion states saw two to three times more adult Medicaid patients (in proportional terms) than in non-expansion states (for example, 15.6% versus 6.3% for PCPs; 11.6% versus 3.1% for surgeons).

For OB-GYN, the ratio between the proportion of visits by Medicaid beneficiaries in the expansion and non-expansion states is much smaller, 19.4% versus 13.4%. This may reflect more generous Medicaid eligibility in non-expansion states for pregnant women compared to other adults.

As we monitor these metrics, a few questions will be of particular interest:

  • Where will the increase in Medicaid volumes in expansion states level off?
  • To what extent is the increase in Medicaid visits driven by established patients who were previously uninsured?
  • What are the effects of increased Medicaid volumes on medical practices?

We will attempt to address these (and other) complex issues throughout the year.

For a better understanding of our goals, methodology, data sample size, and full findings since the inception of the ACAView series, please read our first report, “First Observations Around the Affordable Care Act.” And if you have questions or suggestions for further analysis, please direct them to athenaResearch Vice President Josh Gray at jogray@athenahealth.com or @JoshGray_hit .


Analytics & Research

Data Drives Insight into Value-based Care Decisions


Anne Meneghetti, MD, Executive Director of Medical Information, Epocrates, an athenahealth companyHow many times have you experienced the angst of finding out that a patient never filled a prescription because of personal finances? How often have you seen a patient go without treatment while prior authorization hurdles were being worked out? Practices are spending more time than ever before on affordability issues like these.

We recently surveyed 70 clinicians about their biggest affordability challenges. Topping their list of responses was the lack of available information on actual drug or procedure costs for patients, cited by 43% of respondents, while patient inability to afford care was listed second, by 28% of those surveyed.

In Jonathan Bush’s provocative new book, “Where Does It Hurt? An Entrepreneur’s Guide to Fixing Health Care,” the athenahealth CEO advocates for greater freedom to choose one’s own care options based on cost-effectiveness and personally meaningful differentiators. Yet without reliable insights into the specific costs and multi-dimensional outcomes for various options, neither clinicians nor patients are positioned to make clear choices.

Thankfully, guidance is emerging from multiple sectors.

The Patient-Centered Outcomes Research Institute (PCORI) was authorized by Congress to fund comparative effectiveness research to drive informed care decisions. A viewpoint piece in the June issue of the Journal of the American Medical Association (JAMA) calls upon specialty societies, such as the American Academy of Family Physicians (AAFP) and American College of Physicians, to create and disseminate specialty-specific tools and guidelines that help clinicians make complex value-based decisions. Specialty society guidance has also emerged from the American Board of Internal Medicine’s Choosing Wisely® Campaign, which encourages professional organizations to spark conversation between providers and patients about the value of various tests and treatments. For example, AAFP has suggested guidelines on when to question antibiotics for sinusitis or otitis media, and when to reconsider routine screening with PSA, DEXA, carotid artery stenosis testing and Pap smears. The American Academy of Pediatrics recommends criteria for routine CTs for minor head injury, simple febrile seizures, and abdominal pain. In addition, the organization offers advice on use of antibiotics for asymptomatic bacteriuria, cough and cold medicines for children under four years old, and GERD medications for “happy-spitter” infants.

Epocrates is doing its part to help bring clinical intelligence to the exam room to support value-based prescribing decisions. Within our core app, you can find hundreds of health plan and retail pharmacy formularies. Select “Alternatives” to compare affordability of other options in the same therapeutic subclass. Search the “Manufacturer/Pricing” section for a comparison between retail costs and formulary coverage; in some cases, retail pricing may be the most affordable choice.

The increasing focus on comparative effectiveness research, guidance from specialty societies, and cost data integrated into medical apps like Epocrates, will offer clinicians relevant insights for making complex value-based decisions of care.

What are your biggest pain points in identifying and obtaining affordable options for patients?


Analytics & Research

ACAView: Measuring the Impact of Patient Acuity


Since launching ACAView, our joint initiative between the Robert Wood Johnson Foundation (RWJF) and athenahealth, in early April, open enrollment under the Affordable Care Act (ACA) has closed for 2014 and The White House has issued final numbers: eight million people enrolled through the marketplace and five million outside the marketplace. Add another three million enrolled in Medicaid or the Children’s Health Insurance Program (CHIP) and the total number of people enrolled under the ACA’s individual mandate is close to 16 million.

Since some of these enrollees had previous forms of insurance coverage, it is important to estimate overall reductions in the number of uninsured. RAND estimates that 9.3 million more Americans have insurance in Q1 of 2014, compared to Q3 of 2013, but these figures exclude the surge of enrollments in the last half of March. The Congressional Budget Office (CBO) estimates 12 million net newly insured people through either the marketplace or Medicaid (including 1 million who lost insurance), but these estimates exclude enrollments outside the marketplace.

In short, “newly insured” and “enrollment numbers” are counted in different ways and can be confusing. But let’s conservatively assume that the number of net new insured individuals is roughly nine million, or 2.8% of the population. Are these new beneficiaries having a measurable impact on medical practices?

In our previous report, we saw that, at least for the first quarter, a national sample of 12,700 physicians across the athenahealth network did not see an increase in new patients[1] due to the ACA. While not all new patients are newly insured, an increase in this population would suggest that coverage expansion is having an impact on medical practices. Instead, the percentage of total provider visits with new patients actually dropped slightly in the first three months of 2014 compared to 2013. Several factors may help explain why the ACA’s coverage expansion has not led to an immediate and measurable impact:

  1. The number of newly insured patients in the first quarter of 2014 may have been too small to have a measurable impact.
  2. Not all newly insured patients required care.
  3. It may require weeks or months for patients to schedule appointments and be seen.

Our data suggests the influence of new patients on provider activity may take considerable time to unfold. Figure 1 shows the percentage of visits by new patients to Primary Care Providers (PCPs) at practice locations active before 2011. New patients account for 15% to 20% of office visits in the beginning of the year, growing as a proportion throughout the year. Note that a patient defined as new at any point during 2014 remains classified as new throughout the entire calendar year. In other words, these new patients are tracked as a cohort as the year progresses. We chose this definition to measure the level of effort physicians place in treating patients that are new to the practice across the year.

The proportion of visits by new patients in the first quarter actually dropped slightly between 2013 and 2014. As the newly insured seek out care, we will monitor the proportion of total provider visits for new patients compared to last year.


In addition to tracking the percentage of new patient visits, it is also important to consider whether those new patients have a higher rate of chronic conditions compared to previous years, and therefore, increase the proportion of care they receive from providers. That is, will the ACA result in the release of pent-up demand, with previously uninsured patients seeking care for a host of chronic and/or complex conditions that were previously left untreated?

So far, this does not appear to be the case. Figure 2 shows the proportion of visits, for Q1 of 2013, in which a chronic condition (diabetes, hypertension, hyperlipidemia) was diagnosed. New patients are compared to established patients, by insurance type (commercial, Medicaid, Medicare). Results for commercial and Medicaid beneficiaries are shown only for adults under 65 and results for Medicare beneficiaries are shown only for adults 65+.

Not surprisingly, Medicare beneficiaries have higher rates of chronic disease than those with private insurance or Medicaid. It is also unsurprising that Medicaid beneficiaries have high rates of chronic conditions. But the most relevant comparison is that established patients have a higher rate of chronic diseases compared with new patients. In other words, new patients have a lower burden of chronic disease compared with established patients. This is true regardless of which age group (0-17, 18-49, 50-64, 65+) was examined.


This comparison shows numbers only for 2013. Have we seen any changes in the prevalence of chronic disease for new patients, so far in 2014? For the most part, no.

Figure 3 compares chronic condition diagnosis rates for first quarter of 2013 to first quarter of 2014, for commercially insured patients between 18 and 64 years of age. On a national basis, neither new nor established patients saw an increase in diagnosis rates of chronic conditions.


We also examined chronic disease rates for different census regions (West, Midwest, Northeast, South); insurance types (commercial, Medicaid, Medicare), and practice size (1-5 providers, 6-20 providers, 21+ providers). In most of these clusters, the rate of chronic conditions for new patients did not increase between 2013 and 2014, any more so than the rate for established patients.

A potential exception is in the South. Figure 4 shows that for commercially insured patients of small practices in the South, ages 18-64, the rate of diabetes and high blood pressure diagnosis increased between 2013 and 2014 for new patients but remained fairly flat for established patients. We should caution that further observation and analysis is needed to evaluate whether this pattern holds up throughout the year.


It appears then, that during the first quarter of 2014, the ACA did not result in a shift of the composition of new patients towards those with more chronic diseases. A possible exception is with small practices in the South.

As part of our ACAView tag initiative, we will continue to provide updates on the impact the ACA has on physician practices. In coming months, we will update this look at new patient visits and disease profiles, and explore such topics as the amount that new patients owe for their care and whether they honor their financial obligations. As always, we welcome your comments.

Check out Josh Gray’s Google+ Profile. Follow @JoshGray_HCIT on Twitter.

1We define new patients as one who has not visited a particular physician in two years or more.


Analytics & Research

No Lack of Attention to ADHD


Attention deficit-hyperactivity disorder (ADHD) continues to draw public attention, with articles appearing in the November New England Journal of Medicine and most recently in the New York Times. The Times article emphasized the rising use of ADHD drugs by both adults and children in 2012, based on a recent report issued by Express Scripts about ADHD medication trends. The Express Scripts study showed a steady growth in the number of children taking ADHD medication through 2012. Recently, athenaResearch examined diagnostic data coming in from physicians on the athenahealth network to see whether 2013 data indicate any slackening of growth in ADHD diagnoses.

The ADHD Diagnosis Debate
The public attention to ADHD includes intense debate about whether the large numbers of ADHD diagnoses and prescriptions are appropriate. Proponents of ADHD medication believe that drug treatment has conferred substantial benefits on numerous children and adults. In contrast, skeptics believe the increase in ADHD diagnosis and treatment is unnecessary, citing several factors that may have contributed to the increase. Among the skeptics’ contentions is that greater academic performance pressures on students may lead parents to push pediatricians for a medical solution to behavior that in past years would have been tolerated. Those questioning the current level of ADHD diagnosis also suggest that some pediatricians may lack the time for careful clinical interviews or the training for neuropsychological testing – both needed to make reliable ADHD diagnoses. As a result, some cases are possibly misdiagnosed as ADHD, rather than anxiety, mood or conduct disorders. Finally, some believe that because behavioral therapy for ADHD is fairly time consuming and expensive, parents and physicians may prefer medication (page 9 of Express Scripts report).

We are not in a position to judge the relative merits of arguments for and against current levels of medical treatment of ADHD. However, given the public focus on the issue, we thought it would be useful to examine recent practice patterns to determine whether pediatricians have become more conservative in their diagnosis and treatment of ADHD over the last year or so.

2013 ADHD Diagnosis Patterns
To shed light on more recent patterns, we examined a sample of 538 pediatricians across 31 states that have used athenahealth services between January 2010 and the end of 2013. Our sample consisted of roughly 3.5 million office visits over this three-year span.

Our Findings
Concerns about ADHD have not stemmed from the long-standing increase in ADHD diagnosis. For every subcategory we considered, the proportion of pediatrician visits resulting in an ADHD diagnosis increased at roughly the same rate as was evident between 2010 and 2012.

For girls, the proportion of visits with a diagnosis of ADHD increased from 3.6% in 2010 to 4.2% in 2012, and then to 4.6% in 2013. For boys, ADHD diagnoses increased from 9.1% in 2010 to 10% of all visits in 2012 and then to 10.5% in 2013. The same pattern was evident in all subgroups.



In short, at least for pediatricians within the athenahealth network, we have not yet seen an inflection point in which concerns about ADHD over-diagnosis and overtreatment have translated into a more conservative approach in clinical practice.

For those interested in scrutinizing the data more closely, figures are provided in the following table.



Check out Matt Nix’s Google+ Profile.


Analytics & Research

ACAView: Measuring the Impact of Health Care Reform on Day-to-Day Physician Practice


Iyue Sung, Director of Core AnalyticsWith this post, we are pleased to introduce ACAView, a joint initiative between the Robert Wood Johnson Foundation (RWJF) and athenahealth. 2014 marks the launch of the Affordable Care Act’s (ACA) most important coverage expansion provisions, designed to dramatically reduce the number of uninsured Americans. Between now and the end of 2016, millions of individuals are expected to sign up for subsidized insurance coverage through newly established health care exchanges, or marketplaces. Other tracking initiatives are closely monitoring the number of individuals that sign up for this coverage as well as those that take advantage of expanding Medicaid coverage in some states.

With ACAView, we will take a different approach. We will focus on the provider perspective; more specifically, how the ACA affects the practice patterns and economics of physicians and other care team members around the country. This is also part of a wider effort, Reform by the Numbers, RWJF’s rich source of timely and unique data about the impact of health reform.

ACAView will monitor the impact of coverage expansion on a monthly basis, mining insights from athenahealth’s cloud-based network of more than 50,000 providers and 50 million patients. Our cloud-based, centrally hosted software platform provides us with near real-time visibility into practice patterns of physicians around the country.

Our goal is to inform, exchange ideas, and provide a timely, front-row view of how this landmark legislation affects a robust cross-section of providers across the nation. In subsequent reports, we will examine an evolving set of metrics that address a broad range of topics. We will also share our analyses on the extent to which our providers represent all providers in the US. For more about our data on practices and patients, as well as our preliminary list of metrics, please read our Methodology report.

No Meaningful Change to Date in New Patient Volumes
Among the many unknown questions surrounding coverage expansion is the number of new patients physicians will accommodate. This is a critical issue because one of the goals of health care reform is to allow individuals to form stable physician relationships, rather than seek care in high-acuity settings or forgo care altogether. If the ACA is working, we would expect physicians to see a higher percentage of new patients over the course of the year. Over the long term, this number should eventually return to historical levels as these new patients become established.

Figure 1 shows the percentage of provider visits accounted for by new patients, for the first two months of 2013 and 2014. These percentages are based on physician practices active on athenahealth’s network before 2011. In January through March of 2014, new patients accounted for 17% of visits to primary care practices, down slightly from the 17.9% for the same period in 2013. Other specialties, with the exception of pediatrics, also showed a slight decline in the proportion of new patient visits. In general, we view these differences as too small, or the timeframe too early, to indicate a meaningful change.



The absence of an increase in new patient visits in the first two months of the year does not surprise us. As of April 1, 7.1 million individuals had enrolled in private insurance plans, through either state or federal marketplaces. This represents approximately 2% of the population (estimates for Medicaid enrollment were not yet available at the time of this report). Of that 2%, an unknown proportion of these individuals had some form of previous coverage, so they are not necessarily “newly insured.” It will take some time for newly insured patients to locate new physicians, make appointments with them, and receive care. We look forward to monitoring this metric to identify meaningful changes when and if they occur.

Will there be Noticeable Differences in the Health Status of New Patients?
Another question is whether the new patients that physicians see are sicker than they were in the past. We will examine this issue in greater detail in our next blog post, but provide an early example here. Figure 2 shows the percentage of new patients with a diagnosis of diabetes from January through March 2014 compared to January through March 2013. The chart also shows the same statistics for established patients (patients who have visited in the last two years), who have a higher rate of diabetes. For both groups, we see no change to date, but will continue to monitor this and other chronic disease indicators.



The questions of whether the ACA will cause physicians to devote a higher share of their case mix to seeing new patients, or whether new patients will be more likely to have chronic disease (compared to new patients from previous years, or established patients) are just two issues we will consider over the course of the year.

Other questions we will examine include the following:

  • How much will new patients owe for their care?
  • How will reimbursement levels change for new patients relative to historical patterns?
  • How long will new patients have to wait for care from the time an appointment is made?

Our objective with this joint initiative is to answer a broad set of questions as the year progresses, and we welcome your commentary and suggestions along the way. For continued updates, follow Reform by the Numbers, as well as the ACAView tag on the athenahealth CloudView Blog.

You can connect with our researchers through email at ACAView@athenahealth.com. We also invite you to follow Josh Gray, VP of athenaResearch, on Twitter @JoshGray_hit on Twitter.

Matt Nix and Chris Jones of athenahealth conducted the analysis used in this post.


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