New Patient Visit Benchmark and the ACA

I mentioned I had a lot of work to do after the NCE this week.  Here’s one of the items hanging over my head (next: Down Syndrome growth charts!).

During my lecture on pediatric benchmarks, someone threw me a curveball.  I feel like I’m usually pretty good with my ability to answer questions about the data off the top of my head, but this was a new one.  I shared with the audience our “new patient” benchmarks from the last 4 years:

2011: 3.1%
2012: 3.1%
2013: 3.1%
2014: 3.4%

What is being measured here?  Something very specific.  It’s literally a comparison of the 9938X+9920X codes to the 9939X+9921X codes.  It doesn’t tell you the entire new patient story, just the rate at which new patients are coming in “off the street.”  It doesn’t count newborns, for example (who can be very difficult to count for technical reasons), but it’s easy to calculate and gives you particular insight in your practice.

I introduced this slide and remarked how consistent the number has been over the last 4 years.  Then some wiseguy said, “Actually, that’s a 10% jump.  Could this be because of ACA and expanded health insurance?”

I was, for me, dumbfounded (it’s not like I stopped talking).  He was absolutely right. I could see how it might be the case.  I needed to find out.

I went back to my data.  I decided to segregate it by state for states where we have enough clients that I feel comfortable considering the results.  Here’s what I found:

MA: 2.00%
VT: 2.10%
NJ: 2.40%
PA: 2.70%
NC: 3.00%
IL: 3.40%
Average -  3.50%
TX: 3.90%
GA: 3.90%
CA: 4.00%
WA: 5.00%
FL: 5.20%
OK: 6.30%

Noting that the sample size is suspect, here’s what we know.

  • The states with the biggest increase in new patient visit volume in 2014 are being sued (or have been) by their chapter AAPs for lack of access for poor children. (FL and OK).
  • All but one of the “below average” states participated in the ACA Medicaid expansion program. And that state (NC) already had a great Medicaid program.
  • 4 of the 6 “above average” states above did not participate in the Medicaid expansion program.

I think this is the opposite of what we initially expected.  We expected to see that expanded Medicaid programs would draw in more patients.  They didn’t, really (if we pretend our sample here is valid).  Why not?  Check out this chart and scroll down to the horizontal bar graphs.  As you can see, the total possible number of new Medicaid patients in VT+MA+PA+IL+NJ isn’t as large as FL alone.  And NC, even though it didn’t vote to expand Medicaid, already had (arguably) the best Medicaid-for-children program in the country.  In other words, in states where Medicaid is already expanded, regardless of the ACA, we saw little change.  NJ is an exception – it’s a notably poor Medicaid program, they chose to expand it, and there weren’t many new patients.

I welcome additional comments, no matter how partisan.

4 replies
  1. Suzanne Berman, MD, FAAP
    Suzanne Berman, MD, FAAP says:

    I’m not sure you can really draw a correlation between “new patients for practice X” and “newly insured Medicaid, SCHIP, or Exchange patients who didn’t have insurance before.”

    I think you could argue the opposite conclusion from the same data:
    * Florida and Oklahoma pay crap rates for their Medicaid services.
    * Ergo, there are not enough pediatricians in FL and OK to see these kids in a timely, accessible manner.
    * Ergo, kids can’t see their regular PCP anymore conveniently because she’s 30 miles away and has a 3 month wait time for a checkup.
    * Ergo, kids are going to migrate elsewhere, anywhere, where they can get an EPSDT or an earache looked at. This might be a new medical home. Or it might be a one-off visit with someone, without the intent to establish care with the new practice — they just want their ear checked, today. In either case, this may be a new patient visit.

    On the other hand, NC (which has been doing the medical home as a state even before it was sexy) may have more stable patient panels.

    Can you control for practices that started up during the reporting year? Because if I moved to location X and opened a new practice there, all my patients will be new patients.

    Another possibility is the “rediscovered patient rate.” This is the kid who’s 17 who’s been yours since birth. But after age 8, they don’t come in much. But you’ll see them at 11-12 (for 7th grade imms), at 14-15 (for sports physical) and age 18-19 (for college checkup, or in my practice, confirmation of pregnancy.) If these kids are coming in every 3 years, rather than every other year or every year, then they’re new-according-to-CPT patients, even though they’re really not “new.”

    Reply
    • Chip Hart
      Chip Hart says:

      First, there’s no question that the data itself leaves a lot to be desired and there are few, if any, conclusions we can draw from it properly. We’re just guessing and making stuff up. I am, anyway.

      Second, let me start by addressing your final point. Unless we have a reason to think that rediscovered patients had a reason to jump by 10% (or more) in 2014, and that they are all being coded as new patients (which I am sure most of them are not), I don’t think this is an issue.

      Hmmm, continuing in reverse, about the new practice question. Again, we’d have to assume the distribution of new practices among these states in this data is significantly variable. You’re right, though, that COULD be an issue. I just spot checked – unscientifically – the data for the two states where I think we have real new practice volume (CA, TX) and I don’t believe it is an issue. Feel free to call my bluff.

      Now let’s get to your larger comment set.

      Your chain of conclusions is valid, but I don’t think they reflect what’s in the data here.

      First, FL has really bad Medicaid payments. So does NJ, though. Worse, in fact (you can see data at http://kff.org/medicaid/state-indicator/medicaid-to-medicare-fee-index/ and I believe NJ has dropped to #49). OK is actually ranked #4. What does this mean? I don’t think it means that PCC clients in the bottom half of the list were picking up more the patients from other practices, including one-offs, etc. If so, why was 2015 so much higher in those states?

      I DO think that the states at the top of the list have more stable Medicaid populations, subjectively.

      Reply
  2. Suzanne Berman, MD, FAAP
    Suzanne Berman, MD, FAAP says:

    What about the trend of pediatricians to drop nursery privileges and just start seeing newborns at the weight check visit? Maybe not 10% in one year, but shouldn’t the trend be upward? (I don’t know many pediatricians who don’t do rounds, but then START doing them.) This would certainly cause an increase in the appearance of new patient codes. I would also expect some regional variation.

    I think what you’d have to do to test this is rerun the data, and sort the new patient codes into 2 groups: one in which (date of service) – (date of birth) <=14 days (or however you want to classify a newborn), and everyone else. We have always seen our own newborns, so I can run our data as a control group.

    As far as my other point:
    a) Medicaid to Medicare payment ratios are a large part, but not the only part, of willingness of physicians to see new Medicaid patients. The M:M payment ratio-to-pedi-availability correlates, but it's not linear. A lot of it has to do with overall pediatrician supply in a region. I will post data to that assertion after I get more coffee 🙂
    b) Medicaid to Medicare payment ratios posted on sites like KFF do not really reflect what the majority of pediatricians are paid (or not paid) for their work. Those rates are "straight state" Medicaid, but we know that the majority (70%? 75%?) of kids are actually in managed Medicaid plans. (Note how Tennessee NEVER has an entry in any of those tables — because we're 100% managed Medicaid.)

    Chip, you're actually in a better position than probably anybody in this country to share what pediatricians who take managed Medicaid actually make as a relation to Medicare, as it compares to posted Medicaid rates.

    Reply
  3. Suzanne Berman, MD, FAAP
    Suzanne Berman, MD, FAAP says:

    This article is nearly 15 years old now, but I love it so much (even though I’m not *that* S. Berman):

    http://pediatrics.aappublications.org/content/110/2/239.abstract

    …which showed that Medicaid payment rates as a percent of Medicare strongly correlated to pediatricians taking new Medicaid patients — but pediatrician workforce, degree of capitation, and paperwork hassles were also significant.

    The AAP and others has published periodic surveys of Medicaid participation data since then, but many of them don’t carve out “safety net pediatrician” like this study did, which I think is an important distinction. If you’re a community health center or are employed by a teaching hospital, of course you take new Medicaid.

    I ran the Chip New Patient Metric and found:
    2011 4.7%
    2012 4.3%
    2013 4.0%
    2014 4.2%

    When I divided it into new patients aged 15 days old, I got:

    2011 10.2% of all new patients were newborns under 2 weeks old (i.e. we see newborns in the hospital, but we didn’t see this one)
    2012 9.9%
    2013 8.8%
    2014 14.6%

    …a lot more variability than I’d expect, for reasons I can’t explain.

    Reply

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