Hannah T. Neprash

Introduction: In 2017, Medicare introducee Cognitive Assessment and Care Plan (CACP) billing code, which reimburses healthcare providers for comprehensive dementia visits. Uptake of CACP has been very low; drivers of use and underuse are not known. We sought to understand whether CACP spreads through practices after a champion provider adopts CACP. Methods: We used 100% samples of Medicare Fee‐For‐Service claims and Medicare Advantage encounters from 2017 to 2022 to model the relationship between peer CACP adoption and individual CACP adoption. Results: Our sample contained 607,164 providers, 8553 of whom billed for CACP from 2017 to 2022. Having a peer adopt CACP was associated with higher odds of adopting CACP individually (odds ratio [OR]: 17.1, confidence interval 95% CI: 16.1 to 18.2). The association was stronger if the peer shared the same specialty (OR: 23.5, 95% CI: 22.1 to 24.9). Conclusion: Being exposed to a peer who adopted CACP was a strong predictor of providers’ own uptake of CACP.

Objective: To characterize the nature and consequence(s) of interdependent physician electronic health record (EHR) work across inpatient shifts. Materials and Methods: Pooled cross-sectional analysis of EHR metadata associated with hospital medicine patients at an academic medical center, January–June 2022. Using patient-day observation data, we use a mixed effects regression model with daytime physician random effects to examine nightshift behavior (handoff time, total EHR time) as a function of behaviors by the preceding daytime team. We also assess whether nighttime patient deterioration is predicted by team coordination behaviors across shifts. Results: We observed 19 671 patient days (N = 2708 encounters). Physicians used the handoff tool consistently, generally spending 8–12 minutes per shift editing patient information. When the day service team was more activated (highest tercile of handoff time, overall EHR time), nightshift experienced increased levels of EHR work and patient risk of overnight decline was elevated. (ie, Busy predicts busy). However, lower levels of dayshift activation were also associated with nightshift spillovers, including higher overnight EHR work and increased likelihood of patient clinical decline. Patient-days in the lowest and highest terciles of dayshift EHR time had a 1 percentage point increased relative risk of overnight decline (baseline prevalence of 4.4%) compared to the middle tercile (P = .04) Discussion: We find evidence of spillovers in EHR work from dayshift to nightshift. Additionally, the lowest and highest levels of dayshift EHR activity are associated with increased risk of overnight patient decline. Results are associational and motivate further examination of additional confounding factors. Conclusion: Analyses reveal opportunities to address task interdependence across shifts, using technology to flexibly shape and support collaborative teaming practices in complex clinical environments.

The rapid growth of clinical artificial intelligence (AI) applications poses a unique challenge to Medicare's prospective payment systems, with two issues at the forefront. First, the productivity gains from AI may dwarf those of previous non-AI innovations, but they are uncertain and will take time to realize. Second, AI forces the Centers for Medicare and Medicaid Services (CMS) to think very differently about software. For many clinical applications of AI, the software itself is the service. It does not make sense to treat this expense as overhead, but direct reimbursement will likely exceed the true cost of using AI. Finally, although CMS currently pays for only a small fraction of all AI-enabled medical devices approved by the Food and Drug Administration, Medicare may already be spending more on AI as a result of additional AI-generated findings and follow-up care.

After the 2024 cyberattack on Change Healthcare, CMS distributed $3.3 billion to providers experiencing revenue disruptions, including $2.2 billion to hospitals. We found that the opt-in, one-size-fits-all nature of this relief funding simultaneously resulted in overpayments to many participating hospitals and underparticipation by many hospitals that had likely been disrupted by the cyberattack.

This cohort study analyzed Medicare claims data between 2010 and 2024 to quantify the rate of physician exits from traditional Medicare.

Importance: Under certain circumstances, advance practice clinicians (APCs), such as physician assistants and nurse practitioners, can bill Medicare directly or indirectly (ie, incident to the services of a physician). With indirect billing, the submitted claim states the care was provided by the physician, and the reimbursement is higher.Objective: To quantify volume and spending on office-based encounters billed indirectly in the Medicare program.Design, Setting, and Participants: This cohort study used Medicare fee-for-service and Medicare Advantage claims data to identify indirectly billed APC services. To do so, office-based Medicare Part B claims (ie, clinician services) were linked to Part D claims for prescription drug fills. Because the latter contains the prescribing clinician’s unique identifier, this linkage distinguished between directly and indirectly billed services provided by APCs. In this way, the fraction of encounters and component services billed indirectly by APCs and physicians were quantified.Main Outcomes and Measures: Share of fee-for-service and Medicare Advantage office encounters provided by APCs and billed indirectly. Share of a physician’s billed claims actually provided by an APC and billed indirectly.Results: In 2022, of all office encounters provided by an APC, 38.9% were billed indirectly. Conversely, for the median physician in 2022, indirect billing on behalf of APCs represented 11.1% of all billed encounters. Billing for care delivered by APCs was most common among surgical specialists (29.7% of encounters) and least common for primary care physicians (3.9%). If all indirectly billed APC-provided care was billed directly by the APC, Medicare would have saved $270 million in 2022.Conclusions and Relevance: The results of this cohort study suggest that APCs provide a substantial fraction of office-based care received by Medicare beneficiaries. Identifying indirectly billed APC-provided care is integral to understanding who serves Medicare beneficiaries.

More than 83 million people in the United States live in primary care shortage areas. As the US healthcare system faces a contracting primary care physician workforce, advanced practice providers are playing an increasingly important role in the delivery of primary care services. In parallel, public discourse regarding the differences in care delivery by advanced practice providers versus physicians has also expanded. In this commentary, we describe 3 main evidence gaps hindering optimal physician and advanced practice provider work organization in contemporary primary care delivery: (1) gaps in understanding the unique and overlapping competencies of each role group, (2) gaps in evaluating and defining optimal role delineation, and (3) gaps in payment models supporting effective collaboration. We subsequently present key needs in these 3 areas, including technology-based approaches to track physician and advanced practice provider competencies, increased empirical data on different clinical teaming structures, and exploration of novel models for primary care payment. We also note the need for an enhanced understanding of patient perspectives regarding primary care role types and teaming structures.