Currently Viewing:
The American Journal of Managed Care November 2017
Using the 4 Pillars to Increase Vaccination Among High-Risk Adults: Who Benefits?
Mary Patricia Nowalk, PhD, RD; Krissy K. Moehling, MPH; Song Zhang, MS; Jonathan M. Raviotta, MPH; Richard K. Zimmerman, MD, MPH; and Chyongchiou J. Lin, PhD
The Influence of Provider Characteristics and Market Forces on Response to Financial Incentives
Brock O’Neil, MD; Mark Tyson, MD; Amy J. Graves, SM, MPH; Daniel A. Barocas, MD, MPH; Sam S. Chang, MD, MBA; David F. Penson, MD, MPH; and Matthew J. Resnick, MD, MPH
Patients' Perspectives of Care Management: A Qualitative Study
Ann S. O’Malley, MD, MPH; Deborah Peikes, PhD, MPA; Claire Wilson, PhD; Rachel Gaddes, MPH; Victoria Peebles, MSW; Timothy J. Day, MSPH; and Janel Jin, MSPH
Impact of Health Reform on Young Adult Prescription Medication Utilization
Amy Pakyz, PharmD, PhD, MS; Hui Wang, PhD; and Peter Cunningham, PhD
Reframing the Unaffordability Debate: Patient Responsibility for Physician Care
Katherine Hempstead, PhD; Josh Gray, MBA; and Anna Zink, BA
Electronic Reminder's Role in Promoting Human Papillomavirus Vaccine Use
Jaeyong Bae, PhD; Eric W. Ford, PhD, MPH; Shannon Wu, BA; and Timothy Huerta, PhD, MS
Improving Antibiotic Stewardship: A Stepped-Wedge Cluster Randomized Trial
Adam L. Sharp, MD, MS; Yi R. Hu, MS; Ernest Shen, PhD; Richard Chen, MD; Ryan P. Radecki, MD, MS; Michael H. Kanter, MD; and Michael K. Gould, MD, MS
Currently Reading
Changes in Cardiovascular Care Provision After the Affordable Care Act
Joseph A. Ladapo, MD, PhD; and Dave A. Chokshi, MD, MSc
Validation of a Claims-Based Algorithm to Characterize Episodes of Care
Chad Ellimoottil, MD, MS; John D. Syrjamaki, MPH; Benedict Voit, MBA; Vinay Guduguntla, BS; David C. Miller, MD, MPH; and James M. Dupree, MD, MPH

Changes in Cardiovascular Care Provision After the Affordable Care Act

Joseph A. Ladapo, MD, PhD; and Dave A. Chokshi, MD, MSc
The authors evaluated whether the 2010 Affordable Care Act was associated with changes in physicians’ provision of preventive cardiovascular services.
Our study supports the argument that the ACA’s cost-sharing provisions are an effective way to increase uptake of clinical preventive services, although overall levels of service provision were still lower than those recommended by the USPSTF and these gaps increase the population risk of CVD. Our findings are in contrast to some earlier evaluations of the ACA that found minimal or no effects on preventive care. However, the absolute effects of the ACA’s preventive cardiovascular care provisions were often modest. Physician decision making may be more sensitive to more proximal factors such as educational interventions, enhanced reimbursement for preventive services, or ease of operational processes, such as referrals for smoking cessation advice or point-of-care A1C testing. For services delivered during a preponderance of clinic visits, such as hypertension screening or tobacco use screening, strategies may differ and revolve around implementation of practice-level processes that ensure near-universal screening. For those offered during a lower proportion of visits, such as aspirin therapy or diabetes screening, clinical decision support (eg, electronic health record defaults) may be more effective. 


Our study has several limitations. We were unable to account for the presence of grandfathered plans exempt from some ACA provisions, patient or physician awareness of ACA provisions, or the effects of insurer medical loss ratio regulations that may have increased overall preventive service provision. Our findings may therefore underestimate (or overestimate, particularly in the cases of hypertension and tobacco use screening, where control populations were self-pay/uninsured) the effect of the policy change on physicians’ provision of preventive cardiovascular services. In addition, diffusion of high-deductible insurance plans may have exerted indiscriminate downward pressure on appropriate and inappropriate preventive care, a finding that was demonstrated in the RAND health insurance experiment.32 Related to this, if private plans or state Medicaid programs that were otherwise exempt from the ACA’s provisions chose to reduce cost sharing on preventive cardiovascular services in response to a changing climate of health reform, these shifts would cause us to understate the ACA’s effects. We also performed multiple statistical tests, and our findings should be interpreted in this context. Further, we did not have data on patients’ incomes, and some research suggests that patients from lower income groups—and the physicians who care for them—may be more sensitive to the elimination of marginal cost sharing than patients from higher income groups. 


Physicians’ provision of cardiovascular preventive care increased for some USPSTF-recommended services following enactment of the ACA. The results of our direct assessment of physicians’ clinical decision making in response to policy changes encoded in the ACA support the notion that cost-sharing provisions are an effective way to increase uptake of evidence-based clinical preventive services, although substantial gaps in preventive care persist. The sex disparity in aspirin use also underscores wider concerns about poorer-quality cardiovascular care in women versus men. Other interventions, including those with an educational, reimbursement-based, or practice-level focus, may be complementary approaches to influencing physician decision making and reducing the population burden of CVD.


Dr Joseph Ladapo had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Author Affiliations: Division of General Internal Medicine, David Geffen School of Medicine at UCLA (JAL), Los Angeles, CA; NYC Health + Hospitals and Departments of Population Health and Medicine, New York University School of Medicine (DAC), New York, NY.

Source of Funding: Dr Ladapo’s work is supported by a K23 Career Development Award (K23 HL116787) from the National Heart, Lung, and Blood Institute, R01 MD011544 from the National Institute on Minority Health and Health Disparities, and by the Robert Wood Johnson Foundation (72426). 

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article. 

Authorship Information: Concept and design (JAL, DAC); acquisition of data (JAL); analysis and interpretation of data (JAL, DAC); drafting of the manuscript (JAL, DAC); critical revision of the manuscript for important intellectual content (JAL, DAC); statistical analysis (JAL); provision of patients or study materials (JAL); obtaining funding (JAL); administrative, technical, or logistic support (JAL, DAC); and supervision (JAL, DAC). 

Address Correspondence to: Joseph A. Ladapo, MD, PhD, David Geffen School of Medicine at UCLA, 911 Broxton Ave, Los Angeles, CA 90024. E-mail: 

1. Go AS, Mozaffarian D, Roger VL, et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2013 update: a report from the American Heart Association. Circulation. 2013;127(1):e6-e245. doi: 10.1161/CIR.0b013e31828124ad.

2. Preventive services covered by private health plans under the Affordable Care Act. Kaiser Family Foundation website. Published August 4, 2015. Accessed January 16, 2017.

3. Sanghavi DM, Conway PH. Paying for prevention: a novel test of Medicare value-based payment for cardiovascular risk reduction. JAMA. 2015;314(2):123-124. doi: 10.1001/jama.2015.6681.

4. Frieden TR, Berwick DM. The “Million Hearts” initiative—preventing heart attacks and strokes. N Engl J Med. 2011;365(13):e27. doi: 10.1056/NEJMp1110421.

5. Ladapo JA, Rodwin BA, Ryan AM, Trasande L, Blustein J. Scientific publications on firearms in youth before and after Congressional action prohibiting federal research funding. JAMA. 2013;310(5):532-534. doi: 10.1001/jama.2013.119355.

6. Qaseem A, Alguire P, Dallas P, et al. Appropriate use of screening and diagnostic tests to foster high-value, cost-conscious care. Ann Intern Med. 2012;156(2):147-149. doi: 10.7326/0003-4819-156-2-201201170-00011.

7. Kale MS, Bishop TF, Federman AD, Keyhani S. Trends in the overuse of ambulatory health care services in the United States. JAMA Intern Med. 2013;173(2):142-148. doi: 10.1001/2013.jamainternmed.1022.

8. Ambulatory health care data: questionnaires, datasets, and related documentation. National Center for Health Statistics website. Updated August 31, 2017. Accessed June 4, 2013.

9. 2009 NAMCS micro-data file documentation. CDC website. Published April 26, 2012. Accessed June 4, 2013.

10. Norris SL, Kansagara D, Bougatsos C, Fu R; U.S. Preventive Services Task Force. Screening adults for type 2 diabetes: a review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2008;148(11):855-868.

11. US Preventive Services Task Force. Screening for obesity in adults: recommendations and rationale. Ann Intern Med. 2003;139(11):930-932.

12. US Preventive Services Task Force. Screening for high blood pressure: U.S. Preventive Services Task Force reaffirmation recommendation statement. Ann Intern Med. 2007;147(11):783-786. doi: 10.7326/0003-4819-147-11-200712040-00009.

13. Clinical summary: lipid disorders in adults (cholesterol, dyslipidemia): screening. US Preventive Services Task Force website. Published October 29, 2014. Accessed February 16, 2016.

14. Wolff T, Miller T, Ko S. Aspirin for the primary prevention of cardiovascular events: an update of the evidence for the US Preventive Services Task Force. Ann Intern Med. 2009;150(6):405-410.

15. US Preventive Services Task Force. Counseling and interventions to prevent tobacco use and tobacco-caused disease in adults and pregnant women: U.S. Preventive Services Task Force reaffirmation recommendation statement. Ann Intern Med. 2009;150(8):551-555.

16. Singleterry J, Jump Z, Lancet E, Babb S, MacNeil A, Zhang L; Centers for Disease Control and Prevention (CDC). State Medicaid coverage for tobacco cessation treatments and barriers to coverage—United States, 2008-2014. MMWR Morb Mortal Wkly Rep. 2014;63(12):264-269.

17. Sommers BD, Buchmueller T, Decker SL, Carey C, Kronick R. The Affordable Care Act has led to significant gains in health insurance and access to care for young adults. Health Aff (Millwood). 2013;32(1):165-174. doi: 10.1377/hlthaff.2012.0552.

18. Ladapo JA, Blecker S, Douglas PS. Physician decision making and trends in the use of cardiac stress testing in the United States: an analysis of repeated cross-sectional data. Ann Intern Med. 2014;161(7):482-490. doi: 10.7326/M14-0296.

19. Ladapo JA, Chokshi DA. Continuity of care for chronic conditions: threats, opportunities, and policy. Health Affairs blog website. Published November 18, 2014. Accessed April 6, 2016.

20. DeVoe JE, Fryer GE, Phillips R, Green L. Receipt of preventive care among adults: insurance status and usual source of care. Am J Public Health. 2003;93(5):786-791.

21. Ambulatory health care data: questionnaires, datasets, and related documentation: reliability of estimates. Published January 15, 2010. Accessed June 4, 2013.

22. Decker SL, Kostova D, Kenney GM, Long SK. Health status, risk factors, and medical conditions among persons enrolled in Medicaid vs uninsured low-income adults potentially eligible for Medicaid under the Affordable Care Act. JAMA. 2013;309(24):2579-2586. doi: 10.1001/jama.2013.7106.

23. McWilliams JM, Meara E, Zaslavsky AM, Ayanian JZ. Use of health services by previously uninsured Medicare beneficiaries. N Engl J Med. 2007;357(2):143-153. doi: 10.1056/NEJMsa067712.

24. Goff DC Jr, Lloyd-Jones DM, Bennett G, et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129(25, suppl 2):S49-S73. doi: 10.1161/01.cir.0000437741.48606.98.

25. Carroll MD, Kit BK, Lacher DA, Shero ST, Mussolino ME. Trends in lipids and lipoproteins in US adults, 1988-2010. JAMA. 2012;308(15):1545-1554. doi: 10.1001/jama.2012.13260.

26. Wright JD, Hughes JP, Ostchega Y, Yoon SS, Nwankwo T. Mean systolic and diastolic blood pressure in adults aged 18 and over in the United States, 2001-2008. Natl Health Stat Report. 2011(35):1-22,24.

27. Bairey Merz CN, Andersen HS, Shufelt CL. Gender, cardiovascular disease, and the sexism of obesity. J Am Coll Cardiol. 2015;66(18):1958-1960. doi: 10.1016/j.jacc.2015.08.860.

28. Han X, Robin Yabroff K, Guy GP Jr, Zheng Z, Jemal A. Has recommended preventive service use increased after elimination of cost-sharing as part of the Affordable Care Act in the United States? Prev Med. 2015;78:85-91. doi: 10.1016/j.ypmed.2015.07.012.

29. Jensen GA, Salloum RG, Hu J, Ferdows NB, Tarraf W. A slow start: use of preventive services among seniors following the Affordable Care Act’s enhancement of Medicare benefits in the U.S. Prev Med. 2015;76:37-42. doi: 10.1016/j.ypmed.2015.03.023.

30. Mehta SJ, Polsky D, Zhu J, et al. ACA-mandated elimination of cost sharing for preventive screening has had limited early impact. Am J Manag Care. 2015;21(7):511-517.

31. Hamel L, Firth J, Brodie M. Kaiser Health Tracking Poll: March 2014. Kaiser Family Foundation Website. Published March 26, 2014. Accessed May 21, 2016.

32. Brook RH, Ware JE Jr, Rogers WH, et al. Does free care improve adults’ health? results from a randomized controlled trial. N Engl J Med. 1983;309(23):1426-1434. doi: 10.1056/NEJM198312083092305.
Copyright AJMC 2006-2018 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
Welcome the the new and improved, the premier managed market network. Tell us about yourself so that we can serve you better.
Sign Up

Sign In

Not a member? Sign up now!