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Changes in Cardiovascular Care Provision After the Affordable Care Act
Joseph A. Ladapo, MD, PhD; and Dave A. Chokshi, MD, MSc
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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. 

Limitations

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. 

CONCLUSIONS

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.

Acknowledgments

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: jladapo@mednet.ucla.edu. 
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