New lawsuit accuses health insurer Cigna of denying claims in bulk

An algorithm, not a doctor, predicted a rapid recovery for Frances Walter, an 85-year-old Wisconsin woman with a shattered left shoulder and an allergy to pain medicine. In 16.6 days, it is estimated, she would be ready to leave her nursing home.

On the 17th day, her Medicare Advantage insurer, Security Health Plan, followed the algorithm and cut off payment for her care, concluding she was ready to return to the apartment where she lived alone. Meanwhile, medical notes in June 2019 showed Walter’s pain was maxing out the scales and that she could not dress, go to the bathroom, or even push a walker without help. 

It would take more than a year for a federal judge to conclude the insurer’s decision was “at best, speculative” and that Walter was owed thousands of dollars for more than three weeks of treatment. While she fought the denial, she had to spend her life savings and enroll in Medicaid just to progress to the point of putting on her shoes, her arm still in a sling.

Health insurance companies have rejected medical claims for as long as they’ve been around. But the investigation found artificial intelligence is now driving their denials to new heights in Medicare Advantage, the taxpayer-funded alternative to traditional Medicare that covers more than 31 million people.

Behind the scenes, insurers are using unregulated predictive algorithms, under the guise of scientific rigor, to pinpoint the precise moment when they can plausibly cut off payment for an older patient’s treatment. The denials that follow are setting off heated disputes between doctors and insurers, often delaying the treatment of seriously ill patients who are neither aware of the algorithms nor able to question their calculations.

Older people who spent their lives paying into Medicare, and are now facing amputation, fast-spreading cancers, and other devastating diagnoses, are left to either pay for their care themselves or get by without it. If they disagree, they can file an appeal, and spend months trying to recover their costs, even if they don’t recover from their illnesses.

“We take patients who are going to die of their diseases within a three-month period of time, and we force them into a denial and appeals process that lasts up to 2.5 years,” Chris Comfort, chief operating officer of Calvary Hospital, a palliative and hospice facility in the Bronx, N.Y., said of Medicare Advantage. “So what happens is the appeal outlasts the beneficiary.”

In other words, "Deny until dead".  Or don't diagnose or treat patients with less than six months to live.

The algorithms sit at the beginning of the process, promising to deliver personalized care and better outcomes. But patient advocates said in many cases they do the exact opposite — spitting out recommendations that fail to adjust for a patient’s individual circumstances and conflict with basic rules on what Medicare plans must cover.

“While the firms say [the algorithm] is suggestive, it ends up being a hard-and-fast rule that the plan or the care management firms really try to follow,” said David Lipschutz, associate director of the Center for Medicare Advocacy, a nonprofit group that has reviewed such denials for more than two years in its work with Medicare patients. “There’s no deviation from it, no accounting for changes in condition, no accounting for situations in which a person could use more care.”

Medicare has its own set of guidance (rules) for benefit determination as set forth in the Code of Federal Regulations. 

As the influence of these predictive tools has spread, a recent examination by federal inspectors of denials made in 2019 found that private insurers repeatedly strayed beyond Medicare’s detailed set of rules. Instead, they were using internally developed criteria to delay or deny care. Although some insurers follow Medicare's guidelines private insurers often set their own guideline.  Since MA plans are private plans they are free to do so unless Medicare restricts it.

In interviews, doctors, medical directors, and hospital administrators described increasingly frequent Medicare Advantage payment denials for care routinely covered in traditional Medicare. UnitedHealthcare and other insurers said they offer to discuss a patient’s care with providers before a denial is made. But many providers said their attempts to get explanations are met with blank stares and refusals to share more information. The black box of AI has become a blanket excuse for denials. 

New lawsuit accuses health insurer Cigna of denying claims in bulk

'Misleading': Alarm raised about Medicare Advantage 'scam' -

'Misleading': Alarm raised about Medicare Advantage 'scam' - Raw Story - Celebrating 19 Years of Independent Journalism

Democratic U.S. lawmakers on Tuesday joined senior citizens, people with disabilities, and healthcare campaigners at a Capitol Hill press conference to kick off a week of action demanding Congress move to stop abuses by so-called Medicare Advantage programs peddled by profiteering insurance companies and "reclaim Medicare."

Congressional Dems, Activists 'Raise the Alarm' About Medicare Advantage 'Scam'

"It is time to call out so-called Medicare Advantage for what it is," said Rep. Rosa DeLauro. "It's private insurance that profits by denying coverage and using the name of Medicare to trick our seniors."

"We are here to raise the alarm about Medicare Advantage. We are here to protect our Medicare," Sen. Elizabeth Warren (D-Mass.) said to robust applause.

The Evolution of Private Plans in Medicare

Issue: Since the 1980s, private plans have played an increasingly important role in the Medicare program. While initially created with the goals of reducing costs, improving choice, and enhancing quality, risk-based plans — now known as Medicare Advantage plans — have undergone significant policy changes since their inception; these changes have not always aligned with the original policy objectives. 

"This year, for the very first time, more than half of all beneficiaries are enrolled in Medicare Advantage instead of traditional Medicare," she continued. "But Medicare Advantage substitutes private insurance companies for traditional Medicare coverage, and that private coverage is failing both Medicare beneficiaries and taxpayers."

"Not only do Medicare Advantage insurers rip off the government, they routinely deny care to patients who need it."

"It's all about the money," Warren said. "Private insurers are in Medicare Advantage to play games to extract more money from the government."

"Experts estimate that Medicare Advantage insurers will receive more than $75 billion in overpayments this year alone, and that's the real punch to the gut," she continued. "Not only do Medicare Advantage insurers rip off the government, they routinely deny care to patients who need it."

History of Changes in Payment and Quality in Medicare Private Plans

Act	Payment	Quality Improvement and Measurement
TEFRA (1982)	• 95% of per capita traditional Medicare costs • Risk adjustment based on demographics	• Evidence of increased preventive care • HEDIS created in 1991
BBA (1997)	• Traditional Medicare spending controlled and capitation rate updates reduced by 2.8% • Rates fixed at 1997 level and adjusted to pay highest of floor rate, annual update of 2%, and blended rate • Risk adjustment based on health status and demographics	• No change in quality or quality measurement
BBRA (1999)	• Bonus for first risk plan entering market • Increase in traditional Medicare spending, on which plan payment was based	• No change in quality or quality measurement
BIPA (2000)	• Minimum update temporarily raised to 3% • Floors in rural and urban counties raised • Risk adjustment based on demographics and diagnostic categories	• No change in quality or quality measurement
MMA (2003)	• Highest of urban or rural floor, 100% of average county-level traditional Medicare costs, higher of 2% or national traditional Medicare cost growth update over 2003 rate, and blended rate update • Bidding system with rebate at 75% of difference between benchmark and bid	• Star rating for plan quality instituted in 2008
MIPPA (2008)	• No change in payment	• Quality reporting and provider network reporting mandated for PFFS by 2011
ACA (2010)	• Counties ranked from lowest to highest traditional Medicare costs and divided into four assemblages: county benchmarks at 115%, 107.5%, 100%, and 95% of county traditional Medicare costs • Rebates at 50% but higher at 65% and 70% for plans with 3.5–4 and 4+ stars, respectively • 5% bonus to benchmarks of plans with 4+ stars • Risk adjustment updated to correct for coding intensity	• Nearly 50% of plans had 4+ stars in 2017 • Enrollment in plans with 4+ stars

Reclaim Medicare (video)

"We can strengthen traditional Medicare, and by doing that, we can save money and we can use some of those savings to expand benefits, like hearing, dental, and vision... and add an out-of-pocket cap for all beneficiaries... and lower the eligibility age for Medicare."

"Medicare money should be spent to deliver services for people," Warren added, "not to boost profits for insurance."

Rep. Rosa DeLauro (D-Conn.) said that "it is time to call out so-called Medicare Advantage for what it is. It's private insurance that profits by denying coverage and using the name of Medicare to trick our seniors.

Like the lawmakers, Alex Lawson, executive director of the advocacy group Social Security Works, blasted "bad actors in Medicare Advantage" who he said "are delaying and denying the care seniors and people with disabilities need."

"Corporate insurance is designed to generate profits by delaying and denying care, harming and killing patients instead of providing care,"

Wendell Potter, who heads the Center for Health and Democracy, repeated the common refrain that "so-called Medicare Advantage is neither Medicare nor an advantage. It is simply another scheme by the insurance companies to line their pockets at the expense of consumers by denying and delaying care."

"The healthcare market is confusing for consumers and the misleading branding of calling private insurance Medicare only makes this worse," Potter stressed.

Progressive lawmakers have also criticized President Joe Biden for delaying promised curbs on Medicare Advantage plans amid heavy insurance industry lobbying.

ERIC TOPOL AND A.I.

The amazing power of "machine eyes"

A COLLECTION OF TOPOL'S BEST

PART I

https://erictopol.substack.com/i/134587450/your-chest-x-ray-indicates-you-may-have-diabetes

https://erictopol.substack.com/i/134587450/your-chest-x-ray-indicates-your-ejection-fraction-may-be-low-and-the-presence-of-valve-disease

https://erictopol.substack.com/i/134587450/your-electrocardiogram-shows-you-are-having-a-heart-attack

https://erictopol.substack.com/i/134587450/large-language-models-are-answering-medical-questions-increasingly-correctly

https://erictopol.substack.com/i/134587450/ai-outshines-in-health-care-at-paperwork

PART II

https://erictopol.substack.com/i/134767572/a-randomized-trial-of-generative-ai

https://erictopol.substack.com/i/134767572/ai-and-bias-in-healthcare

https://erictopol.substack.com/i/134767572/ai-and-infectious-disease

https://erictopol.substack.com/i/134767572/robots-for-rehab-and-promoting-empathy

https://erictopol.substack.com/i/134767572/chatbots-instead-of-research-participants

https://erictopol.substack.com/i/134767572/summary

Medicare physician pay fell 26% since 2001. How did we get here? ] Things you do not know

Physician reimbursement left behind since 2001.  Despite inflation payment to physicians has been regressive due to the budget neutrality features in the Federal Budget.

Physicians have been on the road fighting for Medicare physician payment reform for well over a decade, and the system remains on an unsustainable path. Temporary patches and ongoing cuts to the Medicare physician payment system have left physician practices and patient access to care at serious risk.

Payment cuts, freezes and redistributions have further exacerbated the challenge. When adjusted for inflation, Medicare physician payment has effectively declined (PDF) by 26% from 2001 to 2023.

Despite that stark reality, Congress and the administration are still not focused on fixing the root of the problem—the payment system itself. But it’s time for that to change. It's essential that leaders in Washington work with the physician community on immediate, preventative measures, as well as long-term solutions that will reform the payment model once and for all.

A bill has been introduced in Congress to tie the Medicare physician payment schedule to the Medicare Economic Index, a move that is essential to protecting access to high-quality care for the 65 million older adult Americans covered by Medicare.

By instituting an annual inflation-based update, the legislation would put physicians on equal footing with virtually all other health professionals and organizations paid by Medicare. Physician payment rates have been subject to a six-year payment freeze that will last until 2026 and are seeing 2% across-the-board Medicare pay cuts that started in January.

This Medicare payment policy failure came as physicians had to deal with inflation, COVID-19, burnout and the rising cost of running a practice. When the freeze ends, the statutory update for most physicians will be limited to 0.25% indefinitely, far below even normal rates of inflation. 

Physicians and patients can no longer allow Medicare to kick the can down the road, as it has done with the national debt ceiliing.

Medicare physician pay fell 26% since 2001. How did we get here? | American Medical Association: Medicare’s unsustainable pay system threatens access to care. The failure to update physician pay for inflation is a huge part of the problem.

A paradigm shift away from condoms: Focusing STI prevention... : JAAPA

The Death of Condoms

 

I'm a big believer in the power of blogging. Not only does it allow us to express our ideas and opinions, it also helps us stay connected to friends, family, colleagues, and even strangers from all over the world. It's an amazing way to share stories and experiences that we otherwise wouldn't be able to.                              

Over the past few decades, evolving and diverse sexually transmitted infection (STI) prevention methods—methods significantly more effective than barrier protection—have caused a paradigm shift away from the traditional, limited, blanket recommendation to use condoms. Although condoms provide a barrier to body fluid-based STIs such as gonorrhea, chlamydia, and HIV, condom use is limited and often misunderstood, and counseling patients to use barriers may be ineffective.¹

Condoms do not protect against many diseases.  

Barrier protection has limited efficacy. Consistent condom use among patients identified as heterosexual and men who have sex with men (MSM) is 80% and 70% effective, respectively, for preventing HIV transmission.  Among MSM, inconsistent condom use is no more protective than no condoms at all for the prevention of HIV.Herpes simplex virus (HSV), human papillomavirus (HPV), Molluscum contagiosum, primary syphilis, and infestations (scabies and lice) are spread by skin-to-skin contact, limiting barrier effectiveness. Consistent condom use is about 70% effective at reducing HPV transmission and is of limited effectiveness against other STI transmission.

CONCLUSION

Rather than focusing on condom use, clinicians can improve patient sexual health by following CDC guidelines to perform routine, opt-out HIV testing for all people in all healthcare settings. discuss PrEP with all sexually active patients regardless of age, relationship status or structure, number of sexual partners, or barrier protection use screen for gonorrhea and chlamydia infections of the pharynx, genitals, and rectum at the site(s) of exposure, regardless of signs or symptoms13strictly follow guidelines for bacterial STI treatment, especially oral gonorrhea. Vaccinate all patients for HPV and provide vaccination against hepatitis A, B, and C when indicated. 

Educating patients on safer sexual practices including limiting the number of partners, mutual monogamy, and using condoms is also important in order to reduce the risk of STI transmission. Additionally, clinicians should be aware that e-cigarettes are not an effective method of contraception. 

Additional resources are available from the Centers for Disease Control and Prevention (CDC) to help with STI prevention, screening, and treatment. Clinicians should also consider partnering with community organizations that can provide additional support and education for their patients. It is important to remember that safe sex practices include more than just using condoms; they encompass behavior changes such as abstaining

A paradigm shift away from condoms: Focusing STI prevention... : JAAPA

Monthly Musings On American Healthcare

A compendium about healthcare

Thought ideas to improve healthcare

July 2023 What do the best healthcare leaders have in common?

June 2023 Best summer reading for healthcare professionals?

May 2023 Will our nation make time to mourn 1.1 million Covid-19 deaths?

April 2023 Where are the healthcare regulators?

March 2023 What is the promise (and peril) of AI-enabled healthcare?

February 2023 Will ChatGPT change medical practice?

January 2023 How did healthcare become a “conglomerate of monopolies”?

2022

2021

2020

2019

2018

2017

Monthly Musings On American Healthcare by Dr. Robert Pearl

What's New for Treatment of Alzheimer's Disease

Overview

Alzheimer's disease is a brain disorder that gets worse over time. It's characterized by changes in the brain that lead to deposits of certain proteins. Alzheimer's disease causes the brain to shrink and brain cells to eventually die. Alzheimer's disease is the most common cause of dementia — a gradual decline in memory, thinking, behavior and social skills. These changes affect a person's ability to function.

About 6.5 million people in the United States age 65 and older live with Alzheimer's disease. Among them, more than 70% are 75 years old and older. Of the about 55 million people worldwide with dementia, 60% to 70% are estimated to have Alzheimer's disease.

The early signs of the disease include forgetting recent events or conversations. Over time, it progresses to serious memory problems and loss of the ability to perform everyday tasks.

Medicines may improve or slow the progression of symptoms. Programs and services can help support people with the disease and their caregivers.

There is no treatment that cures Alzheimer's disease. In advanced stages, severe loss of brain function can cause dehydration, malnutrition or infection. These complications can result in death.

Broader Medicare coverage is now available for Biogen and Eisai’s Leqembi (the brand name for lecanemab) following the Food and Drug Administration’s (FDA) move to grant traditional approval to the drug that treats individuals with Alzheimer’s disease. The Centers for Medicare & Medicaid Services had previously announced this would be the case and released more details on coverage today.

Now that the FDA has granted traditional approval, a CMS-facilitated registry is open for clinicians to access here. Additional background information is available for providers here and for patients here and at medicare.gov.

Under the Medicare National Coverage Determination, if FDA grants traditional approval to other drugs in this class, Medicare will cover them using this same coverage framework.

Thanks to the Mayo Clinic a book is available to explain what is known about Alzheimer's Disease.

It can be purchased here

A guide for people with dementia and those who care for them

Dementia is a serious health challenge. By some estimates, the number of people living with dementia could triple by 2050.

While Alzheimer's disease is the most common cause of dementia, many related types of dementia also affect adults worldwide.

Although the diseases that cause dementia have long been considered unrelenting and incurable, there is hope.

Lecanemab for Alzheimer's disease: An option for you?

The drug lecanemab appears to slow mental decline in people with early Alzheimer's disease. Learn whether it might be right for you.

By Mayo Clinic Staff

Lecanemab is a drug given to slow the progression of mild Alzheimer's disease (AD). This drug reduces clumps of proteins that play a key role in AD. Reducing brain amyloid-beta proteins modestly slows memory and thinking decline from AD.

Lecanemab is for people who have early symptomatic AD. In a recent drug trial, taking lecanemab over 18 months slowed the rate of cognitive decline. It's not yet known whether the drug helps in other ways such as slowing the development of AD in people without symptoms of memory loss.

Lecanemab is given by IV infusion every two weeks. Your care team likely will watch for side effects and ask you or your caregiver how your body reacts to the drug.

Because lecanemab is a new drug, there is still much to learn about it. Some people who take lecanemab have side effects such as:

Dizziness.

Headache.

Visual changes.

Worsening confusion.

Swelling or bleeding in the brain.

Rarely, death.

Brain shrinkage.

Not for everyone

Lecanemab is not helpful for people with full cognitive function or later stages of AD. The drug does not prevent or cure AD. Your health care team will help you decide if lecanemab is an option for you.

The medicines you take for other conditions and your health history may affect whether you can take lecanemab. A history of cancer or bleeding in your brain or use of anticoagulant drugs, such as warfarin or apixaban, may prevent you from taking lecanemab.

If you take lecanemab, you likely will have regular MRI scans to check for brain bleeds. If your side effects are severe, you may need anti-seizure drugs or care in a hospital. You also may have to stop taking the drug.

What is Lecanemab and how does it work?  Lecanemab is a monoclonal antibody drug.

What is the pathophysiology of Alzheimer disease?

 Alzheimer's disease is characterized by an accumulation of abnormal neuritic plaques and neurofibrillary tangles. Plaques are spherical microscopic lesions that have a core of extracellular amyloid beta-peptide surrounded by enlarged axonal endings.

Lecanemab is a monoclonal antibody consisting of the humanized version of a mouse antibody, mAb158, that recognizes protofibrils and prevents amyloid beta deposition in animal models of Alzheimer's disease.

Three drugs used to treat AD are all in one family, called cholinesterase inhibitors, which boost brain levels of acetylcholine: Galantamine (Razadyne®) Rivastigmine (Exelon®) Donepezil (Aricept®)

None of these drugs offer a cure for AD. These drugs appear to slow down the process of AD. Research into new treatments is ongoing. Promising drug therapies under investigation include medications to target the formation of abnormal neuritic plaques, reduce inflammation in affected brain areas, and prevent cell death. Vaccines that prompt the body’s immune system to attack amyloid beta are also being researched.

In addition to medical treatment, certain lifestyle changes may help individuals with AD. This includes physical exercise, social interaction, mental stimulation, and a healthy diet rich in antioxidants and omega-3 fatty acids. Caregivers should also help ensure the individual is getting enough sleep. Additionally, individuals with AD should avoid alcohol, smoking, and caffeine as these can worsen symptoms. Finally, participation in clinical trials may provide access to experimental treatments for AD.

Biblio:

Clin Med (Lond). 2016 Jun;16(3):247-53. doi: 10.7861/clinmedicine.16-3-247.

Australas Psychiatry. 2018 Aug;26(4):347-357. doi: 10.1177/1039856218762308. Epub 2018 Apr 3.

PMID: 29614878 Review.

Curr Neuropharmacol. 2020;18(11):1106-1125. doi: 10.2174/1570159X18666200528142429.

PMID: 32484110 Free PMC article. Review.

 Comprehensive Review on Alzheimer's Disease: Causes and Treatment.

Breijyeh Z, Karaman R.

Molecules. 2020 Dec 8;25(24):5789. doi: 10.3390/molecules25245789.

PMID: 33302541 Free PMC article. Review.

 

A review on advances of treatment modalities for Alzheimer's disease.

Se Thoe E, Fauzi A, Tang YQ, Chamyuang S, Chia AYY.

Life Sci. 2021 Jul 1;276:119129. doi: 10.1016/j.lfs.2021.119129. Epub 2021 Jan 27.

PMID: 33515559 Review.

Physician Turnover in the United States

Medical groups, health systems, and professional associations are concerned about potential increases in physician turnover, which may affect patient access and quality of care. 

To address this concern, they are working together to develop innovative strategies to retain physicians. These include providing financial incentives, such as loan repayment programs and signing bonuses; offering flexible work schedules; increasing administrative support staff; creating career development opportunities for physicians; and improving the overall work environment. Additionally, physician organizations are exploring how technology can be leveraged to help retain doctors, such as through telemedicine and remote patient monitoring. 

The hope is that these measures will enable physicians to better manage their workloads, allowing them to spend more time providing quality care and less time dealing with administrative tasks. A strong emphasis on physician retention could help ensure the continued availability of reliable medical care for patients across the country.

A study from the Annals of Internal Medicine by Amelia M. Bond, PhD, Lawrence P. Casalino, MD, PhD, Ming Tai-Seale, PhD indicates there was little change in physician turnover.  The study, however, was based upon billing practices for Medicare patients. 

To examine whether turnover has changed over time and whether it is higher for certain types of physicians or practice settings.

Design:

The authors developed a novel method using 100% of traditional Medicare billing to create national estimates of turnover. Standardized turnover rates were compared by physician, practice, and patient characteristics.

Setting:  Traditional Medicare, 2010 to 2020.

Participants: Physicians billing traditional Medicare.

Measurements:  Indicators of physician turnover—physicians who stopped practicing and those who moved from one practice to another—and their sum.

Results:

The annual rate of turnover increased from 5.3% to 7.2% between 2010 and 2014, was stable through 2017, and increased modestly in 2018 to 7.6%. Most of the increase from 2010 to 2014 came from physicians who stopped practicing increasing from 1.6% to 3.1%; physicians moving increased modestly from 3.7% to 4.2%. Modest but statistically significant (P < 0.001) differences existed across rurality, physician sex, specialty, and patient characteristics. In the second and third quarters of 2020, quarterly turnover was slightly lower than in the corresponding quarters of 2019.

Implications:

The data suggest that physician turnover is an ongoing challenge for healthcare organizations, particularly in rural areas. It also suggests that healthcare organizations may be more successful in recruiting and retaining physicians if they can identify the factors associated with increased turnover, anticipate changes in the local or larger healthcare market, and design strategies to retain existing staff. The findings from this study add

Conclusion:

Over the past decade, physician turnover rates have had periods of increase and stability. These early data, covering the first 3 quarters of 2020, give no indication yet of the COVID-19 pandemic increasing turnover, although continued tracking of turnover is warranted. This novel method will enable future monitoring and further investigations into turnover. It also indicates that healthcare organizations should remain engaged in identifying the factors associated with increased turnover and developing strategies to retain existing staff. With this information, healthcare organizations can create better working environments and more efficient health service delivery for their patients. ~~~~~~~~~END~~~~~~~~~~~

This study flies in the face of frequent statements and beliefs about physician burnout, depression, suicide, and career change.

There are no national estimates of physician turnover, so it is not known whether turnover has increased, as is sometimes assumed (2). If changes in turnover over time exist, they could be driven by the large shift in the composition of physicians and their practices as the number of female physicians and the size of practices have grown in recent years. Even if turnover rates have not changed, they may vary by physician and practice characteristics, geographic location, or the composition of a practice’s patient population. The degree to which turnover merits additional or targeted organizational and policy intervention and investment requires information on these questions.1. Shanafelt T, Goh J, Sinsky C. The business case for investing in physician well-being. JAMA Intern Med. 2017;177:1826-1832. [PMID: 28973070] doi:10.1001/jamainternmed.2017.4340

Measuring Physician Turnover

We defined 2 types of physician turnover, physicians who moved from one practice to another and those who stopped practicing (that is, left practice), henceforth “movers” and “leavers.”

When identifying movers, our goal was to determine whether a physician who was working with one practice ended the relationship and joined a second practice. In billing data, it is possible to identify the month a physician begins billing a new practice or TIN. However, billing a new practice does not necessarily indicate movement; it could, for example, indicate that a medical group is using more than 1 TIN, that a medical group was acquired by another practice, or that a physician worked part-time in 2 practices. We developed 3 preconditions to determine whether the billing of a new practice constituted a physician moving: A physician had to have a relationship with both the first and new practices through sufficient months of billing—we used 4 months as the primary specification, with 3 and 6 months in sensitivity analyses; the relationships with the first and second practices had to be temporally independent (that is, a physician must bill at least 4 months with their old practice and new practice in different months); and the potential move should not represent a medical group reorganizing its financial structure. Specifically, the old practice had to continue to exist after a physician moved, and a physician could not continue to bill with many of their former peers. Section II of the Supplement provides full details on methods and sample flow charts

The goal in identifying physician leavers was to identify physicians who fully retired from practice or stopped practicing for an extended period. This method considered an extended period to be 2 years and identified physician leavers as those who stopped billing for 2 years (Section II of the Supplement). In sensitivity analyses, we applied periods of 3 months, 1 year, and 3 years.

Primary measures of moving and leaving were reported on a July-to-June basis because measurement of moving required up to 6 months of billing data before and after a potential month of moving. Rates of moving were reported for years 2010 to 2020. Rates of leaving were reported for years 2010 to 2018 because measurement of leaving required 2 years of billing data after a potential month of leaving.

In a supplementary analysis examining turnover during the beginning of the COVID-19 pandemic, we used modified quarterly measures that could be constructed through the third quarter of 2020. Moving required a physician to have a 3-month rather than a 4-month relationship with both the first and new practices. Leaving required a physician to stop billing for 3 months rather than 2 years.

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2. Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. Lancet. 2009;374:1714-1721. [PMID: 19914516] doi:10.1016/S0140-6736(09)61424-0

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3. Willard-Grace R, Knox M, Huang B, et al. Burnout and health care workforce turnover. Ann Fam Med. 2019;17:36-41. [PMID: 30670393] doi:10.1370/afm.2338

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4. Reddy A, Pollack CE, Asch DA, et al. The effect of primary care provider turnover on patient experience of care and ambulatory quality of care. JAMA Intern Med. 2015;175:1157-62. [PMID: 25985320] doi:10.1001/jamainternmed.2015.1853

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5. Chanfreau-Coffinier C, Washington DL, Chuang E, et al. Exploring the association of care fragmentation and patient ratings of care quality: a mediation analysis of women veterans' experience with VA care. Health Serv Res. 2019;54:816-826. [PMID: 30989651] doi:10.1111/1475-6773.13153

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6. Rodriguez HP, Rogers WH, Marshall RE, et al. The effects of primary care physician visit continuity on patients' experiences with care. J Gen Intern Med. 2007;22:787-793. [PMID: 17431698] doi:10.1007/s11606-007-0182-8

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