Supplementary Online Content

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1 Supplementary Online Content Song Z, Ayanian JZ, Wallace J, He Y, Gibson TB, Chernew ME. Unintended consequences of eliminating Medicare payments for consultations. JAMA Intern Med. Published online November 26, doi: /jamainternmed emethods. Study Population Inclusion Criteria etable 1. Change in Fees Between 2009 Consultations and 2010 Office Visits (the Effective Fee Cut) etable 2. Change in Office Visit Fees From 2009 to 2010 (the Compensatory Fee Increase) etable 3. Definitions of Clinical Complexity etable 4. Sensitivity Analyses This supplementary material has been provided by the authors to give readers additional information about their work.

2 Unintended consequences of eliminating Medicare payments for consultations e-methods. Study population inclusion criteria Our study population was drawn from the Thomson Reuters MarketScan Medicare Supplemental claims database and included Medicare beneficiaries who had any of the ICD-9 diagnoses listed in (1) or had any claim for a prescription medication belonging to a class of drugs listed in (2). Given our non-randomly drawn sample of Medicare beneficiaries, we adjust all analyses using the Centers for Medicare and Medicaid Services Hierarchical Condition Category (CMS-HCC) risk-adjustment system (version 2010), which uses nationally-representative coefficients derived using age, sex, and clinical diagnoses. The CMS- HCC score is used in risk adjustment of payments for Medicare Advantage plans. For all analyses, we also included sensitivity analyses in which the risk scores are omitted (e-table 4). 1. Any individual who have an International Classification of Diseases, 9th edition (ICD-9) diagnosis of ANY of the following: ( ) hypertensive diseases ( ) ischemic heart disease ( ) pulmonary heart diseases ( ) heart failure and related diseases ( ) cerebrovascular diseases ( ) vascular diseases ( ) other vascular diseases ( ) diabetes mellitus OR 2. Any individual who had a claim for ANY of the following prescription medications: HMG-CoA reductase inhibitors (statins) Other lipid-lowering agents Diuretics ACE inhibitors Angiotensin II receptor blockers (ARBs) Vasodilators Beta-blockers Antiarrhythmics Cardiac glycosides

3 e-table 1. Change in professional fees between 2009 consultations and 2010 office visits (the effective fee cut)* Consultation fees in 2009 Office visit fees in 2010 HCPCS code Fee ($) HCPCS code Fee ($) % Change (new) (lowest complexity) (estab.) (new) (estab.) (new) (estab.) (new) (estab.) (new) (highest complexity) (estab.) * On the left hand side are consultation codes ( ) and their 2009 fees, which were eliminated in On the right hand side are 2010 fees for office visits, which physicians were instructed to substitute towards. The % change column describes the change in fees for 2010 office visits compared to 2009 fees for consultations. Codes are office visits for new patients. Codes are office visits for established patients. All fees are national Payment Amounts for outpatient professional fees derived from the Medicare Part B Physician Fee Schedule.

4 e-table 2. Change in office visit fees from 2009 to 2010 (the compensatory fee increase)* HCPCS code 2009 Fee ($) 2010 Fee ($) % Change (new) (estab.) (new) (estab.) (new) (estab.) (new) (estab.) (new) (estab.) * This table shows the change in office visit fees from 2009 to Codes are office visits for new patients. Codes are office visits for established patients. All fees are national Payment Amounts for outpatient professional fees derived from the Medicare Part B Physician Fee Schedule.

5 e-table 3. Definitions of clinical complexity for patient encounters Level of Complexity Description A problem focused history; A problem focused examination; and Straightforward medical decision making. Self limited or minor Consultation (99241) 15 min New office visit (99201) 10 min Established office visit (99211) 5 min An expanded problem focused history; An expanded problem focused examination; and Straightforward medical decision making. Low severity Consultation (99242) 30 min New office visit (99202) 20 min Established office visit (99212) 10 min A detailed history; A detailed examination; and Medical decision making of low complexity. Moderate severity Consultation (99243) 40 min New office visit (99203) 30 min Established office visit (99213) 15 min A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Moderate to high severity Consultation (99244) 60 min New office visit (99204) 45 min Established office visit (99214) 25 min A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Moderate to high severity Consultation (99241) 80 min New office visit (99205) 60 min Established office visit (99215) 40 min The following definitions are shared by the common procedural definition (CPT) coding system, used by most commercial insurers, and the Healthcare Common Procedure Coding System (HCPCS) used by Medicare. and presenting problem(s) are identical for consultations, new office visits, and established office visits.

6 e-table 4. Sensitivity analyses The following table lists interrupted time series estimates of the 2010 Medicare policy s effect on spending and volume, by type of patient encounter as well as for all encounters. The base model results (row 1) are compared to results from sensitivity analyses (rows 2-6). Sensitivity analyses are alterations from the base model. P values are in parentheses. Base model Omit quarter indicators Omit HRR indicators Omit linear trend Omit age, sex, and risk score Continuous 4-year enrollees Adjusted change in spending ($ per beneficiary per quarter) New All office Established Encounters Consults visits office visits Adjusted change in volume (per 100 beneficiaries per quarter) New All office Established Encounters Consults visits office visits -1.4 (p=0.18) (p<0.001) 8.7 (p<0.001) 1.3 (p=0.19) (p=0.18) (p<0.001) (p<0.001) (p=0.19) (p<0.001) (p<0.001) (p<0.001) (p=0.85) (p=0.002) (p<0.001) (p<0.001) (p<0.001) (p<0.001) (p<0.001) (p<0.001) (p=0.04) (p<0.001) (p<0.001) (p<0.001) (p=0.42)