The problem is compounded by the fact that low-income uninsured adults in states that opted not to expand Medicaid eligibility as part of the Patient Protection and Affordable Care Act appear to have more health-related issues than those uninsured adults living in states that expanded public insurance coverage.
A multi-institutional team led by researchers at the Perelman School of Medicine at the University of Pennsylvania has found that despite widespread rumors of limited access to primary care services, providers across the country were capable of accepting new patients prior to the start of the Affordable Care Act coverage expansions. That doesn't mean they did.
The simulated-patient study, to be published in the April 7th issue of JAMA Internal Medicine, found that in the states surveyed, primary care physician offices provided an appointment for 85 percent of the callers posing as patients with private insurance and for 58 percent of the callers posing as patients with Medicaid. Appointment rates were 79 percent for uninsured with full cash payment, but only 15 percent for those who could not pay more than $75 at the time of the visit. For all insurance types in most states, median wait times for a new patient appointment were just under one week.
“A key finding from our study is that despite the widely publicized shortage of primary care physicians, primary care capacity does exist in each state,” said the study’s lead author, Karin Rhodes, MD, MS, associate professor and director of the Center for Emergency Care Policy&Research in the Department of Emergency Medicine at Penn. “This is important information in light of concerns about the capacity of the U.S. health system to meet the demands of millions of new patients who are now obtaining insurance under the Affordable Care Act.”
For the study, researchers from the Perelman School of Medicine’s Department of Emergency Medicine, the University of Pennsylvania’s Leonard Davis Institute of Health Economics, and the Urban Institute conducted a simulated patient study in 10 diverse states to gather baseline data about access to primary care for nonelderly adults who are seeking primary care appointments as new patients prior to the major provisions of the Affordable Care Act.
Between November 2012 and March 2013, the research team made almost 13,000 calls to approximately 8,000 primary care practices while posing as new patients requesting appointments for either routine care or a serious health concern (such as newly diagnosed untreated hypertension). The callers were assigned to either private insurance, Medicaid, or no insurance. Importantly, for the Medicaid scenario, the researchers only called practices that participate in the state’s Medicaid program.
“This study highlights the importance of assisting new Medicaid beneficiaries to quickly identify practices that both accept their insurance and have the capacity to accept new patients.” said senior author Daniel Polsky, PhD, professor of Medicine and executive director, Leonard Davis Institute of Health Economics. “Even if a new Medicaid beneficiary were to call the two-thirds of primary care practices that participate in their state’s Medicaid program, only 58 percent of those practices were giving an appointment to a new Medicaid patient.” Polsky is hopeful that the primary care rate bump, which raises the Medicaid payment for primary care services up to the level of Medicare, will help encourage more primary care providers to accept new Medicaid patients.
“Perhaps the most discouraging news from this study is how few low income uninsured patients would be able to get a new patient appointment,” said Dr. Rhodes. “We estimate that only 15 percent of uninsured patients could get an appointment if they were able to pay $75 at the visit and make a payment arrangement for the remainder. And even that may be an optimistic scenario, given that the vast majority of uninsured adults are low income (living below 250 percent of the poverty level). In the 25 states that have not expanded Medicaid under the Affordable Care Act, it will be important to shore up the health care safety net.”
Despite these findings, Rhodes continued “The really good news is that if you get an appointment, most patients could be seen within one to two weeks, indicating that there is still lots of capacity in the system.”
The study serves as an important baseline measure that can be used to track changes in new patient appointment rates associated with Affordable Care Act health insurance expansion. For example, the same search problems found for Medicaid enrollees may be applicable to adults gaining coverage through the new private insurance marketplaces, especially in low-cost plans with narrower provider networks.
The states studied were Arkansas, Georgia, Illinois, Iowa, Massachusetts, Montana, New Jersey, Oregon, Pennsylvania, and Texas. They were selected for diversity along numerous dimensions. Collectively they comprise almost a third of the U.S. non-elderly, Medicaid, and currently uninsured populations.
Additional Penn co-authors on the new study include Robert Wood Johnson Foundation Health and Society Scholar, Brendan Saloner, PhD, and two Perelman School of Medicine students, Ari Friedman, MS and Charlotte Lawson. Co-authors Genevieve Kenney, PhD and Douglas Wissoker, PhD, senior fellows at the Urban Institute, were key contributors to the study. The team is simultaneously releasing two policy briefs (see links below) through the Urban Institute with additional findings that put the study results in a broader context.
Funding for the study was provided by a grant from the Robert Wood Johnson Foundation (70160). The Blue Cross Blue Shield Foundation of Massachusetts provided additional support for a supplemental sample in Massachusetts.
Urban Institute Policy Briefs: