By JOSH GRAY & IYUE SUNG

Since launching ACAView, our joint initiative between the Robert Wood Johnson Foundation (RWJF) and athenahealth, in early April, open enrollment under the Affordable Care Act (ACA) has closed for 2014 and The White House has issued final numbers: eight million people enrolled through the marketplace and five million outside the marketplace. Add another three million enrolled in Medicaid or the Children’s Health Insurance Program (CHIP) and the total number of people enrolled under the ACA’s individual mandate is close to 16 million.

Since some of these enrollees had previous forms of insurance coverage, it is important to estimate overall reductions in the number of uninsured. RAND estimates that 9.3 million more Americans have insurance in Q1 of 2014, compared to Q3 of 2013, but these figures exclude the surge of enrollments in the last half of March. The Congressional Budget Office (CBO) estimates 12 million net newly insured people through either the marketplace or Medicaid (including 1 million who lost insurance), but these estimates exclude enrollments outside the marketplace.

In short, “newly insured” and “enrollment numbers” are counted in different ways and can be confusing. But let’s conservatively assume that the number of net new insured individuals is roughly nine million, or 2.8% of the population.  Are these new beneficiaries having a measurable impact on medical practices?

In our previous report, we saw that, at least for the first quarter, a national sample of 12,700 physicians across the athenahealth network did not see an increase in new patients[1] due to the ACA. While not all new patients are newly insured, an increase in this population would suggest that coverage expansion is having an impact on medical practices. Instead, the percentage of total provider visits with new patients actually dropped slightly in the first three months of 2014 compared to 2013. Several factors may help explain why the ACA’s coverage expansion has not led to an immediate and measurable impact:

1. The number of newly insured patients in the first quarter of 2014 may have been too small to have a measurable impact.
2. Not all newly insured patients required care.
3. It may require weeks or months for patients to schedule appointments and be seen.

Our data suggests the influence of new patients on provider activity may take considerable time to unfold. Figure 1 shows the percentage of visits by new patients to Primary Care Providers (PCPs) at practice locations active before 2011. New patients account for 15% to 20% of office visits in the beginning of the year, growing as a proportion throughout the year. Note that a patient defined as new at any point during 2014 remains classified as new throughout the entire calendar year. In other words, these new patients are tracked as a cohort as the year progresses. We chose this definition to measure the level of effort physicians place in treating patients that are new to the practice across the year.

The proportion of visits by new patients in the first quarter actually dropped slightly between 2013 and 2014. As the newly insured seek out care, we will monitor the proportion of total provider visits for new patients compared to last year.

In addition to tracking the percentage of new patient visits, it is also important to consider whether those new patients have a higher rate of chronic conditions compared to previous years, and therefore, increase the proportion of care they receive from providers. That is, will the ACA result in the release of pent-up demand, with previously uninsured patients seeking care for a host of chronic and/or complex conditions that were previously left untreated?

So far, this does not appear to be the case. Figure 2 shows the proportion of visits, for Q1 of 2013, in which a chronic condition (diabetes, hypertension, hyperlipidemia) was diagnosed.  New patients are compared to established patients, by insurance type (commercial, Medicaid, Medicare). Results for commercial and Medicaid beneficiaries are shown only for adults under 65 and results for Medicare beneficiaries are shown only for adults 65+.

Not surprisingly, Medicare beneficiaries have higher rates of chronic disease than those with private insurance or Medicaid. It is also unsurprising that Medicaid beneficiaries have high rates of chronic conditions. But the most relevant comparison is that established patients have a higher rate of chronic diseases compared with new patients. In other words, new patients have a lower burden of chronic disease compared with established patients. This is true regardless of which age group (0-17, 18-49, 50-64, 65+) was examined.

This comparison shows numbers only for 2013. Have we seen any changes in the prevalence of chronic disease for new patients, so far in 2014? For the most part, no. 

Figure 3 compares chronic condition diagnosis rates for first quarter of 2013 to first quarter of 2014, for commercially insured patients between 18 and 64 years of age. On a national basis, neither new nor established patients saw an increase in diagnosis rates of chronic conditions.

We also examined chronic disease rates for different census regions (West, Midwest, Northeast, South); insurance types (commercial, Medicaid, Medicare), and practice size (1-5 providers, 6-20 providers, 21+ providers). In most of these clusters, the rate of chronic conditions for new patients did not increase between 2013 and 2014, any more so than the rate for established patients.

A potential exception is in the South. Figure 4 shows that for commercially insured patients of small practices in the South, ages 18-64, the rate of diabetes and high blood pressure diagnosis increased between 2013 and 2014 for new patients but remained fairly flat for established patients. We should caution that further observation and analysis is needed to evaluate whether this pattern holds up throughout the year.

It appears then, that during the first quarter of 2014, the ACA did not result in a shift of the composition of new patients towards those with more chronic diseases. A possible exception is with small practices in the South.

As part of our ACAView initiative, we will continue to provide updates on the impact the ACA has on physician practices. In coming months, we will update this look at new patient visits and disease profiles, and explore such topics as the amount that new patients owe for their care and whether they honor their financial obligations. As always, we welcome your comments.