Physician Data on Impact of Health Reform In 2014

Screen Shot 2015-05-13 at 3.05.39 PMOver the past year, our athenaResearch team has been working with the Robert Wood Johnson Foundation (RWJF) on ACAView, an initiative that provides researchers, policymakers and the public with regular updates on how the Affordable Care Act (ACA) is affecting physician provider practices. To accomplish this, we curate and analyze data from a nationally distributed sample of 16,000 providers on the athenahealth cloud-based network. This gives us a timely view into national physician practice patterns and an ideal platform for measuring the impact of health care reform on the day-to-day practice of medicine.

After reporting some initial findings a handful of times, we’ve recently published our comprehensive report from the first year of the ACA rollout: “ACAView: Observations on the Affordable Care Act: 2014” (PDF). Here are some of the more interesting findings from the data:

Many feared a surge of new patient volume. That hasn’t occurred.

In 2014, the coverage provisions of the ACA went into effect, with the intention of bringing millions of patients into stable physician relationships that would improve their health status. Just before the coverage expansion, some commentators expressed concern that physicians might lack the practice capacity to treat these new patients, many of them with unmet medical needs. That has not happened.

Looking at a sample of approximately 5,500 primary care providers, the proportion of visits with new patients barely changed, inching up from 22.6% in 2013 to 22.9% in 2014*.  Similar patterns are evident for providers in OB-GYN, pediatrics, and other specialties.

If 14 million patients are newly insured under the ACA, why aren’t physicians seeing many more new patients? Commenters on our report offer several speculations.

In an article on Vox, Sarah Kliff points out that the newly insured represent only about 4% of the population, not an overwhelming number relative to practice capacity. Formerly uninsured patients may also be receiving care in alternative settings, such as convenient or urgent care clinics, which are not included in the ACAView sample.

Another speculation is that some formerly uninsured patients may continue to seek care at emergency departments rather than forming stable primary care relationships.

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As for overall health, visit acuity and diagnoses per visit were relatively unchanged. ACAView data illustrates that new patients who sought care were no sicker in 2014 than 2013. The proportion of visits for patients with diagnoses of diabetes, hypertension, and hyperlipidemia did not change substantially. The one exception was an increase in the proportion of mental health diagnoses, but this change was underway before 2014 and does not appear to be a result of ACA-driven coverage expansion.

The proportion of uninsured patients seen in physician offices has fallen sharply in Medicaid expansion states, but only slightly in non-expansion states.

In 2012, the Supreme Court ruled that the decision to expand Medicaid eligibility can be made at the state level. In the wake of that decision, 28 states have expanded eligibility, and the experiences of expansion states and non-expansion states have diverged dramatically.

Within our ACAView sample, in states that decided to expand eligibility, 4.6% of patient visits in 2013 were with uninsured patients. Then, after expansion began, this fell to 2.8% in 2014, a relative decline of 39% year over year.  In non-expansion states, the proportion of visits by uninsured patients fell from 7% to 6.2%, a relative decline of only 11%.

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A sharp increase in Medicaid case mix largely explains the drop in the proportion of uninsured visits in expansion states, as he proportion of visits involving major public and private insurers, is normally quite stable. With coverage expansion, however, the proportion of visits with Medicaid patients in expansion states spiked quickly, from 12.2% of visits in December 2013 to 15% in March 2014, peaking at 16.7% of all visits in September.

In contrast, the proportion of visits with Medicaid patients in non-expansion states actually declined slightly – despite the fact that, as a result of the publicity around the ACA, the number of individuals with Medicaid coverage in those states actually increased. The slight decline could be related to physicians in non-expansion states becoming more focused on opening their patient panels to those who are newly insured by one of the federally qualified subsidized health plans now available through the health care marketplaces.

More commercially insured patients are switching to Medicaid.

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As previously noted, more people found themselves eligible for Medicaid in 2014. For qualified individuals employed in low-paying jobs, Medicaid is often an attractive option when compared with employer-sponsored coverage, which typically requires employees to contribute to premiums and leaves them subject to significant copays and deductibles. In contrast, out-of-pocket medical costs for Medicaid patients are either zero or minimal.

For this reason, more people with commercial insurance are switching to Medicaid. In our sample, 1.1% of individuals who were commercially insured in 2012 (and who visited an athenahealth provider in both 2012 and 2013) shifted to Medicaid coverage. As shown below, the number of those who transitioned increased to 1.8% between 2013 and 2014, a large relative increase during a year that the economy performed well.

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To learn more about our ACAView initiative and read all of our findings, read “ACAView: Observations on the Affordable Care Act: 2014” (PDF). You can also follow ACAView and other research work on the athenahealth CloudView blog, or connect with our team at athenaresearch@athenahealth.com or @IyueSung and @JoshGray_HIT on Twitter.

Josh Gray is VP for athenaResearch  Independent consultant David Clain contributed to this report.

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12 replies »

  1. Steven, my question is whether or not the elderly patient that needs to be seen as an emergency should be seen by anyone else but an M.D. In my own practice I have seen numerous misdiagnosis of bronchitis when the patient was in CHF, GERD where the underlying problem was cardiac, etc. This occurred with M.D.’s and with PA’s etc. What happens when we decrease the training? I always thought the M.D. was needed more to see the emergency than to see the patient with chronic hypertension, but I note that things have changed and the M.D.’s schedule is full so the patients are seen by the PA. Thus I am skeptical for this reason and the fact that today we have some great nurses, NP’s and PA’s, but I wonder if the quality will be kept up as greater use is made of them and advertising pushes people into those fields rather than true desire.

    We are treading in waters that are unknown and likely to have a lot of surprises.

  2. “some commentators expressed concern that physicians might lack the practice capacity to treat these new patients, many of them with unmet medical needs. That has not happened.”

    I wonder what this really means. Much if not most of the increase in patients under the ACA came from patients insured with Medicaid and we see a large increase in ER visits. Those in the exchanges are finding they have very large deductibles/ coinsurance and to many of them I bet they consider themselves essentially uninsured. We have to remember that family incomes have decreased and the number of unemployed eligible working adults that is very high. Therefore I don’t know why anyone would look at “That has not happened” in a positive fashion.

  3. We’re not tracking those metrics John, but I agree that you are pointing to some of the most critical issues afflicting the health care system. I am hoping that some of the team-based care and medical home models will increase satisfaction levels for physicians entering practice.

    One of the most dispiriting things I have witnessed in the last five years is some of the most talented and inspired physicians I know (some of whom I have known since college) losing their joy in practice or giving up on medicine entirely.

  4. Josh,

    Thanks for the link. I’ll look at this closely. I’m not particularly surprised and I do not think the frustration stops there.

    How many years have you been doing this snapshot? It would be useful to look at the longer term trends. My sense is that we thought things were bad a year ago, then they got worse.

    And do you have a sense of what the impact is? Are you getting a sense of the numbers of physicians who are a). changing jobs within medicine or b). giving up and leaving the field?

  5. John, thanks for the comment and for your work with THCB.

    Here’s our latest on checking the pulse of physicians across the U.S. – results from a national survey of ~3,000 physicians reveals near unanimous frustration over the inability to share information across the care continuum.
    http://newsroom.athenahealth.com/phoenix.zhtml?c=253091&p=irol-newsArticle&ID=2034495 full survey results here:

  6. Great point Steven and thanks everyone for a great conversation. There is definitely a disconnect, in my mind, between bringing in new people for care into a system that, at least in some markets, lacks sufficient primary care capacity. I think it is vastly preferable for the newly insured to establish real relationships with physicians rather than settle for a series of disconnected transaction. (That is just as true for the long insured as for the newly insured). The challenge now is for all health care providers to be working to the top of their licenses (PAs and NPs absorbing PCP work, PCPs absorbing specialist work). And to restore some of the satisfaction and joy to the calling of primary care.

  7. Very useful analysis. Positive in most ways, but worrisome, too. I concur with above comments that these data indicate/suggest continued use of ERs and shift to use of urgent care/minute clinic facilities. Excess ER use has to be discouraged; it’s wasted money and resources. Increased use of urgent care facilities is a good trend in general but is still an evolving phenomena, and it’s as yet unclear how much it supplants having a PCP. If it does, that’s bad. CVS and other urgent care center entrepreneurs may have to rectify that. There’s disagreement about the impact of possible doc shortage in coming years, as the baby boom generation docs retire. My own view is that a lot of routine care should be shifted to other clinicians (nurses, PAs, etc) anyway. There’s long been an underuse of physician skills/expertise as they spend too much time seeing people with colds, flu, and minor ills. I look forward to further data and analysis from this tracking project.

  8. “we’ll continue to see the shift of even previously insured individuals or those that are going into Medicaid and Medicare have less access to a PCP.”

    They may have less access to a PCP, but more access to appropriate care in an ER, or even minute-clinic, which now the hospital and provider will get paid for.

    The ACA did not create the PCP shortage.

  9. What was briefly mentioned but really ought to be the most important impact from ACA legislation is the significnat increases in urgent care and ER visits from the previously uninsured, which this report did not measure. PCP capacity was maxed out long before ACA went into effect due to the years of attrition and poor compensation for PCPs. Knowing that, there is no surprise that the numbers did not change after ACA went into effect. As more and more PCP attrition occur in the next few years due to retirement, lack of incoming providers, and those that are moving into direct care practices, we’ll continue to see the shift of even previously insured individuals or those that are going into Medicaid and Medicare have less access to a PCP.

  10. Great stuff, I will dig more deeply into the report.

    Meanwhile – have you guys ever thought of doing a “physician happiness” index, sort of like what they do with small European countries? Would be interesting to compare happiness levels by state, region, specialty, medicaid expansion vs. non-expansion … possibly even by tech adoption?

    (The last would be hard to do and could easily come off as too shamelessly rah rah, but a really interesting proposition if you could design a question scientifically.)