Over 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.
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%.
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.
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.
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 firstname.lastname@example.org or @IyueSung and @JoshGray_HIT on Twitter.
Josh Gray is VP for athenaResearch Independent consultant David Clain contributed to this report.