PPACA Will Have 'Modest Effects' on Care Access, Study Finds

Research suggests that fears about what would happen to healthcare access with the addition of millions of people to the insurance rolls may have been overblown or at least unfounded.

One concern about the Patient Protection and Affordable Care Act has been the anticipated longer wait times for physician visits with the addition of millions of newly insured people who would gain coverage through Medicaid expansion or the health insurance markets.

We've heard the doomsday scenarios about clogged emergency departments full of people who can't find a primary care physician, are forced to use the most expensive care access point for non-emergency care, thus defeating the very purpose of the reforms.

It's a topic we've covered a lot here, and this concern over wait times carries a simple and compelling reasoning: If there aren't enough physicians now, and the shortage is expected to worsen as more physicians retire and the nation grows older, what will happen to healthcare access when millions more people are added to the insurance rolls?

FL Teaching Hospitals Eye Specialist Shortage

A study out today from The Commonwealth Fund suggests that those fears—to this point—may have been misplaced and overblown or at least unfounded.

Examining state-level estimates for increased demand for physician and hospital services, the study projects that the 11 million newly insured lives translates into 1.34 primary care office visits per week, an increase of 3.8% nationally, and 1.2 to 11 additional hospital outpatient visits per week, an increase of 2.6% nationally. [The methodology is detailed in the report. I didn't delve into it for the sake of expediency. If you think the methodology is flawed, please explain why in our comments section below. I'd also be interested in hearing from providers about their experiences with patient volumes and wait times over the past year since the ACA has gone into effect.]
 
"Increases of the magnitude likely to be generated by the Affordable Care Act will have modest effects on the demand for health services, and the existing supply of providers should be sufficient to accommodate this increased demand," the study concludes.

No Surprise
Sherry Glied, a coauthor of the study, and a dean at New York University's Robert F. Wagner School of Public Service, told me that her findings are not surprising.

"There are a couple of things you want to think about as you work through what the effects might be on medical utilization," she says. "One important one is that the people who use the most services in the U.S. now are on Medicare, seniors, and people who are disabled and on Medicaid and these groups are already covered. So, most of the people who are gaining health insurance because of the ACA are people who are relatively healthy. They don't use a lot of visits a year because they are relatively healthy people."

These relatively healthy people are buying insurance for protection against the unlikely event that they'll need it.

"In most cases they are not going to use a lot of visits, so the base number of visits that we are already producing are the bulk of visits that will ever be produced," Glied says. "Those seniors are already getting their visits and those disabled are already getting their visits and we are adding just incrementally these newly insured people. Even when they were uninsured, they still went to the doctor, just not very often. So it's only the increment over that."

Geographic Variations
What surprised Glied in her research was the astonishing state-to-state disparity in physician wait times that has little to do with the physician-to-patient ratios.

"This is what struck us in writing the paper," Glied says. "There is not a clean mapping between the number of doctors in practice in an area and the number of visits they produce or the timing of those visits. In fact, it is almost perverse. Some of the places in the country that have the most doctors per person actually have the longest waits for visits."

In other words, care access is uncoordinated.  

"So, there is lots of potential to accommodate those additional patients since they aren't a huge number to begin with in terms of the new visits, using the supply of doctors we have now in most places," Glied says.

Her point is well taken.

Accounting for the disorganization of healthcare access damages the claim that the PPACA will create the mother of all physician wait times, because such a claim relies upon the laughable assumption that our healthcare delivery system is operating at peak or near-peak efficiency with little room for improvement.

"What we see across the country is that practice patterns are so different that there has just got to be space for adaptation," Glied says. "There are places in the country where doctors are managing many more patients and the waits for appointments are quite short. Maybe some places are going to have to think about how to organize practices more effectively."

Exhibit A is Massachusetts, a state with 132 primary care physicians per 100,000 people – the highest such ratio in the nation. Massachusetts also had the longest physician wait times in the nation before Gov. Mitt Romney in 2006 pushed through universal healthcare. After RomneyCare took effect, Massachusetts still had the longest physician wait times in the nation.

"What happened after insurance expanded in Massachusetts? The data suggests nothing," Glied says.

"The change in utilizations and waiting times, there was a blip one year and then it went down. It's been steady before and after, but for not very good reasons that have more to do with the way medical practices are organized in Massachusetts, because there are loads of doctors in Massachusetts." (A separate study conducted by Harvard researchers in 2013 for Health Affairs came to a similar conclusion.)

Claiming that expanding the insurance rolls will increase patient wait times also fails to take into account the ability within the nearly $3 trillion healthcare sector to adapt and adjust. With so much money at stake, providers will find a way to improve access. If they can't, nontraditional entrants into the market will.

"We are already seeing changes in the way healthcare is delivered," Glied says, "There is more use of non-physician professionals such as nurse practitioners and physician assistants to supplement physicians. There is more use of retail medicine options, more email and other encounters for accessing the medical system. We are seeing change over time. So, we shouldn't imagine that medicine is any less prone to organizational and systemic change than many of the other things that we have seen change around us."

Instead of fixating on inevitably longer wait times, Glied says providers need to re-examine how they do business.

"It is not right for us to say that we are being overwhelmed by patients. That is not what the data show," she says. "What the data show is this is in the hands of the medical profession to make access to care work from a patient's perspective. There are opportunities to do better."