The ACA Open Enrollment at 2 Months: The View From Across the Country

A Primary Care Roundtable Discussion

Laurie Scudder, DNP, NP


March 13, 2014

Before the ACA: Was the System Already Stressed?

A survey of physician practices in 15 metropolitan areas conducted in late 2013 by Merritt Hawkins concluded that wait times experienced by patients requesting appointments varied dramatically across regions and specialties.[1] The longest in the nation was in Boston, where the average wait time for a new patient to see a family practice physician was 66 days (a decrease from wait times calculated after a similar survey in 2009). The average cumulative wait time to see a family physician in all 15 markets was 19.5 days, approximately the same as 20.3 days in 2009. This survey was conducted between June 2013 and November 2013, and thus did not assess the impact of patients newly enrolled in health plans under the Affordable Care Act (ACA).

The ACA at 2 Months: What Does It Look Like Across the Country?

But now we are 2 months into ACA implementation -- and we asked our panel of advisors about the effect of more patients on their own practices. Was their experience consistent with the results of this survey?

Bradley Fox, MD, a family physician at Saint Vincent Health Center in Erie, Pennsylvania, noted that it was "too soon to really have a good grip on whether or not this has changed enrollment requests or my insurance makeup at all." He did offer, however, that it was not too soon for his patients to be asking him about it. "I can tell you that not a day goes by that 2 or 3 patients ask me point-blank how the ACA has affected me and whether it has changed how I do things, so it is something on their minds for sure."

From the other side of the country, Charles Vega, MD, a family physician and Residency Program Director at University of California, Irvine, noted that he practices in a federally qualified health center that exclusively cares for patients with Medicaid and Medicare, along with a smaller percentage of patients without any coverage whatsoever. His practice has witnessed a slight increase in clinic demand over the past 2 months, which "has given the lie to some of our collective panic about waves of patients throwing themselves at our doors...Patients aren't racing into our clinic as soon as they get their Medi-Cal cards. But it has been heartening to see those patients who dropped out 3 to 4 years ago returning to our practice and reinvesting in their well-being."

Mark Williams, MD, Clinical Professor of Medicine at the University of North Carolina School of Medicine, who practices at New Hanover Regional Medical Center in Wilmington, noted that, as an employed physician, he was somewhat insulated from changes in enrollment or insurance makeup. He did, however, provide an anecdote about a newly insured patient requesting an expensive screening that was not indicated by her clinical situation, and he speculated that newly enrolled patients may put demands on the system as they request services that may not be needed or consistent with guidelines, a process he called "guideline creep."

The experience of the employed physician is increasingly relevant to this discussion, as documented by physician recruitment companies who report that 64% of physician search assignments from April 1, 2012, to March 31, 2013, came from hospitals looking to hire.[2] In contrast, in 2004, hospitals generated just 11% of physician searches. In this report, the companies suggested that "the independent, private practice model is becoming an anachronism." What has remained consistent, however, is the types of physicians being sought. For the seventh year in a row, primary care tops the list of the most recruited medical fields, with first place belonging to family physicians and second to general internists. [Editor's note: Employed Doctors Report: Are They Better Off? presents the results of a recent Medscape survey examining the experiences of employed physicians.]

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