Physicians Did Not See Patient Increase After ACA Plan Sign-up

Ken Terry

September 05, 2014

Despite the enrollment of more than 8 million people in the state and federally facilitated health insurance exchanges, as well as an increase of 4.8 million people enrolled in Medicaid, a recent study shows that the number of new-patient visits to physician practices did not increase in the first 5 months of 2014 compared with during the same period last year. In fact, new-patient visits declined slightly during that period for all specialties except pediatrics.

The study was released by the Robert Wood Johnson Foundation (RWJF) and athenahealth, a cloud-based electronic health record vendor that has detailed data on practice patterns for all its customers. The study looked at data from practices that have been using athenahealth's software since 2010 or earlier. The sample includes approximately 14,300 providers, of whom 35% deliver adult primary care.

Among the other key points of the findings:

  • There was no difference in new-patient visits between states with high enrollments in Affordable Care Act (ACA) exchange plans and those with low enrollments.

  • The number of new-patient visits was not affected by whether the states in which practices were located had decided to expand their Medicaid program. About half the states have expanded Medicaid.

  • Contradicting the expectation of some experts that newly insured patients would have a pent-up demand for healthcare services, no increase was seen in the intensity of services provided or in the percentage of patients with chronic conditions. For both 2013 and 2014, in fact, new patients aged 18-64 years had a lower rate of chronic diseases than established patients in primary care practices.

The report offers a few possible explanations for the lack of growth in new-patient visits:

  • Some newly insured patients, including those on Medicaid, may have continued to receive care in emergency departments, rather than in physician offices.

  • It might have taken more time than expected for the newly insured to shop for physicians, schedule appointments, and be seen.

  • Severe weather in January and February may have discouraged some patients from seeking care.

The study's findings are consistent with those of a Medical Group Management Association survey conducted last April. In that study, about 75% of responding practices said they had at least 1 contract with an ACA health plan. Fifty-six percent of respondents said that in the first 4 months of the year, they had seen no effect from these plans on their practice population size; 24% said their patient panels had increased slightly.

Noting that the RWJF/athenahealth study had confirmed these results, Anders Gilberg, senior vice president of government affairs for the Medical Group Management Association, told Medscape Medical News, "Our members told us that there wasn't the huge influx of patients that had been predicted."

Gilberg advanced several reasons for this. First, he said, the health insurance companies established their ACA plan networks more slowly than expected, and many of these were very narrow networks that made it more difficult for patients to find physicians.

Another factor, he said, is the nature of the ACA plans. The majority of them have high deductibles, ranging from $1000 to $3000. "So there was catastrophic coverage, but the patient had substantial out-of-pocket cost to see the doctor, even at a negotiated rate."

Some previously uninsured patients who enrolled in ACA plans might have been established patients who paid out of pocket before they obtained coverage, Gilberg pointed out. The RWJF/athenahealth study, which counted only new-patient visits, did not account for this possibility.

The government's enrollment policies might have also played a role, he noted. Although the open enrollment period for health insurance exchange plans ended March 31, the date that coverage took effect depended on when people enrolled. If they signed up on February 15, their insurance would been have effective March 1. But if they signed up a day later, they would not have been covered until April 1.

As for why the study showed no difference in new-patient visits between states that expanded Medicaid and those that did not, Gilberg pointed out that physicians are less likely than hospitals to accept Medicaid patients. Even if they do accept them, they might not have an open-door policy for that kind of insurance, he said.

"Given the reimbursement rate of Medicaid, we've seen physician practices have the ability to keep those panel sizes at a certain level."

David Zetter, a practice management consultant in Mechanicsburg, Pennsylvania, said that he doubts many physicians who did not take Medicaid patients before the ACA are accepting them now, regardless of whether their state expanded the program.

He was not surprised that the enrollment of millions of previously uninsured patients had had so little effect on physician practices through May. "The schedules of most physicians are already filled, so how are they going to take on more patients?" he said.

Although physicians cannot turn away members of plans they are contracted with, he added, he is seeing practices scheduling patients further into the future because their providers do not have time to see them.

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