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Posted by on Jul 22, 2014 in Health | 24 comments

Reports Show More People Insured But No Increase In New Patient Volume For Physicians Since January Under Affordable Care Act

Some favorable data on the Affordable Care Act which came out before today’s news of another Republican court victory in their ongoing efforts to deny people the benefits of Obamacare: [icopyright one button toolbar]

The New England Journal of Medicine has reviewed the increase in coverage under the Affordable Care Act and concluded:

Taking all existing coverage expansions together, we estimate that 20 million Americans have gained coverage as of May 1 under the ACA (Figure 3Figure 3Categories of Expanded Health Insurance Coverage under the Affordable Care Act (ACA).). We do not know yet exactly how many of these people were previously uninsured, but it seems certain that many were. Recent national surveys seem to confirm this presumption. The CBO projects that the law will decrease the number of uninsured people by 12 million this year and by 26 million by 2017. Early polling data from Gallup, RAND, and the Urban Institute indicate that the number of uninsured people may have already declined by 5 million to 9 million and that the proportion of U.S. adults lacking insurance has fallen from 18% in the third quarter of 2013 to 13.4% in May 2014.

However, these surveys may underestimate total gains, since some were fielded before the late March enrollment surge and do not include children. With continuing enrollment through individual marketplaces, Medicaid, and SHOP, the numbers of Americans gaining insurance for the first time — or insurance that is better in quality or more affordable than their previous policy — will total in the many tens of millions.

As we look to the future of the coverage provisions of the ACA and their effect on the U.S. health care system, several observations seem justified. First, as the number of individuals benefiting from the law grows, its wholesale repeal will grow less likely, although the law could still be importantly modified in the future.

Second, experience with the ACA will vary enormously among states. Those deciding not to expand Medicaid will benefit far less from the law, and since many of these states have high rates of uninsured residents and lower health status, the ACA may have the paradoxical effect of increasing disparities across regions, even as it reduces disparities between previously insured and uninsured Americans as a whole.17

Third, the sustainability of the coverage expansions will depend to a great extent on the ability to control the overall costs of care in the United States. Otherwise, premiums will become increasingly unaffordable for consumers, employers, and the federal government. Insurers who seek to control those costs through increasingly narrow provider networks across all U.S. insurance markets may ultimately leave Americans less satisfied with their health care. Developing and spreading innovative approaches to health care delivery that provide greater quality at lower cost is the next great challenge facing the nation.

The full article is available to non-subscribers and there is also further discussion at Talking Points Memo.

There has been concern that the increase in number of insured might lead to an increase in number of people seeing physicians despite predictions and early evidence that this would not be a significant problem in most areas. I have seen several reports indicating that doctors generally are not seeing more patients as a result of the Affordable Care Act. The most recent came from Athena Health and the Robert Wood Johnson Foundation. Here is a summary of their findings:

  • Influx in New Patient Volume Not Detected: In the first five months of 2014, a national sample of 14,300 health care providers across the athenahealth network did not see an increase in new patient volume.* Instead, the percentage of total visits with new patients actually dropped slightly compared to the same period in 2013. These findings suggest that an increase in newly insured patients, resulting from the ACA, has yet to have an impact on new patient volume at medical practices.
  • Health Care Reform Widening the Medicaid Gap: In states that are expanding Medicaid coverage under the ACA, the data shows an overall increase in adult (18-64) Medicaid beneficiary patient visits. In expansion states, on average, the percentage of Medicaid-covered patients who are being seen by primary care physicians is rising, with Medicaid patients accounting for 12.3% of care in December of 2013 compared with an increased rate of 15.6% in May 2014. Surgeons and other specialists also show increases. Conversely, states that are not expanding Medicaid coverage have seen Medicaid visits remaining flat. These findings indicate that the implementation of the ACA is widening the gap of the total share of Medicaid patients that doctors in expansion vs. non-expansion states are caring for.
  • No Increase in Chronic Disease Diagnoses Among New Patients: Findings from the first five months of 2014 indicate that established patients have a higher rate of chronic diseases compared with new patients seeking care. When comparing diagnosis rates of chronic conditions from the first five months of 2013 to the first five months of 2014, across both new and established patients, no increase in diagnosis rates of chronic conditions is detected for either population.

It is possible that some of the newly insured are initially going to the Emergency Room and therefore are not picked up as an increase in visits by primary care physicians. In May I reported on a study by the American College of Emergency Physicians which found that 37 percent of ER physicians reported that patient volume had increased slightly, 9 percent reported that it had increased greatly, and 27 percent reported that the number of ER visits had remained the same.

It is also a good finding that the newly insured are not turning out to be sicker than the previously insured. Many insurance companies held off on entering the exchanges last year out of fear that they might wind up with sicker patients, costing them more money. Those which sold coverage have wound up doing well with more insurance companies planning to enter the exchanges to sell coverage for next year. This should help reduce anticipated increases in premiums and give consumers more choice.

Forbes has further discussion of the differences in states which are offering the expanded Medicaid program compared to those which do not.

Originally posted at Liberal Values

Update: The headline was corrected to add “New” before patient volume

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  • dduck

    ” in coming years is an expected shortage in clinical training sites in community hospitals and clinics. This is where students get the hands-on experience they need to supplement classroom instruction and earn their degrees.”

  • DORIAN DE WIND, Military Affairs Columnist

    Ron alluded to the DC Circuit court decision that would have made ACA subsidies issued through the federal exchanges in 36 states illegal.

    However, just a little while later the Fourth Circuit Court of Appeals in Virginia ruled that ACA subsidies issued through the federal exchanges are legal.

    Fourth Circuit Judge Roger Gregory argued that because the statutory language of the Affordable Care Act (ACA) is ambiguous, courts should defer to the interpretation of the Internal Revenue Service and allow the subsides to stand.

    Read the story here.

    “The conflicting rulings sets up a circuit split that could fast track the cases to the Supreme Court.

    Stay tuned.

  • Dr Ron: I went without insurance for almost 9 years until I became eligible for Medicare. I have not gone to the doctor more frequently although I have had a couple of ambulance rides to the hospital, once for a broken collarbone when I fell off a ladder while moving and once when I had chest pains which turned out to be indigestion and had nothing to do with my heart.
    These are a couple of wingnut judges and I don’t really see any possibility that their finding will prevail in appeals.

  • Ron,

    As Dorian pointed out, a different court already ruled the opposite way in a different area today

    If it goes to the Supreme Court there is already precedent for going with the intent of a law as opposed to going with the decision today which is based upon a proof reading error in the text of the law. I don’t think Roberts would overthrow the law this way but you can never be certain what this court will do.

  • dduck,

    Once again you are cherry picking the most pessimistic portions of an article while ignoring other portions which show how the problem might be remedied.

    You also ignore the portions of the article which show how it is your Republican friends who have been hindering attempts by Obama to solve the problem:

    In any case, there is a desperate need for accurate, up-to-date information. But congressional Republicans, who refuse to cooperate in any way with the Affordable Care Act, have blocked a commission that was supposed to sort it all out and make recommendations. The reform law created a National Health Care Workforce Commission, whose members were appointed in late 2010, but the panel has never met and it has no staff or budget to support its operations. This year, President Obama gave up even requesting $3 million for the panel, after losing that battle in previous years

  • dduck

    You don’t seem to have a problem with cherry picking, I don’t either.

  • I do not cherry pick the way you do.

  • dduck

    Thanks for being frank.

  • So there are more insured but no increase in patient volume. Sounds like the majority of the uninsured and chronically ill don’t want to see a physician. Or they need additional perspective on why living obese, getting faded and fast food is not a good enough reason to avoid being called out.

    This begs the question, why did we commit to a trillion in spending for the ACA when there is no increase in doctor visits. Hard to believe this can be good news!!

    We could have given vouchers to the ill and uninsured who go to see physicians for preventative, acute or chronic issues.

    Then, we could have committed a trillion dollars to transform our educational system and privatize schools. Slash the fat cat administrators and actually teach our children.

  • This begs the question, why did we commit to a trillion in spending for the ACA when there is no increase in doctor visits. Hard to believe this can be good news!!

    Clearly, that is a rhetorical question; but anyone feel free to comment on how this is favorable news for the ACA?

  • Of course it is good news. There is nothing negative about this. It doesn’t mean that the newly insured aren’t seeing doctors. It could mean that the previously insured are not seeking new doctors as frequently in the past so that with the newly insured the overall volume is not greater.

    We know that the newly insured are seeing doctors but even if they weren’t the point is that they have insurance for when they do need it. Having insurance doesn’t mean everyone has to be constantly seeing doctors.

    It is good news because it means that the increase in number of insured is not increasing demand for medical care in a way which would lead to shortages. We have always had a certain number of people seeking new doctors and it helps that this number is not significantly higher now than in the past, better enabling the current number of doctors to meet the demand.

  • I would think common sense suggests that more insured people (a good thing) means more doctor visits.

    The rest of us didn’t suddenly lose the need to see physicians. However, as I have reported here before, my wife and I have waited over three months to see a physician at Kaiser California in 2014. Perhaps that accounts for the same/similar/not rising doctor visits.

    Realistically, either the previously uninsured are not seeing doctors in 2014 or those of us who had insurance are having trouble seeing doctors.

    Anyway. Thanks for the good news.

  • the point is that they have insurance for when they do need it.

    Agreed … my points stand.

  • Note that the study is of influx of new patients, not total doctor visits. If fewer people with established doctors are changing doctors then the influx of new patients would remain stable despite the newly insured seeking new doctors.

    Plus many of the newly insured probably already had doctors but were paying cash. They might be going a lot more now to take care of problems they previously had but couldn’t afford to treat, but if they are sticking with the same doctor this would not be seen as an influx of new patients.

    This would also make it easier to accommodate the newly insured. Much more time in a primary care practice is taken up by new patients to get complete physicals, etc. This potentially creates a bottle neck for the newly insured who don’t have doctors. If a new patient to my practice calls, it could be several weeks before we have time slots for new patients available. However if an established patient just obtained insurance, even if it is someone I have not seen very often, we could get them an appointment much quicker.

    Nation wide there have not been problems with increased wait time, but local conditions could be different at any particular facility if local conditions differ from the national average. Such delays may or may not have anything to do with the ACA.

  • Note that the study is of influx of new patients, not total doctor visits

    So your headline is misleading:

    Reports Show More People Insured But No Increase In Patient Volume For Physicians Since January Under Affordable Care Act

  • Yes, the headline is inaccurate as originally posted. Other studies have shown no major increase in volume in private practices (although I have seen reports of major increases in some which deal with Medicaid, such as at Cook Country). However the headline should reflect the studies actually discussed in the post. I will fix it it specify “New Patient Volume.”

  • Ron, thanks. Let’s hope there is a continuing increase in the number of patient visits and an increased number of insured. My view, those of us who are already insured should be willing to bite the bullet. It is worth it.

    Keep up the good work on the front line.

  • dduck

    Thanks, KP, you are atop banana.

  • “Let’s hope there is a continuing increase in the number of patient visits and an increased number of insured”

    From a public policy perspective I would hope for a decrease in number of patient visits along with an increased number of people insured provided that everyone that needs to see a physician is able to. In the short term it is not feasible to do this but in the long term we would also like to decrease overall utilization to reduce costs.

    The important thing is increasing the number insured, not how many patient visits there are.

  • Speaking of new patient visits, my wife had a conversation with our rep for a Medicaid managed care plan yesterday which pertains to this. We don’t take new Medicaid patients, but do participate in the plan so that if an existing patient winds up on Medicaid (such as losing their job, or more recently qualifying for the expanded Medicaid program) they can continue to come.

    The rep stated they wished everyone would be open to new patients but understood that it was not economical feasible for us-plus that if we opened to new patients we would immediately get so many calls from people wanting to be new patients that we wouldn’t know what to do with them. (We already receive more calls from non-Medicaid patients desiring to be new patients than we can easily handle.)

  • Just received new information in an email newsletter showing a slight increse in in-patient volume, partially due to the ACA and partially due to other factors:

    Hospital inpatient volumes trended positive for the first time in several years–albeit by only a slight margin–according to a new survey from Jefferies. The investment bank and securities firm also released data about hospital performance and payer mix.

    Inpatient volume has trended negative for the last few years, due largely to the economic downturn and plan design changes, but average inpatient admissions were up 0.4 percent in the second quarter of 2014, according to the survey results. Researchers attribute the uptick to a combination of the improving economy, the implementation of the Affordable Care Act and patients waiting as long as possible for procedures, compounding demand.

    Polling on provider optimism was also positive, according to the survey. Of the executives from 50 hospitals Jefferies polled, seven in 10 expected inpatient volume to be either flat or up in the third quarter, which is remarkable considering the multiyear trend of negative volumes, according to the survey results. Executives at hospitals with more than 250 beds were particularly optimistic, with all such respondents expecting volume increases in the third quarter.

    The ACA has made a positive impact on hospital performance, according to the survey, with states that expanded Medicaid under the healthcare law expressing significantly more positive views about improvements in payer mix and diversity in the second half of the year.

    “That said, 54 percent of our surveyed hospitals indicated that the ACA has not impacted volume trends yet; it is worth noting though that half of hospitals with 500 or more beds noted improved admission trends as a result of the ACA,” the results stated. Jefferies will continue monitoring developments in states that have not yet expanded the program but are “key for the publicly traded hospitals,” including Tennessee, Pennsylvania and Florida.

    Thirty-four percent of respondents overall said emergency department (ED) admissions had increased, but the numbers were higher in expansion states (42 percent) than non-expansion states (29 percent). This lines up with the results of a study which found Medicaid expansion in Oregon increased ED volumes, FierceHealthcare previously reported.

  • dduck

    “if we opened to new patients we would immediately get so many calls from people wanting to be new patients that we wouldn’t know what to do with them. ”

  • That was always the case with Medicaid, with Medicaid patients increasingly being cared for by larger clinics and having difficulty getting into private practices.

    I would assume the flood of calls would be even greater with the expanded Medicaid program. We would need harder data to confirm this as many of the people in expanded Medicaid programs are people working with low incomes who did previously see doctors on a cash basis, and in some cases had private insurance before. Therefore while I haven’t taken new Medicaid patients for quite a long time (other than those with both Mediare and Medicaid) some of my low income established patients are now on the expanded Medicaid program and I’m continuing to see them–so not every new Medicaid patient has to seek a new doctor.

  • gulp … ahem …

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