Wednesday, April 9, 2014

Fwd: qotd: New patient? What insurance do you have?

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: New patient? What insurance do you have?
Date: Wed, 9 Apr 2014 14:48:54 -0700
From: Don McCanne <>
To: Quote-of-the-Day <>

JAMA Internal Medicine
April 7, 2014
Primary Care Access for New Patients on the Eve of Health Care Reform
By Karin V. Rhodes, MD, MS; Genevieve M. Kenney, PhD; Ari B. Friedman,
MS; Brendan Saloner, PhD; Charlotte C. Lawson, BA; David Chearo, MA;
Douglas Wissoker, PhD; Daniel Polsky, PhD

The goal of the current study was to simulate the experience of
nonelderly adults with 1 of 3 insurance types—private, Medicaid, and
uninsured—seeking new patient appointments in 10 diverse states to
obtain precise estimates of primary care access before the ACA coverage

Between November 13, 2012, and April 4, 2013, we made 12,907 calls to
7788 primary care practices requesting new patient appointments. Across
the 10 states, 84.7% of privately insured and 57.9% of Medicaid callers
received an appointment. Appointment rates were 78.8% for uninsured
patients with full cash payment but only 15.4% if payment required at
the time of the visit was restricted to $75 or less.


Comment by Don McCanne

This study reveals the success rates in obtaining a primary care
appointment as a new patient by non-elderly adults, prior to full
implementation of the Affordable Care Act. So what was it like then,
what will the Affordable Care Act do for that, and what would single
payer have done to change the results?

Being privately insured provided the greatest probability of success in
obtaining an appointment - 85% were able to do so. Close to that - at
79% - were new patients who would pay cash in full at the time of the
visit. Medicaid patients had more difficulty - with only 58% being able
to make an appointment. Worst of all was for those who would pay cash,
but no more than $75 at the time of the visit - only 15% were successful.

Of course, this is what we've known all along. Privately insured
patients have good access, Medicaid patients have poorer access by
virtue of being covered by an underfunded welfare program, and uninsured
patients with limited resources have the worst access of all. Those
willing to pay cash in full may have been covered by a high-deductible
plan but, in any event, were likely to to have the means to pay upfront
charges. So money or good insurance will open the doors, whereas
Medicaid is dependent on the willingness of the primary care provider to
participate in the Medicaid program, and being poor and uninsured… well,
good luck.

What will happen now that ACA is well on its way to full implementation?
The answer is complex, which is no surprise because the ACA model is
itself complex. Let's look at each category of coverage.

For the very wealthy who are quite willing to pay full fees in cash, and
the scheduling staff of the primary care practice understands that,
access should approach 100%. If any queues exist, those individuals
likely can buy their way to the front of the queue.

For privately insured individuals, whether obtaining coverage through
employment or through individually purchased plans within or outside of
the exchanges, access may be less than it is now since insurers with the
new narrower networks exclude many primary care professionals from their
panels. Most individuals will not want to select an out-of-network
primary care professional, especially since out-of-pocket costs could be
staggering since the cap applies only to in-network care (except for
certain emergencies).

Even those employer-sponsored plans that ACA was designed to protect are
now moving in the direction of higher deductibles, narrower networks,
and even private exchanges with a shift to defined-contribution
vouchers. Although the percentage of practices accepting specific
insurance plans will decline because of the doctor being excluded from
the networks, patients will probably still choose private plans as being
their best option. It's just that they will have to shop more before
they find practices that accept their specific insurance.

Finding primary care practices that accept Medicaid may be more
difficult. Although there is a temporary increase in primary care
evaluation and management payments, that will end very soon. It is
likely that there will not be much of an increase in the number of
physicians who will agree to accept the low Medicaid payment rates. If
those who do accept Medicaid find that the increased volume is crowding
out their privately insured patients, then they may feel that they have
to cut back or eliminate accepting new Medicaid patients as well.

With an increase in Medicaid managed care organizations, Medicaid
patients may have this option, but then that limits their access since
they must go to the managed care providers. Also the low payment rates
for Medicaid managed care organizations may result in relatively spartan
care merely because of the insufficiency of funds. Another possibility
is that federally-qualified health centers may be able to increase their
capacity because of new funds authorized by ACA. Hopefully these two
expansions will provide enough capacity to ensure access of Medicaid
patients to at least some form of primary care.

Access for the low-income uninsured - and there will be tens of millions
of them - will certainly continue to be impaired. If Congress further
expands the funding of federally-qualified health centers, then the
uninsured will have that option. But specialized care will likely be out
of reach for most.

So, in general, access to primary care is unlikely to change to any
major degree as the result of the provisions of ACA. Patients will have
less choice of providers, more exposure to out-of-pocket costs, but an
increase in funding should improve access to other options such as
Medicaid managed care organizations or federally-qualified health
centers - especially important for low-income individuals.

What if we had a single payer system instead? Primary care practices
would never have to ask a new patient what insurance they had, or
whether they intended to pay cash. Patients would never have to check
network lists to see whom they could call. (There would still be some
"networks" such as Kaiser Permanente, but they would be integrated
health systems that patients would choose because of their own preferences.)

With single payer, never again would a new patient have to hear this
response from a receptionist: "New patient? What kind of insurance do
you have? Oh, I'm sorry. The doctor isn't able to accept any new
patients now."

No comments:

Post a Comment