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The surprising changes the Affordable Care Act is bringing to primary care practices
That flood of patients experts predicted following healthcare insurance expansion under the Affordable Care Act (ACA)? Even though it’s been almost two years since the creation of federal and state healthcare exchanges, plus the expansion of Medicaid eligibility in some states, the expected access crisis has yet to be seen.
But while numerous studies confirm that practices are for the most part keeping up with demand, the ACA’s impact on primary care physicians and patients has still been profound.
“Quite honestly it’s kind of a relief to me to have more patients who are insured,” says Robert Wergin, MD, board chairman of the American Association of Family Physicians (AAFP.) As a practicing physician in a rural community of 2,000, Wergin is intimately aware of the hardships many of his patients faced in obtaining healthcare prior to the availability of the exchanges and their accompanying subsidies (Medicaid has not expanded in Wergin’s home state of Nebraska).
He cites one patient in particular, a self-employed polio survivor with a multitude of chronic conditions, including scoliosis, muscle weakness, and lung problems related to his childhood disease. Prior to becoming eligible for a subsidy under the ACA, this patient paid more than $1,000 per month for health insurance, and fretted annually whether he’d be able to continue to afford it while running his photography business.
“He always refused to go on disability,” Wergin says, even though he would have qualified easily. Qualifying for a health insurance subsidy, however, dramatically changed the circumstances for both the patient and his doctor.
“You should have seen the relief on his face,” Wergin says. “And it allowed us to have him see a pulmonologist and make other adjustments to his treatment that changed his life. I believe he’ll live longer and do better because of this.
“For physicians, [coverage] makes it easier to say, ‘These are the things we need to do,” he adds. “I don’t order things willy-nilly. But it’s a barrier to say, ‘Gee, can we get by without this imaging? Or maybe we can give it more time and do this, perhaps try to call the imaging center and see if he can make payments.’”
Gaining coverage might also be having an impact on Americans who may not even realize they’re sick. Research shows that the insured are much more likely to receive a diagnosis for diabetes, hypertension, or hypercholesterolemia, according to a study published in Health Affairs. Not surprisingly, the research team from the Harvard T.H. Chan School of Public Health also found that those with insurance had diagnosed chronic diseases under better control, with healthier levels of blood pressure, blood glucose and cholesterol.
“The ACA has removed barriers to preventive healthcare by taking away copays and coinsurance for wellness services,” notes Salvatore S. Volpe, MD, a New-York based primary care physician, chief medical officer of the Staten Island Performing Provider System, and a member of the Medical Economics editorial advisory board. In the long run, these changes should save our health system money, say physicians.
Nonetheless, understanding how patients’ insurance coverage affects their long-term health represents a learning curve for physicians and patients alike, notes Katherine Hempstead, PhD, team director and program officer of the Robert Wood Johnson Foundation.
“Some might say that the cost-sharing is really high, especially for low-income people, to maintain care of a chronic condition,” she says. Although patients’ adherence to a treatment is largely out of physicians’ control, she says, “it’s important to be aware of patients’ [insurance coverage] and think about what the medications they prescribe are going to cost the patient-or [physicians] might not get the outcome they were expecting.”
The reality that health insurance alone does not alleviate all health expenses may also factor in to the modest rise in patient volume, notes Laura Palmer, FACMPE, a senior fellow with the Medical Group Management Association (MGMA). “Patients are having the realization that unless it’s preventive care or something that’s covered in its entirety, they still have a patient portion that’s due that could be pretty substantial in some programs. Just because you have insurance doesn’t mean you’re not going to be a cautious consumer,” she says.
Indeed, a recent Kaiser Family Foundation (KFF) report confirms that newly-insured adults still face financial insecurity. According to the issue brief: “The newly insured are more likely than those who had coverage before 2014 to worry about future medical bills, and they face general financial insecurity at rates similar to the uninsured.”
Wergin agrees, noting that he and his colleagues have faced increased pressure to “work around” patients’ coverage limitations. In many cases, patients understand their benefits, which often involve large deductibles or perhaps one wellness visit per year without a copay, he says.
“I have many patients with chronic illnesses come in and ask for a year’s worth of prescriptions because they know it is going to cost them to come back,” Wergin says, adding that in such a situation he may compromise and ask the patient to come back in six months.
Similarly, patients carrying larger deductibles are more likely to forego non-essential testing and procedures, says Jeffrey Kagan, MD, a Connecticut-based internist and editorial advisory board member for Medical Economics.
Meanwhile, growing numbers of healthcare consumers have options for where and how to obtain many of the same services offered by their PCPs. In particular, retail and urgent care clinics represent an important part of how people are getting care now, says Hempstead. “It’s not only lower cost than a lot of office-based encounters, but it may also lower barriers,” she says. Because they make it easier to obtain care, some patients may use these alternate settings as a substitute for office-based primary care rather than a complement.
Such a shift could be risky for patients, says Wergin. “In terms of primary care, our care is based on a continuous relationship over time. If you do just have a sore throat and you go see a nurse practitioner … at the grocery store, that may be OK, but there may be missed opportunities. Moreover, it perpetuates our current system of fragmented episodic care,” he says.
Some newly insured patients, particularly in underserved areas, may seek care at community clinics and health centers because it is their most available source of care, the KFF report suggests. The report also found that newly insured adults face more access barriers than those who were insured before 2014.
“This finding may indicate that newly insured adults are not as settled into regular care as their previously insured counterparts,” according to the authors. “[I]t may also reflect difficulty finding a provider, problems navigating the health system and health insurance networks, misunderstanding about how to use coverage and when to seek care, or concerns about out-of-pocket costs.”
Nonetheless many patients, including those with a regular primary care physician, choose retail settings because they’re faster and easier, even if not necessarily cheaper, according to Palmer. “Even if the copay is a little higher in one of those environments the convenience of it sometimes-if it’s an affordable expense, say a $10 difference-could be the difference between sitting with a sick kid overnight wondering if they need antibiotics or bringing them in that evening and maybe they won’t miss school tomorrow.”
As a result of this competition, practices that have expanded access may still be at an advantage even without a flood of new patients. Palmer says she is seeing more practices expand hours, use open-access scheduling, and make active use of patient portals than she did two years ago.
When practices build more same-day appointments into their workflow, patients may not always see their own doctor, Palmer says, but making accommodations helps build loyalty to the practice as a whole.
The AAFP encourages practices to become more patient-centered regardless of any competition in their communities. Wergin, for example, doesn’t have any retail clinics in his small town, but still developed with his team a “fast track” system to treat patients with minor illnesses on a near-walk-in basis.
Under the program, any patient who calls the office about one of several designated illnesses, such as sore throat, suspected urinary tract infection, earache or other problem treated by a typical retail clinic, is told to come to the office that day at their convenience. Receptionists are instructed to tell these patients they may have to wait a bit and may see the physician assistant instead of their doctor, Wergin says, but that their problem can be addressed that day.
The visits are streamlined by using nurses to take the patient’s “fast track” history and order any tests that may be needed, such as a urinalysis, before the doctor comes in. An orange flag outside the door further signals to the doctor that the appointment will be quick. If patients bring up other concerns during a fast track visit, they have the opportunity to make another appointment to have those addressed.
“From an economic model, it’s probably the easiest thing I do,” says Wergin. And for continuity of care, the practice’s providers have the benefit of knowing the patient’s history and being able to see him or her again within a few days if the treatment doesn’t work.
Whether your practice has a short or long wait for appointments, it’s important that patients honor time that has been set aside for them, notes Kagan, whose practice has seen an uptick in new patients, many of them with Medicaid, over the past two years.
“If a new patient fails to keep the first appointment, I have taken the policy that we do not reschedule them,” Kagan says. The practice has also recently stopped taking new Medicaid patients, he adds.
Insurance expansion under the ACA has required practices to adapt-whether in terms of needing to accommodate more patients, offer more convenient service, or work with individuals to make the most of their benefits.
These challenges require practices to be innovative with the resources that they have, says Wergin. He and other experts agree that adopting patient-centered, team-based primary care models may be the most effective ways to leverage those strengths.
Now that practices have for the most part adapted to a more insured patient population under the ACA, the future of primary care will center around the care team, including patient caregivers and advocates, and coordinating all of a patients’ care, says Palmer. Rather than asking how we can handle the volume of patients, she recommends practices ask themselves, “How can we work together to have good health?”