Access to Primary Care Physicians Differs by Health Insurance ...

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office calls were unresolved in one telephone call to the office. ... From the Social Science Research Center, Mississippi State University,. Mississippi State.
Original Article

Access to Primary Care Physicians Differs by Health Insurance Coverage in Mississippi Ronald E. Cossman, PhD, Jeralynn S. Cossman, PhD, Sarah Rogers, Xiaojin Song, MS, La’Mont Sutton, BS, and Megan Stubbs, BS

Objectives: The objective of the study was to measure how access to primary health care in Mississippi varies by type of health insurance. Methods: We called primary care physician (general practitioner, family practice, internal medicine, obstetrics/gynecology, and pediatric) offices in Mississippi three times, citing different types of health insurance coverage in each call, and asked for a new patient appointment with a physician. Results: Of all of the offices contacted, 7% of offices were not currently accepting new patients who had private insurance, 15% of offices were not currently accepting new Medicare patients, 38% were not currently accepting new Medicaid patients, and 9% to 21% of office calls were unresolved in one telephone call to the office. Conclusions: Access to health insurance does not ensure access to primary health care; access varies by type of health insurance coverage. Key Words: access to primary care, health insurance, Medicaid, Medicare, Patient Protection and Affordable Care Act

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ealth insurance coverage is critical. It determines one’s access to health services and health status.1 Adding to the complexity is the recognition that periods of time being uninsured can be short or long term, with different policy solutions.2 Even with health insurance, access to care may be limited by several factors, including whether one can contact doctors’ offices by telephone during office hours, whether one can receive a scheduled appointment within a reasonable amount of time, lengthy waits in doctors’ waiting rooms,

From the Social Science Research Center, Mississippi State University, Mississippi State. Reprint requests to Dr Ronald E. Cossman, Social Science Research Center, Mississippi State University, PO Box 5287, Mississippi State, MS 39762. E-mail: [email protected] This work was funded internally by the Mississippi Center for Health Workforce within the Social Science Research Center at Mississippi State University. The authors have no financial relationships to disclose and no conflicts of interest to report. Accepted September 12, 2013. Copyright * 2014 by The Southern Medical Association 0038-4348/0Y2000/107-87 DOI: 10.1097/SMJ.0000000000000057

Southern Medical Journal

BA,

David McBride,

BA,

restrictive clinic hours, and patient access to transportation.3 Additional factors include seasonality (eg, staff vacations), office staffing levels and turnover, reimbursement rates for varying insurance types, levels of paperwork, and the financial resources of the patient. Supply and demand for health care and access to care are measured in three ways. Supply metrics calculate the ratio of healthcare practitioners to the population in a county or some variation of that calculation (eg, Health Professional Shortage Areas [HPSA]).4 Demand measures come from either survey questions in which individuals were asked whether they were able to obtain timely access to health care in the last year5,6 or from an examination of physician reimbursement records such as the National Ambulatory Medical Care Survey. In the present study, we used a third measure of access to health care: calling primary care providers’ offices to determine whether new patients are accepted and whether they are accepted at different rates depending on health insurance coverage type. One-third of Mississippi’s population resided in a primary care HPSA as of July 2012,7 which is one indicator of professional healthcare supply. This is in part the result of Mississippi being the most rural state east of the Mississippi River. Several studies have measured the inability of individuals to see a physician or obtain a timely appointment. One study found that 32% of adults covered by private insurance (ages 50Y64 years) reported difficulties in obtaining an appointment

Key Points & Having health insurance does not equate to access to primary health care in Mississippi. & Up to half of primary care physicians’ offices in Mississippi are not accepting new Medicaid patients. & These findings undercut much of the existing Medicaid expansion in terms of how many individuals will have access to primary care and the volume of diversion to hospital emergency departments. & The existing reimbursement rates and administrative burdens are partially to blame for the relatively low acceptance of government-funded health insurance recipients by physicians’ offices.

& Volume 107, Number 2, February 2014

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Cossman et al

& Access to Primary Care Physicians Differs by Health Insurance Coverage in Mississippi

Table. New patient access by type of health insurance coverage Accept, %

Decline, %

Other, %a

Core primary careb

75

8

17

Obstetrics/gynecology

91

0

9

Pediatrics

83

5

12

Totalc Medicare (older adults)

78

7

16

Core primary care

63

16

21

Obstetrics/gynecology

76

8

16

Pediatrics

NA

NA

NA

Total

64

15

21

Core primary care

47

43

10

Obstetrics/gynecology Pediatrics Total

59 61 50

28 21 38

13 17 12

Type of insurance/specialty Private (Blue Cross Blue Shield of Mississippi)

Medicaid (means-based coverage)

a

Did not resolve an appointment, required call back, or additional information. General practitioner, family practice, internal medicine. c May not total 100% as a result of rounding. NA, not applicable. b

when seeking an initial appointment with a primary care physician.8 Similarly, the study found that 35% of Medicare-insured adults (ages 65 and older) reported problems when seeking a new appointment.8 Decker found that 20.4% of office-based physicians (those not restricted to primary care) were not accepting new Medicaid patients.9 Another study, based on physician records, found that 33% of primary care physicians did not accept new Medicaid patients in 2011Y2012.10 As such, the inability to obtain an appointment with a primary care provider in Mississippi, depending on the type of health insurance, ranges from 20% to 35%, based on either surveys of patients or analysis of payment records.

Methods We used 2010Y2011 data from the Mississippi State Board of Medical Licensure, which consists of 5098 physicians licensed in the state. Because our inquiry was driven intellectually by measuring access to care, we used the HPSA definition of primary care to include general practice, family practice, internal medicine, obstetrics/gynecology, and pediatrics.11 We stratified the list to primary care physicians who were active in patient care in the state (n = 2138). We further reduced the list by combining physicians in the same practice/ office (n = 678), excluding walk-in clinics because service is not dependent on type of insurance. This stratification yielded individual and group practice offices. Our study did not require institutional review board approval because we did not study human subjects; instead we recorded information related to physicians’ business operations. Posing as new patients, we contacted by telephone each office in two separate waves. Wave 1 occurred from May 2012 to June 2012, in

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advance of the Supreme Court’s ruling on the Patient Protection and Affordable Care Act (PPACA) in National Federation of Independent Business v Sebelius. A total of 294 unique offices were contacted during wave 1. Wave 2 occurred from November 2012 to December 2012, during which 384 unique offices were contacted. During each call, we identified ourselves by a pseudonym, volunteered information about the insurance type (private: Blue Cross Blue Shield, Medicare, or Medicaid), and asked to schedule a new-patient appointment with a physician for routine care. Of 678 individual and group practice offices that were identified, 580 were successfully contacted, for a completion rate of 86%. We identified 489 core primary care offices (general practice, family practice, and internal medicine), 99 obstetrics/gynecology offices, and 90 pediatrics offices. A total of 4% of the offices offered an initial appointment with a nurse practitioner, physician’s assistant, or registered nurse; however, we declined, asking to see a physician for the initial visit. Our initial survey population also included walk-in clinics (11%), for which no appointment was necessary, although they were not included in the final tallies.

Results Rates of new-patient acceptance differed markedly by the type of healthcare insurance coverage (Table). A new patient with private insurance almost always was able to reserve an appointment, with 8% of core primary care and 5% of pediatrician offices reporting ‘‘not currently accepting new patients,’’ and none of the obstetrics/gynecology offices declining private-pay patients. When presented with a new patient covered by Medicare, 15% of all offices (pediatricians were not surveyed regarding Medicare) did not accept him or her and * 2014 Southern Medical Association

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Original Article

the new patient was not accepted by 16% of core primary care offices and by 8% of obstetrics/gynecology offices. For Medicaid patients, 38% of all primary care offices stated that they were ‘‘not currently accepting new patients.’’ Nonacceptance rates ranged from 21% for pediatricians and 28% for obstetrics/gynecology offices to 43% for core primary care practices. When examining the ‘‘Other’’ category, offices (ranging from 9% for obstetrics/gynecologyYprivate insurance to 21% for core primary careYMedicare) did not resolve an appointment request in the first telephone call because they required additional information (eg, valid health insurance number, valid date of birth), that the physician examine the individual before accepting him or her as a patient, or a call-back to the patient before scheduling an appointment. Ultimately, the practice may or may not have accepted the new patient. As such, the results presented in the Table underestimate reduced access to health care because of insurance status. There are no confidence intervals to report because the survey was of the entire population, with a contact completion rate of 86%.

Discussion A 2011 national survey found that 68% of adults covered by private insurance (ages 50Y64) reported no problems when seeking an appointment with a new primary care physician.8 This finding is consistent with that in our survey that 78% of Mississippi private insurance patients (all ages) were able to obtain an appointment with a core primary care physician. Similarly, the study found that 65% of Medicare-insured adults (age 65 and older) reported no problems when seeking a new appointment, a result echoed by our finding of 64% among Mississippi primary care physician offices. A study based on the National Ambulatory Medical Care Survey found that in 2011, 79.6% of office-based physicians (not restricted to primary care) were accepting new Medicaid patients, as opposed to our finding that only 50% of primary care offices were accepting new Medicaid patients.9 Nationally the estimate was 69.4%, and ranged from 40.4% to 99.3% at the state level. Inverting the measure to not accepting patients, a 2008 national study found that 58% of primary care physicians reported not accepting new Medicaid patients.12 Although 38% of Mississippi primary care physician offices were not accepting new Medicaid patients when we contacted their offices, another 12% of calls went unresolved (‘‘Other’’), which suggests that the actual nonacceptance rate is between 26% and 50%. Using another metric, 12% of Medicaid patients reported at least one barrier to primary care.8 Mississippi’s Medicaid patients clearly struggle to find a physician because nearly half of primary care offices are not accepting new Medicaid patients. In some cases, however, new Medicaid patients were offered the opportunity to see a nurse practitioner because Medicaid is a federal program regulated at the state level, but there is a great deal of variation in how it is implemented. For example, Medicaid obstetrics/gynecology patients were, in general, unable to Southern Medical Journal

secure an appointment unless they were pregnant. Future research should include a nationwide survey with representative samples of physicians’ offices by state to provide information on these wide variations. In Mississippi as of July 2012, one-third of the population is considered underserved by primary medical care,7 and access to care there is limited because there is an insufficient number of primary care physicians (Mississippi ranks 48th in the nation)13 and rural physicians.14 A contributing cause of insufficient access to primary care in Mississippi is the lack of managed care options and lack of integration among physicians, hospitals, and insurers. Further complications include Mississippi’s high rate of Medicaid coverage (26% vs the US average of 20%)15 and far more limited access to primary health care than people covered by private insurance or Medicare. Consequently, health insurance does not necessarily ensure access to primary care. In tandem with concerns about Mississippians, who are some of the poorest and sickest Americans,16 the lack of regular access to primary care is particularly disconcerting, especially in light of research that an expansion of Medicaid eligibility is associated with a significant decrease in mortality rates,17 emergency department visits, and the burden of cost.18 These findings have multiple implications. First, many states are implementing Medicaid expansion on the assumption that insurance coverage equals access to health care.19 Without the kind of analysis presented in this study, states are likely to overestimate the impact of this expansion on primary care offices and the reduction in demand at hospital emergency departments, notwithstanding the experience in Massachusetts (the state on whose healthcare reform measures the PPACA was modeled) with emergency department visits not increasing more than neighboring states after healthcare reform.20 We are mindful that ours was a meaure at two points (waves of surveys) in time. Healthcare services are in flux and there are many reasons that a practice may not accept new patients. Nevertheless, on the day we called the practices, we were unable to secure an appointment to see a primary care physician in up to 43% of the cases. The second implication is the individual physician’s business model. If new patient (especially one covered by Medicaid) avoidance is a financial decision, disregarding the incentives in the PPACA to primary care physicians to accept Medicaid patients, these research results have ramifications for the existing payment and delivery system. The converse side to reimbursements is healthcare costs. Massachusetts has targeted controlling healthcare costs as a primary goal.21 Third, the option of scheduling an appointment with physician extenders (eg, nurse practitioners, physician assistants, registered nurses) rather than wait an extended period to see a primary care physician was rarely offered. Our survey results, however, indicate that consumers would readily see a nurse practitioner or physician assistant,22 and research shows that nurse practitioners could be used to reduce the national shortage of primary care providers.23 Finally, the future

& Volume 107, Number 2, February 2014

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direction of this research should quantify the geographic differences in access to primary health care, specifically across the ruralYurban continuum.

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10. Decker SL. Two-thirds of primary care physicians accepted new Medicaid patients in 2011Y12: a baseline to measure future acceptance rates. Health Aff (Millwood) 2013;32:1183Y1187. 11. US Department of Health and Human Services, Health Resources and Services Administration. Primary medical care HPSA designation criteria. http://bhpr.hrsa.gov/shortage/hpsas/designationcriteria/primarycarehpsa criteria.html. Accessed August 1, 2013. 12. Cunningham PJ. State variation in primary care physician supply: implications for health reform Medicaid expansions. http://www.hschange.com/ CONTENT/1192/. Published March 2011. Accessed August 1, 2013. 13. United Health Foundation. America’s health rankings. Mississippi primary care physicians: 2011. http://www.americashealthrankings.org/MS/PCP/2011. Accessed August 1, 2013. 14. Cossman J, Street D. Rural and minority MDs in Mississippi: an overview. http://www.nemsahec.msstate.edu/publications/whitepaper/MIGMH%20 Report%203%20final.pdf. Published August 31, 2009. Accessed August 1, 2013. 15. Medicaid enrollment as a percent of total population, 2010. http:// www. statehealthfacts.org/comparetable.jsp?ind=199&cat=4&sub=52&yr= 92&typ= 2&sort=a. Accessed August 1, 2013. 16. Wilkinson R, Pickett K. The Spirit Level: Why More Equal Societies Almost Always Do Better. London, Allen Lane/Penguin Books, 2009. 17. Sommers BD, Baicker K, Epstein AM. Mortality and access to care among adults after state Medicaid expansions N Engl J Med 2012;367: 1025Y1034. 18. Hossain WA, Ehtesham MW, Salzman GA, et al. Healthcare access and disparities in chronic medical conditions in urban populations. South Med J 2013;106:246Y254. 19. Reddy S, Finley M, Posey D, et al. Expanding Medicaid managed care: the right choice for Texas? South Med J 2012;105:545Y550. 20. Chen C, Scheffler, G, Chandra A. Massachusetts’ health care reform and emergency department utilization. N Engl J Med 2011;365:e25. 21. Steinbrook R. Controlling health care costs in Massachusetts with a global spending target. JAMA 2012;308:1215Y1216. 22. Dill MJ, Pankow S, Erikson C, et al. Survey shows consumers open to a greater role for physician assistants and nurse practitioners. Health Aff (Millwood) 2013;32:1135Y1142. 23. Kuo YF, Loresto FL Jr, Rounds LR, et al. States with the least restrictive regulations experiences the largest increase in patients seen by nurse practitioners. Health Aff (Millwood) 2013;32:1236Y1243.

* 2014 Southern Medical Association

Copyright © 2014 The Southern Medical Association. Unauthorized reproduction of this article is prohibited.