Primary Care Access Pre-ACA

Illustration: Jared Rodriguez / Creative Commons

As the Affordable Care Act (ACA) changes roll out, many critics and proponents have voiced concerns about provider availability in the wake of massive increases of insured persons. In fact, recent data suggest that the uninsured rate has already fallen by over 40% in one state. There have been many efforts to foresee primary care availability, even using states such as Massachusetts as prototypes. In this study, researchers attempt to establish a baseline, noting, “The goal of the current study was to simulate the experience of non-elderly 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 expansion.”

Trained callers made 11,347 calls to 8,882 primary care practices in 10 states. The researchers further assigned self-payment calls to request either payment of $75 or less or full payment at the time of the visit. The target sample size per state was 700 calls for private, 700 calls for Medicaid, and 200 for self-pay. Callers completed about 1,300 calls per state, resulting in 47.5% calls for privately insured, 38.4% for Medicaid, and 14.2% for uninsured or self-pay.

Collectively, 91% of calls resulted in appointments, 76% with a requested provider. Across all states, 85% of privately insured, 58% of Medicaid, 79% self-pay with full cash payment, and 15% of self-pay with less than $75 cash payment secured appointments. Median wait times ranged 5-8 days for private and Medicaid clients. The researchers did not provide wait time information for self-pay callers.

Commentary

This study has several strengths that include large call volume, geographic diversity, caller randomization to payer group, and inclusion of uninsured scenarios.

However, in dissecting the study several biases emerge, including skewed age distribution (23% ages 18 to 29 years, 51% 30 to 45 years, and 27% 45 to 64 years), disproportionate call numbers among states (i.e. Texas has a population of roughly more than four times Massachusetts, but received 25% fewer calls), and selection bias in that 11.7% of calls were unable to result in an appointment because the practices’ electronic scheduling system would not proceed without an actual insurance number.

In spite of these limitations, the study still highlights important information concerning primary care access pre-ACA. Adequate access is lacking across all methods of payment, but especially for public insured and uninsured patients.

In the end, the researchers still question, “If we increase and expand public and private insurance, will primary care access keep up with the demands?”

Rhodes, Karin V. et al. JAMA Intern Med. 2014; 174 (6): 861-9.

by

Laura K. Grubb, MD, MPH, FAAP