Health Policy$ense

Primary care access – Perspectives from LDI

primary care

Primary care is critically important for improving health outcomes and promoting public health. LDI Senior Fellows conduct research on primary care that digs deeper into the different components of access - the related but separate concepts of availability, accessibility, accommodation, affordability and acceptability.

Here we’ve pulled out key angles of some of the latest research.

Disparity in primary care supply in an urban area

- In a report commissioned by the Philadelphia Department of Health, LDI’s Liz Brown and colleagues, including LDI Director of Policy Dave Grande, analyze differences in primary care supply by neighborhood in Philadelphia. Through analysis of travel time to primary care by census tract, they identify six areas at risk of being underserved. They also recommend an ongoing surveillance method for the Philadelphia Department of Health, suggesting that the new role of public health departments is to assess and work with stakeholders to ensure access to services for the population rather than to deliver the services themselves. Liz Brown blogged about questions the researchers would like to explore further, and Dave Grande spelled out what key stakeholders should take away from the findings. 

Affordability of primary care for the uninsured

- In Health Affairs, a research team that includes LDI Executive Director Dan Polsky and Senior Fellow Karin Rhodes looked at the cost for a primary care visit for an uninsured patient in 2012-2013, prior to ACA insurance expansions. The authors analyzed data from a ten-state telephone survey in which callers posed as patients. They find that patients were quoted an average price of $160, and most practices required payment in full at the time of visit. Significantly lower prices for the uninsured were offered by family practice offices compared to general internists, in offices participating in Medicaid managed care plans, and in Federally-Qualified Health Centers (FQHCs). Prices were also lower for offices in ZIP codes with higher poverty rates. The authors conclude price is likely to be a barrier for many people remaining uninsured after the ACA insurance expansions.

The (expanded) Medicaid population and primary care

- In the NEJM, LDI’s Dan Polsky and co-authors at Penn and the Urban Institute analyzed the ACA’s Medicaid “fee bump” and conclude that it succeeded in improving primary care availability for the growing numbers of Medicaid patients. The “fee bump” policy reimbursed Medicaid primary care services at Medicare levels and was fully financed by the federal government for two years. In a 10-state study before and after the bump, primary care appointment availability improved 7.7 percentage points for Medicaid patients, while remaining unchanged for privately insured patients. Wait times for appointments remained remarkably stable, at about one week for each group, indicating that increases in Medicaid appointment availability did not come at a cost of delaying time to care. 

However, these pivotal findings came just as most states chose not to use their own funds to continue the “fee bump”. Medicaid fees returned to previous levels in 34 states as of January 1, 2015. Nonetheless, the findings were met with a great deal of interest, including by the Department of Health and Human Services, and the re-institution of the “fee bump” was included in President Obama’s proposed budget in early 2015. The story of this policy is one that’s likely to continue.

- In Medical Care, LDI’s Michael Richards and colleagues provide analysis suggesting that for those newly insured by the ACA, particularly those gaining Medicaid coverage, their best opportunity for getting a primary care appointment is at a FQHC. The authors analyzed data from a “secret shopper” study conducted in 2012-2013 and find that FQHCs granted appointments to Medicaid beneficiaries at much higher rates (80%) than non-FQHC providers (56%). FQHCs are community health clinics that receive federal grants to provide primary care access to underserved populations. Consistent with that mission, these data suggest that Medicaid patients seeking a new provider are likely to be more successful if they look to FQHCs, and that as of early 2013 FQHCs were able to accommodate the current Medicaid population.

ACA impact on demand and the health care workforce ‘shortage’

- A LDI research brief produced with the Interdisciplinary Nursing Quality Research Initiative and written by LDI’s Mark Pauly, Mary Naylor and Janet Weiner, reviews the evidence of an existing or looming primary care shortage in the wake of the ACA. The authors conclude that it is unlikely that the influx of patients and the demand for primary care will overwhelm present capacity, as measured by availability of appointments and wait times. This finding is in line with more recent analysis by the Commonwealth Fund, which concludes that increases of the magnitude likely to be generated by the ACA, a projected 3.8% increase in primary care visits nationally, can be handled by the existing supply of providers.

The authors note that primary care shortages may be felt in certain geographic areas (mostly rural) and perhaps by certain providers, such as Federally-Qualified Health Centers. They suggest that the ability to meet increased demands for primary care from an older, more universally insured population will depend on the development of new, more efficient ways of delivering care.

- LDI’s Julie Sochalski and Dan Polsky discussed some of these complicated primary care challenges in a Wharton/SiriusXM radio panel