Influx of newly insured a prompt for practices to rethink patient flow

The crunch that physician practices, especially those in primary care, are likely to feel once the insurance mandate of the Affordable Care Act is in full force won't be as much about the sheer numbers of newly insured who will walk through the door. Instead, odds are it will be more about the intense level of care and service patients are likely to need when they arrive.

A report from PwC's Health Research Institute notes that the 30 million Americans expected to get insurance under the ACA are, compared with the current insured population, poorer, older, less likely to have full-time employment, less likely to have a college degree and more likely to speak a language other than English. Only a quarter have had previous health insurance.

Eighty-eight percent of the soon-to-be-insured rate themselves as being in excellent or very good health (compared with 91% for the currently insured). But it's expected that many newly insured patients will have health needs, unknown to them, that will need to be taken care of because they stayed away from the doctor's office for so long. Physicians might have to spend more time than usual in their initial patient assessments due to a lack of medical records for the newly insured, particularly in recent years.

“It's not going to be just a matter of everybody trying to do business the same way and see patients as we always have,” said Steven Green, MD, president of the California Academy of Family Physicians. “The newly insured will have complex needs and pent-up demand.”

Fourteen million U.S. residents will join the ranks of the newly insured on Jan. 1, 2014, according to the Congressional Budget Office. The other 16 million will come on by 2021. Averaged out, the number of newly insured for an individual physician doesn't sound so overwhelming. According to the American Medical Association's annual Physician Characteristics and Distribution, 767,782 physicians provided patient care in 2011 in the U.S., and 309,672 of those were in primary care. That would translate into 18 newly insured patients per physician and 45 newly insured patients per primary care physician.

The numbers could vary among doctors, depending on their practice's demographic base and the number of uninsured in the area. For example, a doctor in Texas is a prime candidate to have an above-average number of newly insured patients. The state leads the nation with a 24.2% uninsured rate, according to the U.S. Census, and has a large Spanish-speaking population. Thirty-one percent of the newly insured do not speak English as their primary language, compared with 12% of the currently insured, according to PwC.

The number of newly insured patients in a practice also could be affected by how many physicians in the area are accepting new patients in general.

PwC said the newly insured “are unlikely to overwhelm the health care system or substantially drive up costs immediately after gaining coverage.” But the demographics of that population “paint a hazy future” for doctors, the group wrote in its report. They are “unaccustomed to deciphering the vagaries of the health system,” and physicians “suspect there will be a range of undetected medical issues to address.”

The experience of Massachusetts

Physicians in Massachusetts already know what happens after health reform adds newly insured patients. The state's insurance mandate went into effect in 2006. Like the federal program, it includes payment assistance for people at certain income levels. At that time, the nonelderly uninsured rate in the state was 10.9%, compared with 17.1% for the nation as a whole, according to an assessment of the state's reform program published by the Kaiser Family Foundation in May. By 2010, the state's uninsured rate fell to 6.3% as the national rate rose to 18.4%.

Doctors reported that their experience was similar to the scenario PwC laid out. The issues they faced individually were not simply about the volume of new patients, but about the initial intensity of their care to make up for years of pent-up demand.

“They're like somebody who has never had a credit card before,” said Katherine J. Atkinson, MD, a family physician in a two-doctor practice in Amherst, Mass. She opened her practice to new patients when the state's health insurance exchanges were launched, adding 50 to the practice's 3,000 patient panel. Dr. Atkinson said she needed to add a nurse practitioner to help manage the extra load.

Family Medicine Associates of South Attleboro, a 12-doctor practice in Attleboro, Mass., stretched new patient appointments from 20 to 30 minutes and tried to have newly insured patients return for follow-up visits a month later rather than three or six months.

“They came in with lists in hand, and we did the best we could to handle the influx,” said Daniel Brown, MD, president of the practice. “There was additional chart time, but we developed work flows and tried to address some of the immediate issues and to have a sense of the big picture.”

Those trends won't necessarily change with time, said Joel Feinman, PhD, president and associate director of Valley Medical Group of Greenfield, Mass., which has 27 physicians in four offices in the western part of the state.

“Even now, several years after the exchange was implemented in Massachusetts, patients are still coming in confused about what benefits they have,” Feinman said. “We spend a lot of time trying to reach out and make sure they get the preventive care that they need. We have to get them into the mindset to come to us. And we have someone at the front desk to help them understand what their benefits actually mean.”