Friday, July 18, 2014

Health Care Reform......Do the Number of Enrollees really Matter?

The first five months of this year haven't brought more patients into doctors' offices, despite a large increase in sign-ups during the open enrollment for health insurance exchanges, according to a new report from the Robert Wood Johnson Foundation (RWJF) and athenahealth.
In fact, there was a slight drop in percentage of total visits with new patients compared to the same period last year.

This early finding on the effect of the Affordable Care Act may be misleading.  The reasons may be multiple. The argument that ACA will reduce costs by sending more patients to primary (and, in theory, preventative) care may not hold water, either, contends a post on a New York Times' blog post. .0

The RWJF report said the lack of change in patient volume might be caused by newly insured patients who are still unfamiliar with the healthcare system.
Many may have continued to seek care in emergency rooms instead of physician offices, for example, which could be because consumers don't understand how insurance works. A study published in the Journal of Health Economics found that only 14 percent correctly understood four basic insurance concepts--deductibles, copays, co-insurance and out-of-pocket maximumsFierceHealthPayer previously reported.

The Times post makes another point about patients who seek emergency care: "It is true that some people use the emergency room for minor problems. But that lack of access isn't all about insurance. Even for the insured, one of the major reasons people use the emergency room is that it's more convenient. That doesn't change with the ACA."

Another barrier to access:, it's likely taking some consumers with new exchange plans more time to shop for doctors, schedule appointments and see their new doctor, particularly if they have plans with narrow networks that limit provider choices, according to the JWJF report."

There has been an uptick in states with Medicaid expansion plans, although there is no indication that patients with chronic disease are seeing more providers.  The rate limiting factor in primary  care may be that it is already at capacity and there is no ability, or little to see more patients.  In fact many patients often see a specialist who will offer primary care. Networks an managed care attempt to limit this by blocking access to specialists, requiring primary care referrals. In fact insurers often deny a payment if their is no primary care referral. Prmary care doctors may also be 'maxed out' in processing referrals to specialists.

Based on my own experience primary care doctors may spend 10-20% of their day processing referrals, learning new network providers and deleting former providers due to narrow networks, which in turn will increase the patient load on select specialist increasing wait times for appointments. Patients are well advised to learn the specialists in their network to avoid delays and call for direct appointments after the referral is made.  Patients are creative, innovative and specialists will 'work around' the system as they have done for many years,  leaving te insurers to play with their meaningless paper work

Direct payment and concierge medicine is growing rapidly, and a quick cost comparison between what is called conventional medicine and direct payment reveals suprising and significant cost savings for most patients.  Insurers now are relatively safe following rules, and regulations imposed by state insurance commissioins who strictly set standards and scope of care in the na me of cost containment.  They would do far better by rejecting state and federal rules.

For the first time providers, patients and insurers are closer together in opposing what has been forced upon us all,  by our congress, which passed the affordable care act.  In our democracy the people do have power to vote them out of office.  President Obama is not the problem although he catalyzed events leading to passage of the ACA.

"These findings indicate that the implementation of the ACA is widening the gap of the total share of Medicaid patients that doctors in expansion vs. non-expansion states are caring for," the report said.

RWJF and athenahealth also determined that there hasn't been a rise in chronic conditions being diagnosed, meaning that so far new consumers aren't sicker than people who have had coverage. 

To learn more:
- here's the RWJF/athenahealth statement and report
- read the New York Times post

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