Implementation of the Affordable Care Act – now assured by the re-election of President Obama – is expected to result in up to 50 million currently uninsured Americans acquiring some type of health insurance coverage. But a study by researchers at the Mongan Institute for Health Policy at Massachusetts General Hospital (MGH) finds that a significant percentage of the primary care physicians most likely to care for newly insured patients may be not be accepting new patients. The investigators note that strategies designed to increase and support these "safety-net" physicians could help ensure that newly covered patients have access to primary care.
"This study raises very serious concerns about the willingness and ability of primary care providers to cope with the increased demand for services that will result from the ACA," says Eric G. Campbell, PhD, of the Mongan Institute, senior author of the report to be published in the American Journal of Medical Quality. "Even with insurance, it appears that many patients may find it challenging to find a physician to provide them with primary care services."
In 2000 the Institute of Medicine published a report on the health care "safety net" – physicians and organizations caring for a significant proportion of uninsured or Medicaid-covered patients – that noted a lack of enough safety-net providers and the chronic underfunding of Medicaid. The Affordable Care Act was designed to ensure almost universal health insurance coverage, including expanding the number of individuals eligible for Medicaid. The authors of the current study note that many newly covered patients are likely to turn to physicians in the already-stressed health care safety net and that areas where such patients are likely to live often have limited primary care services. In addition, studies have suggested that physicians caring for disadvantaged groups of patients may provide lower-quality care.
The authors set out to better understand the physicians in the primary care safety net, to determine their willingness to accept new Medicaid patients and to assess their attitudes about and interest in quality improvement activities. As part of a 2009 survey of medical professionalism, physicians were asked to indicate the approximate percentage of their patients who were covered by Medicaid or were uninsured and unable to pay. They also were asked whether they were accepting new Medicaid or uninsured patients, along with several questions regarding services they provided to vulnerable populations and their attitudes towards and participation in quality improvement activities. Because of their focus on the primary care safety net, the investigators restricted their analysis to responses from internists, pediatricians and family practitioners.
Of 840 primary care physicians responding to the survey, 53 percent were safety-net providers, defined as having patient panels with more than 20 percent uninsured or Medicaid patients. Half of all responding primary care physicians indicated they were accepting new patients who either were covered by Medicaid or had no means of paying for their care. But safety-net physicians were considerably more likely to accept both patient groups, with 72 percent taking new Medicaid patients and 61 percent taking new patients with no medical coverage. There were no significant differences between the physician groups in reported attitudes about or participation in quality improvement efforts, and safety-net physicians reported greater awareness of and efforts to address disparities in health care than did non-safety-net physicians.
The authors note that the concentration of care for Medicaid and uninsured patients among a limited number of safety-net physicians and the fact that 28 and 39 percent, respectively, of those physicians are not accepting new Medicaid and uninsured patients indicate that the current health care safety net may have reached its capacity. In addition, they note, safety-net physicians' interest in quality improvement and attention to health care disparities suggests that reported differences in the quality of care they provide probably reflect limited resources available to their practices or barriers to care within the local communities.
"We found the attitudes of safety-net primary care physicians are consistent with providing equitable, universal care, and they were almost twice as likely to look out for possible racial and ethnic disparities within their practices," says Lenny López, MD, MPH, MDiv, of the Mongan Institute, corresponding author of the report. "We're already aware of the need for more primary care physicians, and these results make it apparent that the need for safety-net PCPs is even more critical. We also found that safety-net physicians were more likely to be women, under-represented minorities or foreign medical graduates, so efforts to bring more such physicians into primary care, along with efforts to close the income gap between safety-net and non-safety-net PCPs, could help expand the safety net."
López is an assistant professor and Campbell an associate professor of Medicine at Harvard Medical School. Additional co-authors of the study, which was support by the Institute on Medicine as a Profession, are Christine Vogeli, PhD, and Lisa Iezzoni, MD, Mongan Institute of Health Policy at MGH; Catherine DesRoches, PhD, Mathematica Policy Research, Princeton, N.J.; and Richard Grant, MD, Kaiser Permanente Northern California.