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Obamacare's MD effect: No patient rush, but more money

Obamacare's feared "patient flood" looks more like a tide going out, slightly.

Doctor
Martin Barraud | OJO Images | Getty Images

Despite dire warnings of a big wave of new patients swamping doctors' offices and disrupting care after getting health insurance under the Affordable Care Act, there was actually a small net decrease in patient visits last year for primary care physicians, according to data collected from almost 20,000 doctors.

But even in the face of that decline, primary care doctors actually saw a net revenue increase of 3 percent or more from their patients in 2014. The findings came in data compiled by ACAView, an Obamacare-measuring project of Athenahealth and the Robert Wood Johnson Foundation.

Josh Gray, head of research at Athenahealth, said the findings disprove "two nightmare scenarios" suggested by some prior to the implementation of Obamacare. Those skeptics warned of a double whammy of too many patients to handle and fewer reimbursements for doctors.

"Neither of those scenarios came to pass," Gray said.

The ACA began taking full effect in 2014, when millions of people gained coverage from private health plans sold through government-run Obamacare exchanges, and others who previously had difficulty buying insurance purchased plans outside the exchanges.

About half the states as of 2014 had also expanded their Medicaid programs, which are jointly run with the federal government, to allow nearly all poor adults to obtain health coverage for no monthly premium.

But even with the addition of millions of newly insured people, in states that expanded Medicaid there was a decrease of 0.3 percent of patient visits to primary care doctors monitored by the ACAView project.

In non-Medicaid expansion states, the decrease was more pronounced: a 1.3 percent reduction in patient visits to primary care physicians.

Gray said there are several possible reasons why there was a decrease in patient visits even with coverage expansion.

One possibility is that patients are becoming more cost-conscious due to an increase in the amount their insurance plans force them to pay out of pocket for health services. That trend was occurring prior to Obamacare, but ACA exchange-sold plans tend to have higher out-of-pocket cost structures than job-based health plans.

Gray said the out-of-pocket costs patients face for an office visit could be leading some of them to think twice before going to their doctor.

"It's also possible that newly insured patients are still getting care in the emergency department, or urgent care centers, and are not necessarily seeing the primary care doctors," he said.

And because ACAView did not distinguish between new patients and existing patients, another factor could be decreases in existing patient volumes, Gray said.

A state's decision to not expand Medicaid could explain why primary care doctors in those states saw a greater drop-off in patient visits than in expansion states, where there were bigger increases in the number of people enrolling in Medicaid.

But Gray noted that even in expansion states, "not every practice is accepting new Medicaid patients, and not every practice is accepting an unlimited number of Medicaid patients."

Different story for surgeons

Unlike their primary care brethren, surgeons saw an uptick in patient visits. In non-Medicaid expansion states last year, surgeons had an 3.5 percent increase in patient utilization of their services, and in expansion states there was a 1 percent increase for surgeons.

Surgeons also saw an increase in collections, or payments they get for operating on those patients.

In nonexpansion states, surgeons had a 4 percent increase in collections last year when the ACA began taking full effect.

In expansion states, surgeons saw a 2 percent increase in collections, with a large majority of that extra revenue coming from operations on Medicaid patients, possibly reflecting pent-up demand from those people, according to the ACAView data.

But collections also rose at a healthy clip for primary care doctors despite their decreasing net patient load.

Primary care physicians in nonexpansion states had a 3.3 percent increase in collections in 2014, ACAView's data showed. A majority of that revenue growth came from privately insured people. Patients covered by Medicare, the federally run health coverage program primarily for seniors, drove more than 41 percent of that growth.

In expansion states, there was a 3 percent increase in collections by primary care doctors. Almost half of that rise came in spending on Medicaid patients, while almost 40 percent of the growth came from Medicare patients.

Kathy Hempstead, who directs coverage issues for the Robert Wood Johnson Foundation, said that the rise in collections despite the decrease in visits is due to the visits growing more complex, on average.

"Visits are down, but complexity is up," Hempstead said.

More complex health cases have higher reimbursement rates by insurance payors, Hempstead noted.

In addition to "a little bit of increase in complexity," she said, there has also been a "little increase in prices," which has in turn helped shield primary care doctors' revenue from the decline in patient visits.

Hempstead said that visits could be becoming more complex for several reasons.

"It could be more older patients," she said. "It could be that more people are using retail clinics for less serious things."

Regardless of the reasons, Hempstead said, the data provide "a counterpoint to some of the fears and apprehension that a lot of physicians had on the eve of the ACA that it would be disruptive to their office space practice."

"Despite the many disruptive changes associated with health reform, these data suggest that in terms of revenue growth for office-based physicians, so far it is largely a nonevent," Hempstead said.