• Doctors aren’t accepting new patients with private insurance either

    With so much press being made about doctors refusing patients with Medicare and Medicaid, it seems like public insurance is just a bad deal. Some of us, however, have been arguing that you’re only hearing part of the story. For instance, both Harold and Austin have argued that only looking at one large and broad private plan ignores the fact that many other private plans are much less robust and offer more limited access than BCBS. Others, like me, have argued that by focusing on specialists and adult docs, we miss the populations most often covered by these prorgams.

    A new study just published in Archives of Internal Medicine gets at some of these problems:

    Methods:

    We performed an analysis of trends from 2005 through 2008 using data from the National Ambulatory Medical Care Survey (NAMCS). NAMCS is a nationally representative survey administered by the Centers for Disease Control’s National Center for Health Statistics. It contains information about physicians practicing in nonfederally funded, nonhospital–based offices throughout the United States, excluding those in anesthesiology, radiology, and pathology. Data on hospital associated practices were not available. NAMCS uses a complex sampling design with physician weighting so that national estimates of physician and practice characteristics can be reliably generated… The sample was restricted to physicians who accepted new patients (4632 physicians, 95.1% of the sample). Pediatricians and obstetricians (520 physicians) were excluded in the analysis of Medicare acceptance rates. We report weighted percentages of physicians who accepted new patients by insurance type and year…

    What did the researchers do? They examined data from a representative sample pf physicians. Specifically, they looked at how often physicians accepted new patients by insurance type and year.

    What did they find? The overall acceptance rate of new patients was pretty static from 2005-2008, going from 94.2% to 95.3%. The percentage of physicians accepting new Medicare patients dropped from 95.5% from 92.9% (about 2.5%). But here’s the thing. There was a bigger drop in physician acceptance of patients with private noncapitated insurance from 93.3% to 87.8% (about 5.5%). In fact, they found that over 90% of physicians accepted new Medicare patients. Reports of reimbursement rates driving away physicians may be more anecdotal than widespread.

    So, yes, Medicare acceptance rates dropped, but private insurance acceptance rates dropped more overall. Interesting.

    Using data in tables attached to the study, I also made some charts showing how new patient acceptance rates of physicians differed in the groups I’ve argued matter. Let’s start with primary care physicians:

    What should we note here? First that the difference in the rates of acceptance of new patients with Medicare, private non-capitated patients, and self-pay patients are pretty similar. If you want to get detailed, however, the acceptance rate of private non-capitated patients went down more than the other two groups. Second, Medicaid acceptance rates were lower. They were comparable, however, to the acceptance rate of patients in private capitated plans. Also, not much changed from 2005-2008.

    Here’s pediatricians:

    Now obviously there’s no Medicare line, as these are kids. But notice the Medicaid line? Not much change overall from 2005-2008. Here’s the shocker, though. The acceptance of Medicaid is much closer to that of private non-capitated patients, and much better than that of private capitated plans. Acceptance rates of patients with those plans dropped off pretty severely between 2005 and 2008.

    Finally, here’s Ob-Gyns:

    Medicaid acceptance rates? Up from 2005 to 2008. Acceptance of all private plans? Down from 2005 to 2008. Moreover, Medicaid acceptance rates crush those of private capitated plans once again.

    I’m not arguing that Medicaid and Medicare don’t under-reimburse, or that they don’t have significant issues. They do, and they do.

    But the story you’ve been hearing is that (1) doctors are fleeing Medicare and Medicaid in droves and that (2) doctors much prefer private insurance to either of these programs. That’s not the whole story. Doctors, especially primary care docs, seem more likely to accept new patients with Medicare than with private capitated plans and likely many private non-capitated plans. Medicaid performs comparably to private capitated plans with primary care docs overall. But remember that Medicaid is primarily a plan for pregnant women and children. And ob-gyns and pediatricians are more likely to accept new patients with Medicaid than private capitated plans. And, while they don’t seem to be cutting back on Medicaid patients, they do seem to be accepting fewer patients with private plans overall.

    That’s a much different story. It’s one worth investigating further.

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    • So does this mean that we need to make it easier to become a doctor?

      I think that making it easier to become a doctor in Massachusetts would be a good thing to try. I know foreign trained doctors who would like to practice here but cannot pass the boards.

      Flood the market with Doctors and I bet that they will start to take patients with worse insurance. They might even start to do more charity work to build experience and reputation.

      • Somehow the thought of making it “easier to be a doctor” sounds oddly reminiscent of how we dumbed down the standards for teachers due to shortages of them. No, I like the idea only the best of the best get to make life and death decisions when it comes to my family’s health.

    • And now, it would be very interesting to know who is most likely to have private, capitated plans.

      Thanks so much for posting this — this is the sort of data and analysis that should be forming the debate about health care and reform of delivery and payment. I hope this makes it out of the blogosphere and into mainstream media articles on this topic. You are doing great work!

    • I thought Medicaid was primarily for elders in nursing homes that have exhausted their savings. Did I miss something?

      • Don blogged about this recently. Medicaid covers long term care, Kids and pregnant ladies and the chronically disabled as its three main blocks of patients.

        Steve

    • Let’s see if I understand this correctly: From 2005 to 2008, more and more PCPs are refusing to take new patients from four out of the five new-patient categories. The acceptance rate of the 5th category, self-pay, is unchanged.
      Isn’t this a little strange? This is almost like saying, “more and more merchants are refusing to take credit cards, but the percentage of merchants taking cash/checks remains unchanged.
      So, is there another category of new patients that PCPs are accepting?

    • During a recent uninsured episode with my wife, she was refused by a specialist doc at a University medical center because she was “self-pay”.

    • Reading this it makes me happy that we have universal health care in Australia. Anyone can see a GP, however individual GP’s can charge a gap fee above the government payment. It’s then up to the patient to identify what works for them

    • From the employer side, it is quite evident that the number of doctors accepting capitated plans has decreased over time. We often have to deal with problems where individuals have to wait weeks to get in to see someone or there are contract issues and either the hospital or physician group pull out of the capitated plan.

      I would love to see further data on the availability of specialists – that seems to be an even dicier area for capitated plans.

    • Related Government Accountability Office Report, June 30, 2011.

      MEDICAID AND CHIP
      Most Physicians Serve Covered Children but Have Difficulty Referring Them for Specialty Care

      http://www.gao.gov/new.items/d11624.pdf

    • I’m find although ethically only taking self pay instead of insurance may be the way to go for those in the mental health field, but to state it’s “ethically’ better to do it that way…. is misleading.
      Self-pay opens a door to MUCH MORE unethical practices by Doctors & Therapists.

      These self pay only therapists and Psychiatrist are taking longer to diagnosis, and that’s “if” they diagnosis.
      And forget about attempting to get reimbursed. It’s up the insurance company and the therapist and Dr.

      This self pay creates an issue when a patient is also working with other Specialists, or is seeking a diagnosis to be covered by insurance for other medical needs.

      For instance suppose a patient needs a diagnosis to get educational support, or needs a secondary insurance to cover other special treatments and a diagnosis is required. Is it ethical to forgo a patients medical needs so a Dr. doesn’t have to deal the bureaucratic issues of a patients insurance?

      My teen daughter has emotional needs both inside and outside of school. It’s been almost a year and we have yet had a diagnosis from a self pay therapist and psychiatrist (one won’t see her without the other). She was placed on medication,without a diagnosis (but it helps) which requires us to self pay the psychiatrist once a month for an appointment to get a refill. She see’s the therapist twice a month. All together including the medication it’s $382 a month. That’s over $3,000 for less then a year of therapy and we don’t have a diagnosis which would allow us to get a secondary insurance, which would allow us to leave a self pay office.
      We got the LEA school to pick up on more therapy, in the private school. However, we need to keep the outside self-pay therapist in order to get the medication from the psychiatrist. Our PCP will not prescribe the medication.

      We would move to an office who takes our insurance however either the practice will not take her because of the in school therapy, or they don’t accept self-pay.

      We will have to forgo the medication slowly we can no longer afford to keep her on the medication and the red tape it takes to get it for her.

      Understanding that most mental health issues are stigmatized in society the last thing Drs. and therapists should be doing in this field is no securing faith in this area of medicine.

      If a Dr. tells you leaving the insurance behind is solely for your benefit, consider how far in treatment you are willing to go with a self-pay Dr or therapist. If you do not seem to be getting better, why pay? They work in groups to keep lining their pockets. Hopefully there will be some sort of reform to help patients who face these dilemmas. Or patients will get smart and consider the legalities of these ethics and make these self pay pocket liners use their liability insurance!