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Original Investigation | Health Care Reform

Primary Care Access for New Patients on the Eve of Health Care Reform

Karin V. Rhodes, MD, MS1,2; Genevieve M. Kenney, PhD3; Ari B. Friedman, MS1,2; Brendan Saloner, PhD2,4; Charlotte C. Lawson, BA1; David Chearo, MA5; Douglas Wissoker, PhD3; Daniel Polsky, PhD2,6
[+] Author Affiliations
1Center for Emergency Care Policy & Research, Department of Emergency Medicine,Perelman School of Medicine, University of Pennsylvania, Philadelphia
2Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
3Urban Institute, Washington, DC
4Robert Wood Johnson Health and Society Scholars Program, University of Pennsylvania, Philadelphia
5University of Chicago Survey Lab, University of Chicago, Chicago, Illinois
6Department of General Internal Medicine,Perelman School of Medicine, University of Pennsylvania, Philadelphia
JAMA Intern Med. 2014;174(6):861-869. doi:10.1001/jamainternmed.2014.20.
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Importance  Current measures of access to care have intrinsic limitations and may not accurately reflect the capacity of the primary care system to absorb new patients.

Objective  To assess primary care appointment availability by state and insurance status.

Design, Setting, and Participants  We conducted a simulated patient study. Trained field staff, randomly assigned to private insurance, Medicaid, or uninsured, called primary care offices requesting the first available appointment for either routine care or an urgent health concern. The study included a stratified random sample of primary care practices treating nonelderly adults within each of 10 states (Arkansas, Georgia, Illinois, Iowa, Massachusetts, Montana, New Jersey, Oregon, Pennsylvania, and Texas), selected for diversity along numerous dimensions. Collectively, these states comprise almost one-third of the US nonelderly, Medicaid, and currently uninsured populations. Sampling was based on enrollment by insurance type by county. Analyses were weighted to obtain population-based estimates for each state.

Main Outcomes and Measures  The ability to schedule an appointment and number of days to the appointment. We also examined cost and payment required at the visit for the uninsured.

Results  Between November 13, 2012, and April 4, 2013, we made 12 907 calls to 7788 primary care practices requesting new patient appointments. Across the 10 states, 84.7% (95% CI, 82.6%-86.8%) of privately insured and 57.9% (95% CI, 54.8%-61.0%) of Medicaid callers received an appointment. Appointment rates were 78.8% (95% CI, 75.6%-82.0%) for uninsured patients with full cash payment but only 15.4% (95% CI, 13.2%-17.6%) if payment required at the time of the visit was restricted to $75 or less. Conditional on getting an appointment, median wait times were typically less than 1 week (2 weeks in Massachusetts), with no differences by insurance status or urgency of health concern.

Conclusions and Relevance  Although most primary care physicians are accepting new patients, access varies widely across states and insurance status. Navigator programs are needed, not only to help patients enroll but also to identify practices accepting new patients within each plan’s network. Tracking new patient appointment availability over time can inform policies designed to strengthen primary care capacity and enhance the effectiveness of the coverage expansions with the Patient Protection and Affordable Care Act.

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Figure 1.
Rates of New Patient Availability for Private and Medicaid Insurance Scenarios

Estimates are weighted in proportion to patient populations by insurance status within states. Error bars represent 95% CIs.

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Figure 2.
Rate of New Patient Appointment Availability for the Uninsured Scenario

Estimates are weighted in proportion to patient populations by insurance status within states. Error bars represent 95% CIs. For the uninsured scenario, we defined appointments based on the definition of affordability, considering either all visits affordable or only those requiring cash payments no more than $75 at the time of the visit. The median costs at the appointment for uninsured callers were $123, $130, $125, $143, $150, $150, $125, $176, $124, and $125 for Arkansas, Georgia, Illinois, Iowa, Massachusetts, Montana, New Jersey, Oregon, Pennsylvania, and Texas, respectively.

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Figure 3.
Box and Whisker Plots of Days to Appointment for New Patients by State for Private Insurance and Medicaid Scenarios

Black lines represent median interval to appointment in state, and upper and lower edges of boxes represent the 75th and 25th percentiles, respectively. Upper ends of whisker plots are truncated for Massachusetts (60 days for private and 79 days for Medicaid scenario).

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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