Author Affiliations: Division of Outcomes and Effectiveness, Departments of Public Health and Medicine, Weill Cornell Medical College, New York, New York (Dr Bishop); Division of General Internal Medicine, Department of Medicine, Mount Sinai School of Medicine, New York (Dr Federman); and Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco Veterans Affairs Hospital, San Francisco (Dr Keyhani).
A number of articles in the lay and medical press report a decline in the number of physicians who accept patients with Medicare1- 3; however, to our knowledge, recent trends in acceptance of different types of insurance have not been examined. Using data from a national survey of physicians, we examined trends in physician acceptance of different types of insurance and self-pay patients. Understanding these trends can help inform policy makers of potential access problems, particularly given the shortages in primary care, an aging population, growing prevalence of chronic disease, and insurance expansion under the Patient Protection and Affordable Care Act.4- 6
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.7 NAMCS uses a complex sampling design with physician weighting so that national estimates of physician and practice characteristics can be reliably generated. The institutional review board at Weill Cornell Medical College approved this study.
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. We examined the relationship between acceptance of new patients with Medicare, Medicaid, private capitated insurance, private noncapitated insurance, self-pay patients, and year of participation in the program. Linear regression was used to estimate trends over time adjusting for practice size, physician ownership status, type of office, physician specialty, and location. Stratified analyses were performed to understand differences in acceptance of new patients by physician specialty and practice type. Analyses were performed using Stata statistical software, version 11.0 (StataCorp, College Station, Texas).
The percentage of physicians accepting new patients did not vary significantly between 2005 and 2008, ranging from 94.2% to 95.3%. Physician acceptance of new Medicare patients dropped from 95.5% in 2005 to 92.9% in 2008 (P = .01) (Figure). Physicians in private practice were largely responsible for the declining acceptance of Medicare patients as determined in stratified analyses (95.5% in 2005 vs 93.0% in 2008; P = .01) (eTable).
Percentage of ambulatory physicians who accept new patients by type of insurance, 2005 through 2008. Includes only physicians accepting new patients. Reported percentages are weighted based on the sample of physicians in the National Ambulatory Medical Care Survey. * P = .05 for trend across years adjusted for physician employment status, specialty, practice size, and location. †The sample for Medicare acceptance did not include pediatricians and obstetricians.
There was a more pronounced decline in physician acceptance of patients with private noncapitated insurance (93.3% in 2005 vs 87.8% in 2008; P < .001). A smaller percentage of adult primary care physicians accepted private noncapitated patients over the study period (97.3% in 2005 vs 89.9% in 2008; P < .001).
Rates of acceptance of new Medicaid and private capitated patients were lower than Medicare and private noncapitated insurance, but also showed a decline over the study period. Acceptance of self-paying patients was more than 96% in all years and did not change significantly over the study period.
While reports in the press highlight physicians' dissatisfaction with Medicare,1,2 we found only a small decline in physician acceptance of Medicare patients between 2005 and 2008. In contrast, the decline in physician acceptance of noncapitated privately insured patients was more pronounced. Physicians continued to accept patients who were self-paying.
Although physician reimbursement under Medicare is often cited as the reason why physicians turn away Medicare patients, our findings that more than 90% of physicians continue to accept Medicare patients despite marginal increases in reimbursement suggest that anecdotal reports may be overstating access problems.8 However, it is possible that practices are accepting Medicare patients in general but are accepting fewer.
The observed decline in acceptance of private noncapitated insurance was unexpected and could be related to reimbursement but also to administrative burden.9 Acceptance rates of capitated insurance was lower and may reflect lower reimbursement in this model. Finally, the low and declining acceptance of new Medicaid patients is not surprising given the program's historically poor reimbursement rate.10 Low rates of Medicaid acceptance may threaten access to care for the estimated 16 million Americans who will receive Medicaid coverage as a result of the Patient Protection and Affordable Care Act.6
Our study was limited by our inability to assess acceptance of insurance by physicians practicing in hospital outpatient departments. Nonetheless, our findings suggest that access to care is becoming increasingly restricted for certain types of insurance. Understanding the underlying reasons for the decreased acceptance of insurance could help direct changes in policy and are imperative in light of impending expansion of health insurance coverage in the United States.
Correspondence: Dr Bishop, Department of Public Health, Weill Cornell Medical College, 402 E 67th St, Room LA-218, New York, NY 10021 (firstname.lastname@example.org).
Author Contributions:Study concept and design: Bishop, Federman, and Keyhani. Analysis and interpretation of data: Bishop and Federman. Drafting of the manuscript: Bishop. Critical revision of the manuscript for important intellectual content: Federman and Keyhani. Statistical analysis: Bishop. Study supervision: Federman and Keyhani.
Financial Disclosure: None reported.
Funding/Support: This specific project was not grant supported. Drs Federman and Keyhani are supported by grants from the National Institute on Aging; the National Heart, Lung, and Blood Institute; and the Veterans Administration Health Services Research and Development Service.
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