Accessible Care

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Access to Care under Medicare

Across the United States, people are finding it increasingly difficult to access necessary health care. Some argue that this is evidence of a severe physician shortage, while others argue that the physician supply is adequate but poorly distributed across specialties and geographic regions. Along with the physician supply debate, the diversity of proposals for improving access to appropriate health care reveals the complexity of the problem.

On July 15, Congress overrode President Bush's veto of HR 6331, signing the Medicare Physician Pay Patch Bill into law and postponing cuts to Medicare's physician payments for 18 months. Without this legislation, payments to physicians would have dropped 10.6 percent on July 15 and an additional 5.4 percent on January 1, 2009. According to the bill's supporters, the payment cuts were so dramatic that they "threatened seniors' access to care, and health care for military families," whose TRICARE insurance uses Medicare's physician payment formula.¹ Funding for the bill comes from reducing reimbursements to private insurance companies participating in the Medicare Advantage program, a sum totaling nearly $14 billion over five years.² 

The American Medical Association (AMA) and the American Association of Retired Persons (AARP) both supported the bill on the grounds that cutting payments to doctors would force them to stop accepting Medicare patients, dramatically reducing access to care for the vulnerable populations Medicare serves.^3,4  A survey of 1,000 group practice professionals representing more than 28,679 physicians by the Medical Group Management Association (MGMA) came to similar conclusions regarding the effect of physician payment cuts on access to care.⁵ According to their study, 24 percent of practices had already begun limiting or not accepting new Medicare patients as of March 2008. An additional 46 percent of providers indicated that the impending 10.6 and 5.4 percent cuts would force them to follow suit. 
     
In contrast, reports by the Government Accountability Office (GAO), the Center for Studying Health System Change (HSC), and the Medicare Payment Advisory Commission (MedPAC) present a more positive view of Medicare beneficiaries' access to care. The GAO found a general increase in the proportion of beneficiaries who received physicians' care from 2000 to 2005, as well as in the number of services provided to each beneficiary. Despite a 5.4 percent cut in physician payments in 2002, the GAO reported increases in the number of physicians who billed Medicare for services and the proportion of services for which Medicare's fees were accepted as payment in full.⁶  In addition, a 2005 HSC Issue Brief reports that Medicare beneficiaries' access to physician services stabilized between 2001 and 2003 after declining precipitously between 1997 and 2001.⁷ MedPAC's March 2008 report to Congress details similar success in securing Medicare beneficiaries' access to care.^8,9 In 2006, more than 90 percent of surveyed beneficiaries reported good access, although the small percentages of those reporting difficulty accessing care increased from 2005. 

Despite the encouraging evidence of Medicare beneficiaries' current access to care, both HSC and MedPAC advise Congress to change the formula used to determine physician payment rates. They warn that future cumulative reductions to physicians' pay could have extremely detrimental effects on beneficiaries' ability to access services. Already, the MedPAC report notes that primary care physicians and other nonproceduralists are less likely than other types of physicians to accept new Medicare patients, reminding policymakers that Medicare should "be actively encouraging, not hindering, access to these services given their potential to improve the quality and efficiency of health care delivery."¹⁰

General Physician Accessibility

While the debate continues about whether Medicare patients currently experience appropriate access to care, recent articles from local newspapers in Massachusetts, Alabama, Colorado, Minnesota, Missouri, Virginia, and Maryland all detail growing difficulty accessing care among patients of every insurance status. According to a 2007 report by the Robert Graham Center and National Association of Community Health Centers (NACHC), 56 million people in the United States have "no or inadequate access to a primary care physician due to a local shortage of such physicians."¹¹ The study cites evidence that having a usual source of care is a better indicator of positive health outcomes and utilization of appropriate care than merely having insurance. For those living in areas with a potential shortage of primary care, a dearth of physicians would make it difficult to establish a usual source of care. 

Multiple studies show that, while insurance does not guarantee access to appropriate care, insured people are more likely to have a usual source of care than the uninsured.^12,13 Furthermore, having both insurance and a usual source of care has been associated with higher quality care and better health outcomes.¹⁴ Therefore, the 47 million uninsured Americans in 2006 are significantly less likely to enjoy the health benefits associated with access to quality care.¹⁵ But even the existence of insurance may not significantly improve access to care, as demonstrated by a recent study's findings that nearly 16 million additional Americans were underinsured in 2005.¹⁶ While these Americans had insurance, they lacked adequate financial protection, making it almost as difficult for them to access quality care as for the uninsured. These studies make it clear that insurance is an important factor in making care accessible, although expanding insurance alone cannot solve all problems with access to care. 

Physician Supply

No amount of insurance could ensure access to physicians without an adequate supply of doctors. While all agree that access to care is inextricably tied to physician supply, health care experts are currently embroiled in a debate about whether the country is suffering from a real shortage of physicians, or whether the problem lies with their uneven distribution by geography and specialty. 

The AMA, Association of American Medical Colleges (AAMC), and Council on Graduate Medical Education (COGME) support the argument put forward by Richard Cooper, M.D., of the Medical College of Wisconsin, Milwaukee, that the country is facing a serious physician shortage.^17,18,19,20 Cooper's predictions of a shortfall of 200,000 physicians between 2020 and 2025 rest on an economic analysis of past and present trends in health care. From his research, he has concluded that demand for health care will continue to expand as long as increases in population and economic wealth support it.²¹
 
As continued economic and population growth stimulate demand for health services beyond the capacity of the current workforce, Cooper warns that demographic changes in physician supply will exacerbate the shortfall in available providers. An increasing proportion of physicians, in particular females and young males, place a high priority on lifestyle, leading to shorter working hours per full time physician. In addition, many physicians are nearing retirement as aging baby boomers require more help managing chronic conditions. Cooper cites patients' problems accessing care, the emergence of high-premium "boutique" practices, and increasing job opportunities for physicians as evidence of a worsening supply. 

In reaction to the large body of evidence warning of huge physician shortages, in 2006 the AAMC recommended that medical schools increase enrollment 30 percent by 2015 and that Congress expand Medicare support for the mandatory graduate medical education (GME) training.^22,23 

An alternative analysis of the data suggests no shortage, and perhaps even an oversupply of physicians. David Goodman, M.D., of the Center for the Evaluative Clinical Sciences at Dartmouth Medical School, identifies significant geographic disparities in physician distribution as the cause of much of the perceived physician shortage.^24,25,26  In areas with a high density of physicians, such as Massachusetts, he cites higher spending and poorer patient outcomes compared to low supply regions as evidence that access problems are more the result of a dysfunctional delivery system than a dearth of physicians.²⁷ He argues therefore that merely increasing the supply of physicians will not alleviate the underlying systemic problems that impede patients' access to care. 

In his study of regional variations in physician workforce between 1979 and 1999, Goodman found that variation in distribution across regions decreased only slightly despite huge growth in the total number of practicing physicians in the United States.²⁸  Physicians did not naturally diffuse into areas of low supply as had been expected. Furthermore, he highlights a concerning trend away from primary care residencies into more procedure-oriented specialty practices that would be exacerbated by unrestricted growth in GME.^29,30  Finally, Goodman contends, the funds spent to increase Medicare support for GME would be better spent elsewhere, such as on increasing insurance coverage for low-income Americans, or encouraging systemic changes to a fragmented delivery system.³¹
 
Maldistribution

Regardless of researchers' opinions about the appropriate supply level, they agree that fundamental flaws in the current payment and delivery systems have made it difficult to access primary care. The current fee-for-service (FFS) payment effectively undervalues services crucial to quality primary care.^32,33 Instead of rewarding physicians on the basis of the quality of their care or patient outcomes, Medicare reimburses doctors based on "individual services" rendered.³⁴ 

That payment system is reflected to various extents in the reimbursement policies of many private insurance companies, creating a culture in which primary care, which involves a great deal of care coordination and cognitive, non-procedure oriented care, is remarkably undervalued.^35,36,37,38 In response to this skewed payment system, which underpays primary care physicians for essential services, increasing numbers of medical school graduates are entering more lucrative specialty positions.³⁹  To make up the income disparity with specialists, primary care physicians are compelled to take on more patients than they can comfortably care for, leading to lower-quality care and faster physician burnout and exit from the profession.^40,41,42

Effects of Potential Reforms on Supply

In response to a payment system that rewards procedures over cognitive services, many health care experts and professionals have begun to promote the idea of organizing health care around a system of medical homes. Medical homes are designed to foster strong relationships between patients and physicians, in which the focus is on comprehensive care and the primary care provider explicitly aids the patient in coordinating care. ⁴³ Primary care practices that meet the standards of medical homes have been proven to increase health outcomes by increasing the accuracy of diagnoses, focusing on preventive care, and helping manage chronic conditions.⁴⁴ Likewise, patients cared for in medical homes have lower long-term costs associated with their care because the model limits unnecessary tests and procedures as well as preventable hospital visits.⁴⁵

As the concept of the medical home gains popularity, insurers, practitioners, and the government are partnering to run pilot studies to refine the model and determine how best to implement it in practice.⁴⁶ Given the primary care focus of medical homes, a system focused on medical homes would create an even greater need for primary care physicians than currently exists. To create the base of primary care physicians necessary to implement a successful system of medical homes, payers and practitioners are using the pilot studies to find optimal reimbursement structures that close the gap between pay for specialists' and generalists' care.^47,48 Through more equal reimbursement, proponents of medical homes hope that primary care may become a more attractive option for new doctors, mitigating the shortage of primary care physicians. Likewise, they hope that by allowing primary care physicians to build relationships with their patients and spend adequate time caring for them, medical homes will combat the quick burnout among doctors that leads to premature exit from the field.
 
Conclusion

As is evident from the vast body of literature exploring access to health care, neither the problems nor the solutions are simple. Improving access to care is a financial question as much as it is a fundamental inquiry into the proper role of government. In addition, it raises questions among researchers about how to measure physician supply and whether physician shortfalls stem from distribution across the country and areas of medicine, from an artificial limit to the number of doctors educated each year, or from a combination of both. The endless and far-reaching questions associated with improving access to health care, while revealing the daunting complexity of the issue, prove that the range of approaches to studying and effecting reforms in health care access is a vast and varied one. 

The following are select grants from HCFO's portfolio that address issues related to physician access. For other HCFO grants, see www.hcfo.net.

Title: Resource Use and Efficiency in Episodes of Care
Grantee Institution: Palo Alto Medical Foundation Research Institute
Principal Investigator: Hal S. Luft, Ph.D.
Grant Duration: July 1, 2008-September 30, 2009

The researchers seek to examine some of the underlying assumptions of episode-based payments, which are hypothesized to encourage more clinically and economically efficient practices by primary care physicians (PCPs). Specifically, they will assess whether episode-based measures of resource use at the individual PCP level, rather than the physician group or medical staff level, are statistically reliable and appropriate. Using data from the Palo Alto Medical Foundation (PAMF), a large multispecialty physician group that uses electronic medical records (EMRs), the researchers will examine whether some PCPs have practice patterns significantly more (or less) expensive than the average at either the episode level or with groups of acute or chronic episodes. If there is variation in PCP practice patterns, the researchers will explore the role of components, such as PCP office visits, referrals, imaging, lab tests, and drugs, in these differences. They will also study clinicians' explanations for differences in practice patterns, such as unmeasured severity, location, or other factors. They will compare PAMF-based patterns of care with overall patterns at an episode level (but not physician level) from a large national data set. The objective of the study is to determine whether consistent styles of practice across PCPs within a large medical group can be detected, which would help inform policymakers about whether physician-oriented incentives are worth pursuing.

Title: How Does Fragmentation of Care Contribute to the Costs of Care?
Grantee Institution: Harvard University School of Public Health
Principal Investigator: Eric C. Schneider, M.D.
Grant Duration: March 1, 2008-August 31, 2009

The researchers will develop new measures of care fragmentation that can be used to assess fragmentation within episodes of care and evaluate the relationship between care fragmentation and the costs of care for Medicare beneficiaries. They hypothesize that a higher degree of fragmentation of care will be associated with higher episode-specific costs of care after controlling for type of clinical episode, severity of clinical episode, clinical comorbidities, and the sociodemographic characteristics of patients. To test this hypothesis, the researchers will modify existing measures of fragmentation and develop new measures based on their relevance for episodes of care, select an approach to measuring costs, and select the clinical episodes for which they will test for the association between fragmentation and costs. The objective of this study is to improve quality and reduce the growth of health care costs in the United States by assisting the Medicare program and other insurers to measure and monitor fragmentation and target improvements to episodes with higher fragmentation.

Title: Cost and Efficiency in Treating High-Cost Medicare Beneficiaries: The Role of Physician Practice and Health System Factors
Grantee Institution: Center for Studying Health System Change
Principal Investigator: James D. Reschovsky, Ph.D.
Grant Period: March 1, 2008-August 31, 2009

The researchers will examine key physician practice and market characteristics that may contribute to high costs and inefficient care in the Medicare program. The study is composed of three phases. In phase one, they will analyze the treatment of high-cost Medicare beneficiaries in order to identify key physician, practice, and market characteristics associated with differences between actual and predicted Medicare payments and medical care use. In phase two, they will examine whether the factors associated with greater than predicted resource use affect high-cost beneficiaries' health outcomes. Finally, the researchers will examine possible sources of geographic cost variations for high-cost beneficiaries and the extent to which these variations reflect differences in patient characteristics or supply-related factors and practice patterns of providers in a particular region. The objective of this project is to identify potential policy levers that can influence cost effectiveness in the delivery of medical care to high-cost Medicare patients.

Title: Identifying Best Practices in the Coordination of Care
Grantee Institution: Center for Studying Health System Change
Principal Investigator: Ann S. O'Malley, M.D., M.P.H.
Grant Duration: October 1, 2007 - September 30, 2008

The researchers will examine how care is coordinated in ambulatory care settings. Specifically, they will identify and document "best practices" in physician offices that have developed care coordination processes and determine the financial implications of increased coordination. For example, the researchers will assess whether a periodic care coordination fee or itemized billing for coordination activities is more efficient. They will also examine a group of "average practices" to assess how they set priorities for coordination activities and what barriers they encounter. The objective of the proposed project is to better inform the replication of organized care coordination processes in medical practices.

Title: Physicians' Responses to Variations in Medicare Fees for Specific Services
Grantee Institution: Center for Studying Health System Change
Principal Investigator: James D. Reschovsky, Ph.D.
Grant Period: March 1, 2007 - June 30, 2008

The researchers will examine how physicians' provision of specific medical services to Medicare FFS beneficiaries responds to variations in Medicare physician fees for those services, physicians' characteristics, and to local market factors. The study will test whether the quantities of specific services physicians provide to their Medicare fee-for-services patients are:1) positively related to the Medicare fee for each service; 2) inversely related to the fees paid by private insurance and to the level of demand from non-Medicare patients; and 3) positively related to indicators of physicians' incentives to "induce demand." Potential outcomes include: 1) indicating the percentage change in service volume for a particular fee change; 2) estimating how service volumes vary with local market conditions; 3) characterizing physician opportunities and underlying incentives to induce demand; and 4) identifying services for which service-specific fee adjustments might be an effective tool to constrain unnecessary use. This project expands upon a previous study by the applicants that investigated overall provision of total Medicare services by physicians. The objective of the project is to fill a gap in past and current physician payment research by assessing if changing relative prices of specific services will contribute to meeting the broad policy goals of discouraging the provision of services that unnecessarily add to cost growth without improving quality or outcomes.

1 Baucus, M. "Senate Passes Medicare Bill for Seniors," Committee on Finance, Jul 9, 2008, Also see www.finance.senate.gov/press/Bpress/2008press/prb070908%20Medicare%20vote.pdf.
2 Abramowitz, M. and P. Kane. "Congress Easily Overrides Medicare Veto," Washington Post , Section A02, July 16, 2008.
3 American Association of Retired Persons (AARP). "Keep Medicare Fair," July 15, 2008, Also see  www.aarp.org/makeadifference/politics/Keep_Medicare_Fair/.
4 American Medical Association. "2008 AMA Medicare physician payment action kit," July 16, 2008.
5 Medical Group Management Association. "Group practices forced to limit access for Medicare patients in 2008," March 6, 2008, Also see  www.mgma.com/press/default.aspx?id=17338.
6 Government Accountability Office. "Use of Services Increasing Nationwide," July 2006, Also see www.gao.gov/cgi-bin/getrpt?GAO-06-704.
7 Trude, S. and P. Ginsburg. "An Update on Medicare Beneficiary Access to Physician Services," Issue Brief No. 93, Center for Studying Health System Change, February 2005.
8 MedPAC. "Access to Care in the Medicare Program," Report to the Congress, Section 5, March 2008.
9 MedPAC. "Physician Services," Report to the Congress, Section 2B, March 2008.
10 Ibid.
11 "Access Denied: A Look at America 's Medically Disenfranchised," National Association of Community Health Centers and the Robert Graham Center, 2007.
12 Williams, C. "From Coverage to Care: Exploring Links Between Health Insurance, a Usual Source of Care, and Access," Robert Wood Johnson Foundation, September 2002.
13 "The Importance of Having Health Insurance and a Usual Source of Care," One-Pager No. 29, Robert Graham Center, September 2004.
14 Ibid.
15 "Income, Poverty, and Health Insurance Coverage in the United States, 2006," U.S. Census Bureau, 2007.
16 Schoen, C. et al. "Insured but Not Protected: How Many Adults Are Underinsured?" Health Affairs, Web Exclusive, June 14, 2005.
17 Association of American Medical Colleges. "Statement on the Physician Workforce," June 2006, Also see www.aamc.org/workforce/workforceposition.pdf.
18 Association of American Medical Colleges. "Recent Studies and Reports on Physician Shortages in the U.S.," Center for Workforce Studies, August 2007. Also see www.aamc.org/workforce/recentworkforcestudies2007.pdf .
19 Cooper, R. "Weighing the Evidence for Expanding Physician Supply," Annals of Internal Medicine, Vol. 141, No. 9. November 2, 2004
20 Council on Graduate Medical Education. "Physician Workforce Policy Guidelines: 2000 to 2020," January 2005, Also see  www.cogme.gov/16.pdf .
21 Goodman, D. "Twenty-Year Trends in Regional Variations in the U.S. Physician Workforce," Health Affairs, Web Exclusive. October 7, 2004.
22 Iglehart, J. "Grassroots Activism and the Pursuit of an Expanded Physician Supply." New England Journal of Medicine. Vol. 358, No. 16. April 17, 2008, pp. 1741-1749.
23 Association of American Medical Colleges. "Statement on the Physician Workforce," June 2006, Also see www.aamc.org/workforce/workforceposition.pdf .
24 Goodman, D. and E. Fisher. "Physician Workforce Crisis?  Wrong Diagnosis, Wrong Prescription," New England Journal of Medicine, Vol. 358, No. 16, April 17, 2008, pp. 1658-1661.
25 Goodman, D. "Twenty-Year Trends in Regional Variations in the U.S. Physician Workforce," Health Affairs, Web Exclusive. October 7, 2004.
26 Cross, M. "What the Primary Care Physician Shortage Means for Health Plans," Managed Care, June 2007.
27 Goodman, D. and E. Fisher. "Physician Workforce Crisis?  Wrong Diagnosis, Wrong Prescription," New England Journal of Medicine, Vol. 358, No. 16, April 17, 2008, pp. 1658-1661.
28 Goodman, D. "Twenty-Year Trends in Regional Variations in the U.S. Physician Workforce," Health Affairs, Web Exclusive. October 7, 2004.
29 Fisher, E., et al. "The Implications of Regional Variations in Medicare Spending," Annals of Internal Medicine, Vol. 138, No. 4, February 18, 2003.
30 Goodman, D. and E. Fisher. "Physician Workforce Crisis? Wrong Diagnosis, Wrong Prescription," New England Journal of Medicine, Vol. 358, No. 16, April 17, 2008, pp. 1658-1661.
31 Ibid.
32 Pham, H. and P. Ginsburg. "Unhealthy Trends: the Future of Physician Services," Health Affairs, Vol. 26, No. 6, November/December 2007, pp. 1586-98.
33 Cross, M. "What the Primary Care Physician Shortage Means for Health Plans," Managed Care, June 2007.
34 MedPAC. "Payment Basics: Physician Services Payment System," September 2006, Also see www.medpac.gov/publications/other_reports/Sept06_MedPAC_Payment_Basics_Physician.pdf .
35 Steinwald, A. "Primary Care Professionals: Recent Supply Trends, Projections, and Valuation of Services." Government Accountability Office. February 12, 2008, Also see  www.gao.gov/new.items/d08472t.pdf .
36 Iglehart, J. "Grassroots Activism and the Pursuit of an Expanded Physician Supply." New England Journal of Medicine. Vol. 358, No. 16. April 17, 2008, pp. 1741-1749.
37 Goodman, D. and E. Fisher. "Physician Workforce Crisis?  Wrong Diagnosis, Wrong Prescription," New England Journal of Medicine, Vol. 358, No. 16, April 17, 2008, pp. 1658-1661.
38 Pham, H. and P. Ginsburg. "Unhealthy Trends: the Future of Physician Services," Health Affairs, Vol. 26, No. 6, November/December 2007, pp. 1586-98.
39  Ibid.
40 Sepulveda, M. et al. "Primary Care: Can It Solve Employers' Health Care Dilemma?" Health Affairs, Vol. 27, No. 1, January/February 2008, pp. 151-158.
41 Cross, M. "What the Primary Care Physician Shortage Means for Health Plans," Managed Care, June 2007.
42 Pham, H. and P. Ginsburg. "Unhealthy Trends: the Future of Physician Services," Health Affairs, Vol. 26, No. 6, November/December 2007, pp. 1586-98.
43 National Committee for Quality Assurance. "Recognizing Physician Practices as Medical Homes," 2008, www.ncqa.org.
44 "Federal, State Governments, Insurers Test Medical Home Model of Health Care to Reduce Costs," Kaiser Daily Health Policy Report. kaisernetwork.org, July 21, 2008. Also see http://www.kaisernetwork.org/Daily_Reports/rep_index.cfm?DR_ID=53406
45 "Access Denied: A Look at America 's Medically Disenfranchised," National Association of Community Health Centers and the Robert Graham Center, 2007.
46 Foubister, V. "In Focus: Are Medical Homes Primary Care's Answer?" Newsletter, The Commonwealth Fund Vol. 28, January 24, 2008.
47 American College of Physicians. "What is the Business Model for the PCMH?" 2008, www.acponline.org/advocacy/where_we_stand/medical_home/business_model.htm.
48 Goroll, A., et al. "Fundamental Reform of Payment for Adult Primary Care: Comprehensive Payment for Comprehensive Care," Journal of General Internal Medicine, January 9, 2007, pp. 410-415.