Provider Mix, Regulatory Hurdles, and New Patient Primary Care Visit Availability

The insurance expansions of the Affordable Care Act may increase demand for office-based care, particularly primary care.  Many have questioned the ability of the existing workforce to absorb new patients and have called for increasing physician supply.  A more detailed understanding of which provider offices are best organized to accept new patients by insurance type may help devise interventions to accommodate a surge in demand.

We use data from a simulated patient study where trained field staff - randomly assigned to commercial, Medicaid, or no insurance - called primary care offices requesting the first available new patient appointment for either routine care or an urgent health concern. The study was conducted in ten states (Arkansas, Georgia, Iowa, Illinois, Massachusetts, Montana, New Jersey, Oregon, Pennsylvania, and Texas).

For private and Medicaid insurance, we describe the association between the availability of new patient appointments and the size of a physician office by both the number of physicians and mid-level providers. We then test whether, within-office, the organization of a physician office predicts differences in appointment availability for private and Medicaid patients. Finally, we explore heterogeneity in these results by the prevailing state-based scope of practice laws relevant to a given clinic. Our regulatory groupings are as follows: liberal (IA, MT, OR), moderate (AR, MA, NJ) and restrictive (GA, IL, TX, PA).

In all regulatory environments, mid-level providers are commonly used. Holding the number of clinic physicians constant, the addition of mid-level providers is positively associated with a higher likelihood of receiving an appointment. Importantly, while there is a 30-percentage point appointment rate gap between privately insured and Medicaid callers, the gap shrinks by 10% for practices with one mid-level provider and by nearly 20% for practices with multiple mid-levels relative to practices using no mid-level staff. Clinics receiving a call from each insurance type are also much less likely to only give an appointment to the privately insured caller when mid-level providers are present.

However, these patterns mask important heterogeneity with respect to scope of practice laws. The results for both insurance subgroups are driven by states with the least restrictive provider regulations (i.e., “liberal states”). The presence of mid-level providers increases the likelihood of receiving an appointment by 5-12 percentage points for privately insured patients and 20-30 percentage points for Medicaid patients in light regulation states, while having negligible impact in states that limit mid-level autonomy.

For all sets of results, the mid-level provider impact on Medicaid rates is 2-3 times greater than the privately insured subgroup, suggesting their role in shaping access for Medicaid patients is qualitatively larger.

Our findings indicate that a mix of providers can facilitate greater primary care access; however, a key ingredient is lowering the regulatory hurdles facing mid-level providers. When mid-level autonomy is constrained, clinics may allocate their human capital to tasks that have little bearing on the availability of new appointments. Thus, relaxing regulation may need to occur in step with coverage expansions to achieve many of health reform’s aims.