Assessing Access to New Patient appointments: Comparing Survey to Audit Methodology
Daniel Polsky, Michael Richards, Brendan Saloner, and Karin Rhodes
The insurance expansions of the Affordable Care Act will create millions of newly insured and more stably insured individuals who will now have more economic incentives to access office-based physicians rather than relying on ambulatory care provided by hospitals and their emergency departments. There is concern that if this shift in demand for primary care takes place, there may not be an adequate supply of providers to meet this demand. Moreover, access disparities may increase between privately-insured and Medicaid-insured patients. Since Medicaid pays a fixed (and lower) reimbursement, profit-maximizing providers may respond to a shift in demand by reducing access for new patients, and for Medicaid patients in particular (Sloan, Mitchell, and Cromwell, 1978).
There will be a need to track how well the system is able to provide appointments to new patients, both from the perspective of transparency and in order to identify where interventions may be necessary. Yet there is no single gold standard for measuring the capacity of the outpatient primary care system.
The goal of this study is to compare two methods of assessing whether a representative sample of physicians are accepting new patients into their practice by both private and Medicaid insurance. We compare a traditional provider survey methodology, from the National Ambulatory Medical Care Survey (NAMCS), with a simulated patient (i.e. audit) methodology. The survey asks physicians directly whether they are accepting new patients and the insurance status accepted among those new patients. The audit study uses trained field staff posing as patients - randomly assigned to private and Medicaid – to request the first available new patient appointment.
For the 10 states where the audit study was conducted, both methods find around 85% of primary care physicians accept appointments for new private patients, but differences emerge for Medicaid. The rate of acceptance of new appointments is 69.5% from the survey method and 38% from the audit method. As a supplement to the audit study, a traditional survey of physician offices was also conducted. During that survey, a question similar to the NAMCS was asked and during that survey, 64% of offices said they would accept new Medicaid patients. Those offices “accepting” new Medicaid patients were almost entirely offices that have a Medicaid managed care contract. The audit study shows that, within offices accepting Medicaid managed care, only 58% give appointments to new Medicaid patients assigned to their managed care plans.
We conclude from this comparison that physician responses to surveys regarding accepting new patients with Medicaid reflect their theoretical ability to accept patients due to having Medicaid managed care contracts and are not representative of point-in-time decisions about whether to schedule new patient appointments. As states expand the use of Medicaid managed care, one cannot assume that physicians in the network have the capacity to accept new patients.