Expanding Health Coverage May Not Improve Access

FRIDAY Aug. 7, 2009 -- Even if Congress extends health coverage to the nation's 46 million uninsured Americans, there's no guarantee that everyone will have access to care -- unless payment reforms and new models of care are adopted, some experts say.

Significantly expanding coverage without reforming health-care delivery is "a recipe for failure," said Alwyn Cassil, a spokeswoman for the Center for Studying Health System Change in Washington, D.C. "You won't be able to sustain the expanded coverage because it will just bankrupt us."

Spending on health care this year is projected to reach $2.5 trillion, or 17.6 percent of the U.S. gross domestic product, according to a Kaiser Family Foundation analysis of Medicare and Medicaid data. That's up from 7.2 percent in 1970, and by 2018 it could swell to one-fifth of the GDP, which is a measure of all goods and services produced in the United States.

Meanwhile, a worsening shortage of primary-care providers and rising demand for certain specialists will continue to strain the system, perhaps creating long waits for appointments.

The existing health-care delivery system cannot seamlessly respond to a surge in demand for services, said Jeffrey Bauer, a medical economist.

This is "one of the Achilles heels of reform," said Bauer, management consulting partner at Affiliated Computer Services Inc. and leader of the health futures practice at ACS Healthcare Solutions in Chicago.

"People are already strapped to get a doctor," Bauer said. "As more people have insurance, they will try to get appointments with more doctors, and that will lead to dramatic increases in the time it takes to get an appointment."

Depending on the coverage people have, where they live and whether they have an existing relationship with a physician, some Americans could encounter long delays in getting in to see a doctor.

In Boston, the average wait time for an appointment with a family physician is 63 days -- the highest among 15 metropolitan markets surveyed by the national physician recruitment firm Merritt, Hawkins & Associates in Irving, Texas. The 15-city average was 20.3 days.

Boston's long wait times may be driven by Massachusetts' 2006 health reform legislation, which expanded health insurance coverage to nearly everyone in the state, Merritt, Hawkins noted. Many health policy experts worry that similar access problems will be experienced nationwide if Congress enacts legislation extending health insurance coverage.

Patients on Medicaid already have difficulty accessing health-care providers, according to a recent national online consumer survey by PricewaterhouseCoopers (PWC) Health Research Institute. Nearly a third of Medicaid patients reported waiting 30 days or more for an appointment with a doctor.

What's more, many Americans still use the emergency room inappropriately. According to PWC's consumer survey, more than half of those who went to the emergency room in the last year did so for non-emergency reasons.

"One of the key things that we have found is that the emergency room turns out to be the front door for many folks trying to gain access into the health-care system," said Dr. David Chin, a principal in PricewaterhouseCoopers and leader of its Health Research Institute.

The Institute's findings appear in a new report, "Jammed access: Widening the front door to healthcare".

To improve access without boosting the cost of care, some health-care organizations across the country are experimenting with different models of care, the report finds. One is the use of online consultations for patients who don't require a face-to-face visit.

"Many insurers now are, in fact, engaged in pilots to pay for electronic visits," Chin said.

Another is the growing use of mobile electronic devices to monitor, say, a patient's blood sugar or blood pressure and transmit the results by cell phone to the patient's doctor.

The report also spotlights growth in retail and work-site clinics and notes that some health organizations are exploring a model of care in which a team of health-care providers works collaboratively to address a patient's health-care needs.

But creating a system of care that encourages coordination-of-care will require a shift away from the traditional fee-for-service method of reimbursement, Cassil noted. "How we address payment reform will have everything to do with how the delivery system becomes more efficient."

More information

Read the PricewaterhouseCooper report.

Posted: August 2009


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