The fear was this: The Affordable Care Act would give massive numbers of people new access to health care, creating a surge in demand for medical services and long waits to see the doctor.
But in the seven months since new insurance plans began kicking in, Puget Sound-area, Washington, primary-care providers so far seem to be keeping up with growing numbers of patients. The question now is, can they keep ahead of the demand as the formerly uninsured continue seeking care, and as baby boomers age and a sizable fraction of Washington’s physicians retire.
In just the past year, Providence and Swedish clinics in Western Washington report a 10 percent increase in primary-care visits. But patients are waiting only four or five days for those appointments, and specialty and urgent-care services are available the same day.
Group Health Cooperative officials say they’ve seen higher demand, particularly early in the year, when many new insurance plans took effect. Yet roughly one-third of their patients are able to get an appointment within 36 hours.
Patients at The Everett Clinic are waiting about a week to see pediatricians and family doctors, but those needing quicker care can visit walk-in clinics at all nine of their primary-care sites.
And when researchers pretending to be Medicaid patients called King County providers in April, they found a median wait time of seven days for an adult checkup — a statistic unchanged from December to April, despite an 80 percent increase in Medicaid enrollees over that time
Bothell resident Heather New got coverage at the start of the year through Medicaid, or Washington Apple Health, as it is known locally. Then she shifted to private insurance when she got a job three months later. With both types of insurance, she was able to see a doctor quickly at the HealthPoint clinic in Bothell.
In January, New learned she had diabetes, which the 34-year-old aspiring nurse is managing through diet and exercise. If she needs to see her doctor, she can get in within a few days. “If it’s an emergency, I can get in to the nurse practitioner the same day,” New said.
How are the doctors doing it?
Clinic officials say in some cases they’ve hired more providers, but the bigger strategy seems to be doing more with technology and with the staff they already have.
There are trade-offs. Patients might spend more time with nurses or other providers who have less training than physicians. Some clinics are wedging more patients into a doctor’s day, plus adding email exchanges to their workloads. And there isn’t equal access for all: The wait times in rural areas, as well as for Medicaid patients and for visits with certain specialists, are likely to be longer.
“Health care is going through a transformation,” said Susan Skillman, deputy director of the University of Washington’s Center for Health Workforce Studies.
She doesn’t mean just the Affordable Care Act and the expanded insurance coverage that came with it. Many providers are trying to shift from the current “fee for service” model, which means paying for every doctor’s appointment, treatment and test, to “outcomes-based payments,” where doctors and clinics are rewarded for keeping or making patients healthy.
The hope is this transition encourages more-efficient medical care, such as using teams of health-care providers with different skills and a smarter use of technology. In the old model, no one gets paid for exchanging emails with patients, but if the goal is to make someone healthy and cut medical costs, electronic communications and telemedicine become more cost-effective tools.
At Group Health, a health-maintenance organization where the insurance and medical providers share a stake in cutting costs and providing good care, doctors have used email for years. In the past five, email use has become so popular that 60 percent of a physician’s interactions with patients each day are by email or phone.
“The patients love it,” said Dr. Paul Fletcher, Group Health’s medical director of primary care. Digital communication means there’s no copay, no appointments to schedule and patients don’t always have to trudge in to the office when feeling poorly.
At Group Health’s Northshore clinic in Bothell, patients seeing primary-care providers are cared for by a team that includes seven medical assistants, two licensed practical nurses, five registered nurses, one physician assistant, one advanced registered nurse practitioner (ARNP) and seven physicians. The nurses follow up for more routine problems, such as a bladder infection, or provide education for chronic conditions such as diabetes or high blood pressure. That frees up the more highly trained providers to do diagnosis and handle trickier care.
“We’re all very collaborative,” said Wendy Rychwalski, the ARNP at the Northshore clinic. The team meets each morning to review their patients and cases.
Providence Health & Services similarly uses teams of health-care educators and nurses to give ongoing support for patients with chronic diseases who need to manage their ailments outside of the doctor’s office.
“We’re working hard to redesign care,” said Dr. Craig Wright, senior vice president of physician services at Providence. “We think more and more about the primary-care team and not just the primary-care physician.”
Longer Medicaid waits
While local clinics report moderate wait times, independent sources suggest that’s not always the case. A national survey last year by health-care consulting firm Merritt Hawkins found that in Seattle there was a 23-day wait, on average, for family doctors.
And clinics primarily serving Medicaid recipients are getting hit harder. HealthPoint, with nine medical and six dental clinics in the Puget Sound region, has seen a 20 percent increase in new patients over last year.
The nonprofit center has opened two new clinics in recent years and expanded two others. Heather New, the newly insured patient, didn’t have any trouble getting care at HealthPoint’s Bothell clinic, which opened in 2012, but some of the more established locations have been so slammed they sometimes have been forced to turn new patients away, according to a spokeswoman.
While clinics are squeezing more care out of the current system, it’s a limited fix.
Skillman’s team at the UW analyzed a state Office of Financial Management survey conducted in 2011 and 2012 of primary-care providers and found that 20 percent of them planned to retire in the next five years. Last year, she helped convene a health-workforce summit to talk about addressing the shortages.
The UW and Washington State University are both eager to ramp up their programs for teaching and training primary-care providers, particularly in Eastern Washington and more rural parts of the state where health-care shortages are chronic. In early July the state received $6.3 million in federal grants to boost residency training in areas with medically underserved populations, including Spokane, Yakima Valley and Tacoma.
In the meantime, there is a growing sense of urgency to train more providers, and fast.
“This is not just a local or regional issue. It’s a national issue,” said Dr. Jeff Bissey, associate medical director of primary care at The Everett Clinic. “We need to have more primary-care access, and that will take time.”