Fixing a hole in the ocean

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  • 03/07/2012

Its old news that expanded access to healthcare doesn’t correlate to broader (or wider) use of services. This lesson from (among other places) the United Kingdom hasn’t gotten a lot of attention on this side of the pond. In fact, the reverse is true. Government-mandated access results in a reduction in usage.

Why? The reason is the role of the gatekeeper – otherwise known as the physician. As Nadine Reibling and Claus Wendt (University of Mannheim) write in their paper, Access Regulation and Utilization of Healthcare Services:

“Since cost containment is at the top of the political agenda, efficiency considerations dominate the political discussions on instruments that regulate access to care. This, however, neglects the fact that such measures also have implications regarding equity of access (Saltman and Busse 2002).”

In other words, equity of access isn’t the same as availability of access. What happens, for example, when physicians choose not to accept Medicare or Medicaid patients?  What value is equity when there is a physician shortage? And what does this say about how we value – and compensate – our healthcare providers. What unintended consequences arise when we ignore the growing gap between equity and access?

In November 2010, the Physician Foundation released the results of a national survey of physicians intended to gauge American physicians’ initial reaction to the passage of health reform and to learn the ways in which they plan to respond to it.

Key research findings include:

* The majority of physicians (60%) said health reform will compel them to close or significantly restrict their practices to certain categories of patients. Of these, 93% said they will be forced to close or significantly restrict their practices to Medicaid patients, while 87% said they would be forced to close or significantly restrict their practices to Medicare patients.

* 40% of physicians said they would drop out of patient care in the next one to three years, either by retiring, seeking a non-clinical job within healthcare, or by seeking a non-healthcare related job.

* The majority of physicians (59%) said health reform will cause them to spend less time with patients.

* While over half of physicians said health reform will cause patient volumes in their practices to increase, 69% said they no longer have the time or resources to see additional patients in their practices while still maintaining quality of care.

A brand new study from the Health Research and Educational Trust brings the matter to our own shores via a study of the Children’s Health Insurance Program (CHIP).

A Comparison of Two Approaches to Increasing Access to Care: Expanding Coverage versus Increasing Physician Fees


To compare the effects of a coverage expansion versus a Medicaid physician fee increase on children's utilization of physician services.

Primary Data Source

National Health Interview Survey (1997–2009).

Study Design

We use the Children's Health Insurance Program, enacted in 1997, as a natural experiment, and we performed a panel data regression analysis using the state-year as the unit of observation. Outcomes include physician visits per child per year and the following indicators of access to primary care: whether the child saw a physician, pediatrician, or visited an ER in the last year, and whether the parents reported experiencing a non-cost-related access problem. We analyzed these outcomes among all children, and separately among socioeconomic status (SES) quartiles defined based on family income and parents' education.

Principal Findings

Children's Health Insurance Program had a major impact on the extent and nature of children's insurance coverage. However, it is not associated with any change in the aggregate quantity of physician services, and its associations with indicators of access are mixed. Increases in physician fees are associated with broad-based improvements in indicators of access.


The findings suggest that (1) coverage expansions, even if they substantially reduce patient cost sharing, do not necessarily increase physician utilization, and (2) increasing the generosity of provider payments in public programs can improve access among low-SES children, and, through spillover effects, increase higher-SES children as well.

With all the discussions of equity, perhaps it’s time we asked “Who lost access?” And, more importantly, what can we do about it? Otherwise we’re just (Doc) fixing a hole in the ocean.

Net/Net? If you want more access you have to pay for it.

Nothing fixes a thing so intensely in the memory as the wish to forget it.

-- de Montaigne


Center for Medicine in the Public Interest is a nonprofit, non-partisan organization promoting innovative solutions that advance medical progress, reduce health disparities, extend life and make health care more affordable, preventive and patient-centered. CMPI also provides the public, policymakers and the media a reliable source of independent scientific analysis on issues ranging from personalized medicine, food and drug safety, health care reform and comparative effectiveness.

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