by Mason Weber

In the lead-up to the passage of the Affordable Care Act, much of the debate focused on coverage expansion and its potential effects on physicians’ abilities to effectively care for an increased patient load. These concerns were valid, and continue to be so. An aging population, coupled with slow growth in medical school enrollment and a limited number of available residency positions, have led many to project physician shortages even without expansion. Just this month, the American Association of Medical Colleges released a report projecting physician demand will grow by 17% between 2013 and 2025, resulting in a shortage of anywhere from 46,000 to 90,000 doctors. This projected imbalance between supply and demand remains an alarming possibility, particularly for providers who already feel their time is stretched too thin. However, a new report from the Robert Wood Johnson Foundation (RWJF) and Athenahealth may serve to assuage some of these concerns.

The report finds that the influx of new insured patients has not overwhelmed physicians. Though approximately 7.1 million people were enrolled in 2014 under marketplace coverage, the percentage of new patient visits to primary care physicians (defined as a patient who has not seen a primary care provider in at least 2 years) saw a very modest increase from 22.6% to 22.9%. On a related note, the proportion of visits for comprehensive new patient evaluations only increased from 6.7 to 7 percent. The report addresses a number of potential explanations for this mild increase, including the fact that many uninsured individuals had pre-existing provider relationships before gaining coverage, or that insured individuals may still use an Emergency Department as their primary point of care. The report found that the largest beneficiaries of coverage expansion were previously uninsured patients with existing physician relationships. These individuals have seen a striking increase in coverage in states opting for Medicaid expansion (from 34.8% to 57%), but only mild benefits in states not expanding Medicaid (from 27.8% to 36.5%). Instead, states choosing not to expand saw an increase in the proportion of patient visits with commercial insurance coverage (72% to 74%), versus an increased proportion of Medicaid patients in expansion states (12.8% to 15.6%).

Another explanation for the marginal increase in new patient visits is that many newly insured individuals in the past year were relatively healthy and simply had no need for medical care. Adding these low-cost individuals to the risk pool theoretically makes coverage more affordable for all, the very outcome the individual mandate was meant to bring about. Even newly covered patients who did see a physician did not have more complex or chronic issues, as many postulated might happen before the ACA marketplace was implemented. The average number of diagnoses per visit for new patients only increased from 2.0 to 2.1 between 2013 and 2014, while the percentage of “high complexity” diagnoses in these patients actually decreased from 8.0% to 7.5%. The report also found no increase in the percentage of chronic diagnoses such as diabetes, hypertension, or high cholesterol seen by primary care physicians in 2014. These are all promising trends, suggesting that newly covered patients are not significantly less healthy or more likely to increase medical costs or demand on physicians, as many had projected.

The results of the RWJF report are promising on a systemic level, proclaiming that the healthcare system is capable of meeting the increased demand and that physicians will not be overwhelmed, however, physician satisfaction with the current practice of medicine continues to trend downward. As a current physician in training, I can speak anecdotally to the workload of today’s physicians and its impact on the doctor-patient relationship. Doctors are not any more overwhelmed by the expansion of coverage than they were beforehand, but reports of physician overwork and burnout have been commonplace since the 1990s, particularly with the increased complexity of day-to-day physician practice.

A 2012 study found negative perceptions among physicians and the practice of medicine, with 77.4% of physicians somewhat or very pessimistic about the future of the medical profession and 84% believing that medicine is in decline. More than half of the physicians surveyed (58%) would not recommend medicine as a career to their children or other young people, and over a third would not choose medicine if they had their careers to do over. These physicians reported that over 22% of their time was spent on non-clinical work. In 2013, the New York Times reported that new physicians spend an average of just 8 minutes with each patient, and are often mandated by their administrative superiors to see up to 30 patients per day. Over 50% of established physicians reported that they plan to reduce their patient load or make the switch to a “concierge” practice in the next 5 years. All of this is to say that physicians most certainly still feel overwhelmed and dissatisfied with the practice of medicine, with some of the largest contributing factors being the inability to spend enough time at each patient encounter, as well as increased time spent on non-medical tasks.

As a general rule, physicians’ interests align with those of their patients. Increasing access to both coverage and care is simply good policy for all parties involved. But doctors also want to be able to provide the highest quality care for these patients, and that means spending an appropriate amount of time with each of them. While the issue of limited access to health insurance coverage is in the process of being addressed, the ability of physicians to effectively (not just adequately) provide care remains a largely ignored issue in the ongoing debate of healthcare reform.