Publications

Michigan Physician Survey–perspectives on opioid prescribing policies, medication assisted treatment

A bright yellow background with black outlines of opioid prescribed by physicians.Whether opioid policy reforms and additional resources will have an impact on opioid use depends in part on physician support. Physicians need to be key partners in the implementation of changes in opioid prescribing and in providing supportive treatment approaches. In order to understand the likelihood that these policies will succeed, CHRT’s latest Michigan Physician Survey asked physicians about their views on recent opioid initiatives.

Over the last decade, there has been a startling increase in the number of deaths attributed to opioid overdose. Between 1999 and 2016, the number of overdose deaths in Michigan increased seventeen fold—from 99 to 1,699. In 2017, more deaths were due to overdose than car accidents State of Michigan (2019).

In 2017, Michigan enacted legislation intended to deter over prescribing. Key provisions include a seven-day limit on opioid prescriptions for acute pain and mandatory use of the Michigan Automated Prescription System (MAPS). The seven-day limit was put in place to both reduce the supply of prescription opioids in circulation, as well as require more oversight of patients receiving opioids for acute pain. The MAP system was mandated in order to track all opioid prescriptions to individual patients, regardless of source.[footnote]Department of Licensing and Regulatory Affairs and the Michigan Department of Health and Human Services (2019).

In 2017 and 2018, the Michigan Department of Health and Human Services (MDHHS) encouraged expansion of Medication-Assisted Treatment (MAT) programs. Specifically, MDHHS provided more than $7 million for MAT training, rate incentives, and program expansions in rural areas. Additionally, MDHHS recently announced a tuition reimbursement program for training physicians who become waivered to provide buprenorphine.

CHRT analyzed results from the latest Michigan Physician Survey to determine the opinions of primary care providers (PCPs) on these opioid initiatives.

  • In general, PCPs think the new prescribing policies will help to address the opioid epidemic, but are concerned about administrative burden and patient care.
  • Just one in five physicians offer Medication-Assisted Treatment (MAT) in their practices, and even less are interested in being trained.
  • Physicians who are newer-practicing and serving higher volumes of Medicaid patients are more likely to be currently providing or interested in providing MAT.

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Michigan Physician Survey: Primary care physician perspectives and practice trends

A physician, such as the physicians surveyed in Michigan for this research, sits across from a male patient in dark clothes.CHRT has been surveying primary care physicians (PCPs) in Michigan since 2012—tracking key trends in practice patterns, capacity, payer mix and care team composition. Our 2019 Michigan Physician Survey also asked physicians about care continuity and Medicaid work requirements legislation.

PCPs are a key component of a successful, high quality healthcare system. As the baby-boomer generation ages and the needs of this cohort increase, there is ongoing concern about how well the health care workforce can meet the increasing demands of an older and presumably sicker population.

Additionally, primary care is on the front lines of improving care delivery, such as increasing care management for complex cases, integration of behavioral health care and identifying and addressing social determinants of health.

Key findings of our 2019 Michigan Physician Survey include:

  • Primary care capacity in Michigan is good today, but there is some evidence it may decrease in the future. Capacity to accept new patients is high and has increased across all payer types since 2016. Almost two-thirds (62%) of PCPs indicated capacity for new Medicaid patients and over 80 percent reported capacity for Medicare and privately insured patients. However, 45% of PCPs indicate they intend to stop practicing medicine within the next 10 years— raising important questions about new PCPs or other practitioners in the training pipeline, and the need to continue tracking capacity over the next decade.
  • PCPs report more multi-disciplinary care team members than in 2016. Practices with a relatively higher volume of Medicaid patients were almost twice as likely to have Community Health Workers (CHW) and co-located psychiatrists on the care team. And, for the most part, hospitals and groups practices were more likely to have support staff, such as care managers and nurse practitioners, than single physician practices.
  • High deductibles and other cost issues threaten continuity of care. PCPs see cost and insurance-related issues as the biggest barriers to maintaining continuity of care with their patients; along with lack of transportation and limited health literacy.
  • The majority of PCPs are concerned about the impact Medicaid work requirements may have on care continuity and the complexity of the certification process. They are more evenly split in their opinions about how the new Medicaid work requirements could change the number of Medicaid patients in their practices, whether they would need to hire more staff, and the ethical issues of determining if someone is able-bodied.

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EHR Interoperability and Patient-Centered Care

Image of a screen showing an EHR, with "Medical record" written on top of the page.

Image of a screen showing an EHR, with "Medical record" written on top of the page.In 2009, Congress passed the Health Information Technology for Economic and Clinical Health (HITECH) Act to modernize the U.S. healthcare system through the implementation of Electronic Health Records (EHRs), software systems that create a digital version of a patient’s medical chart. HITECH incentives accelerated widespread adoption of EHRs. However, the ability to exchange information between different EHRs across various healthcare settings — known as interoperability — was not a key requirement when the digital systems were first developed. Eight years later, EHRs are in place at almost 80 percent of physician offices and doctors are increasingly reporting that interoperability is important. Data from the Center for Healthcare Research and Transformation (CHRT) Michigan Physician Survey shows primary care physicians (PCPs) consider interoperability an important feature for providing patient-centered care.

Our data show a significant change in just two years in the perception among PCPs of the value an EHR with interoperability can play in patient care. In 2014 and 2016, CHRT’s Michigan Physician Survey asked PCPs how important having an EHR with interoperability was to their ability to deliver patient-centered care. Significantly greater proportions of PCPs in 2016 said it was “very important” to have EHRs that are interoperable between hospitals and practices, and practice to practice. There was no significant change in the proportion of physicians who saw just having an EHR in their own practice as “very important.”

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Changes in Primary Care Physicians’ Patient Characteristics Under the ACA

The feet and legs of many people sitting in chair in the waiting room of a primary care physician.

The feet and legs of many people sitting in chair in the waiting room of a primary care physician.When the Affordable Care Act (ACA) passed in 2010, health analysts expressed concerns that the expansion in coverage, predominantly through Medicaid and the Health Insurance Marketplace would overload the health system and cause problems with access to care. Specifically, many feared the impact of coverage expansion on primary care doctors. Seven million Americans live in areas where demand for primary care may exceed supply by more than 10 percent. An estimated 20 million people have gained insurance coverage nationally since the ACA’s major coverage provisions went into effect in 2014, including more than 14 million in Medicaid and CHIP, as of March 2016.

In Michigan, insurance coverage increased from 89.0 percent in 2013 to 94.6 percent in 2016. A survey of Michigan primary care doctors shows that the fears of overwhelming the health system have largely not come true. This brief looks at what Michigan primary care physicians (PCP) say about the impact of the coverage expansion on their practices.

Key findings include:

  • The majority of PCPs reported an increase in the number of newly insured patients since healthcare coverage was expanded under the ACA. Many of the newly insured are Medicaid patients.
  • PCPs are now seeing more patients and sicker patients compared to before the ACA. However, most say their individual patients are not making more frequent office visits since the ACA took effect.
  • Most PCPs said their ability to deliver quality care had either stayed the same or improved since the advent of the ACA’s coverage expansion.

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Primary Care Teams in Michigan

A primary care team in scrubs or white coats, arms folded.

A primary care team in scrubs or white coats, arms folded.Primary care teams have become increasingly important in the management of patients with complex chronic care needs. Data from the Center for Healthcare Research and Transformation’s 2016 Michigan Physician Survey show the proportion of primary care physicians (PCP) with primary care team members.

Nearly half of PCPs had a care manager or nurse practitioner, while less than one-tenth had a co-located psychiatrist. Michigan providers employed in group practices and by hospitals were more likely to have primary care team members than those practicing in single physician practices.

PCPs with a high volume of Medicaid patients (greater than 30 percent of the payer mix) were nearly five times as likely to report having a community health worker (CHW) and almost twice as likely to report having a social worker on their primary care teams compared to PCPs with a low volume of Medicaid patients. The opposite is true for PCPs with a high volume of privately insured patients, with this group being significantly less likely to report having a CHW or social worker compared to PCPs with a low volume of privately insured patients.

While there are certainly other factors that shape primary care team composition, this data show that PCPs who treat high volumes of complex and potentially vulnerable patients are the most likely to have teams in place to address the needs of that population.

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Changes in Payer Mix for Michigan Primary Care Physicians: The Impact of Medicaid

Stamps reading Medicare and Medicaid with pills scattered over themAfter Michigan’s Medicaid expansion, the state’s Medicaid population increased from 1.95 million in March 2014 (19 percent of the population) to 2.4 million in December 2016 (24 percent of the population). As a result, Medicaid has become a substantial part of Michigan primary care physician (PCP) practices. Policy changes related to Medicaid should take into account the breadth of impact on physician practices as well as on beneficiaries.

Data from the Center for Healthcare Research and Transformation’s (CHRT) Physician Survey show that the proportion of primary care physician (PCPs) who reported having a large volume, or greater than 30 percent, of patients covered by Medicaid increased by 11 percentage points from 2014 to 2016. The impact of Medicaid on these physician practices needs to be considered in policy discussions.

The survey data presented in CHRT’s Physician Survey briefs were produced from a mail survey of primary care physicians practicing in Michigan. The physician samples were randomly generated from the American Medical Association (AMA) Physician Masterfile, a comprehensive list that includes both AMA members and non-members. Physicians who responded but reported they were no longer practicing primary care were removed from the analysis.

The 2016 survey was conducted between July 2016 and October 2016 and included a sample of 1,500 primary care physicians practicing in Michigan. Potential respondents received up to three mailings, with $10 included in the first mailing to encourage response. The mailing included information on how to complete the survey online via Qualtrics, rather than by hard copy, if respondents preferred this option. Both surveys returned by mail and online were merged to create a final data file.

The final sample included physicians from two primary care specialties: family medicine and internal medicine. The survey had a response rate of 40 percent (603 physicians) and has a margin of error of ±2.5 percent.

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Michigan Physician Survey: Primary care physician perspectives on innovative compensation models

A physician wearing a white coat and stethoscope.

One goal of the Affordable Care Act (ACA) is to “reduce the growth of health care costs while promoting high-value, effective care.” Provisions of the ACA encourage providers to engage in innovative alternatives to traditional fee-for-service compensation models with a focus on value-based purchasing through a variety of mechanisms.

The U.S. Department of Health and Human  Services also recently announced the goal of directing 30 percent of fee-for-service Medicare payments to these kinds of models by 2016 and 50 percent by 2018, up from 20 percent in 2015.

In order to understand how physicians in Michigan see the trajectory for change in compensation, the Center for Healthcare Research & Transformation (CHRT) collaborated with the University of Michigan faculty to survey primary care physicians statewide about their practices and innovative compensation models. The survey findings show that physicians across the state are actively anticipating significant changes in approaches to compensation and are already participating in many initiatives that begin the shift from straight fee-for-service payment to other models.

Key findings include:

  • 28 percent of Michigan primary care physicians reported participation in at least one innovative compensation model.
  • 41 percent of physicians reported expecting fee-for-service payments to decline, while 44 percent and 42 percent reported expecting fee-for-service with incentives and bundled payments (respectively) to increase as a percentage of their practice revenue over the next 1–3 years.
  • The Michigan Primary Care Transformation Project (MiPCT) was the value-based payment initiative that physicians in Michigan reported participating in most frequently in 2014.
  • Bundled payments were uncommon at the time of the survey: on average, physicians reported that only 3 percent of their practice revenue came from bundled payments, and only 5 percent of physicians reported participation in the Bundled Payments for Care Improvement initiative.

Suggested Citation: Smiley, Mary L.; Ndukwe, Ezinne G.; Riba, Melissa; Udow-Phillips, Marianne. Primary Care Physician Perspectives on Innovative Compensation Models. 2014 Michigan Physician Survey (Ann Arbor, MI: Center for Healthcare Research and Transformation, 2015).

Acknowledgements: The staff at the Center for Healthcare Research & Transformation would like to thank Thomas Buchmueller, Matthew M. Davis, Robert Goodman, Helen Levy, Renuka Tipirneni, and the staff of the Institute for Public Policy and Social Research (IPPSR) at Michigan State University for their assistance with the design and analysis of the survey.

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Primary care capacity in Michigan: How are physicians responding?

A primary care physician administers a blood pressure test.

On April 1, 2014, Michigan expanded access to Medicaid to people whose income was less than 138 percent of the Federal Poverty Level, or about $32,900 for a family of four. As of December 2014, over 470,000 Michiganders had enrolled in the expanded Medicaid program, known as Healthy Michigan, and over 270,000 Michiganders had enrolled in coverage through the Affordable Care Act’s Individual Marketplace. After Massachusetts expanded health insurance coverage in 2006, demand for primary care exceeded supply, raising the question of whether Michigan’s primary care providers have been able to keep up with increased demands for care after the Medicaid expansion.

In order to understand the current and anticipated capacity of Michigan physicians to take new patients, particularly those with Medicaid, the Center for Healthcare Research & Transformation (CHRT) collaborated with University of Michigan faculty to survey primary care physicians across the state about their practices, compensation models, and patient populations in late 2013 and early 2014 (2014 Michigan Physician Survey). CHRT collaborated with the Child Health Evaluation and Research Unit to conduct a similar survey in 2012, which provided comparison data.

Key findings include:

  • Michigan’s primary care physicians reported that they have the capacity to accept new patients—87 percent of Michigan primary care physicians reported that they were accepting new patients at the time of the survey.
  • More physicians reported accepting new Medicaid patients when surveyed in 2014 than did so in 2012—from 2012 to 2014, the share of physicians taking new Medicaid patients increased by almost one-fifth (19 percent), from 54 percent in 2012 to 64 percent in 2014.
  • Physicians reported that they expect the trend to continue and grow in the next year—22 percent of respondents expected their payer mix to include more than 30 percent Medicaid patients in the year following the survey, compared to the 15 percent who currently saw this high a volume of Medicaid patients (an increase of 45 percent).

Suggested Citation: Smiley, Mary L.; Riba, Melissa; Davis, Matthew M.; Kerr, Eve A.; Zikmund-Fisher, Brian J.; Ndukwe, Ezinne G.; Ward, Melanie; Udow-Phillips, Marianne. Primary Care Capacity in Michigan: How are Physicians Responding?. 2014 Michigan Physician Survey. (Ann Arbor, MI: Center for Healthcare Research & Transformation, 2014).

Special thanks to Knoll Larkin for assistance with survey administration and to Thomas Buchmueller, Robert Goodman, Helen Levy, and Renuka Tipirneni for assistance with survey development and interpretation.

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Primary care capacity and the Affordable Care Act: Is Michigan ready to expand Medicaid coverage?

A physician speaks with a patient.

Since one of the most immediate questions facing the State of Michigan is whether to expand Medicaid coverage, this issue brief focuses specifically on one area of inquiry—Michigan primary care physicians’ capacity to serve new patients in both Medicaid and the private insurance market.

In the fall of 2012, the Center for Healthcare Research & Transformation (CHRT), in partnership with the Child Health Evaluation & Research Unit (CHEAR) at the University of Michigan, conducted a statewide survey of primary care physicians. The purpose of the survey was to understand the challenges and opportunities primary care physicians are facing in their practices in this era of health care reform.

Our goal was to inform policymakers about a number of key issues ranging from meaningful use of electronic health records to the capacity to care for Michigan residents, especially in light of the expected significant growth in insurance coverage beginning in 2014.

The bottom line of the survey is that primary care physicians in Michigan overwhelmingly anticipate having the capacity to serve more patients with all forms of health coverage, including Medicaid.

Overall, 81 percent of primary care physicians anticipate expanding their practices to include newly insured patients. Of those physicians, 90 percent of pediatricians; 78 percent of internal medicine practitioners; and 76 percent of family physicians reported that they will have capacity to accept additional patients if the number of Michigan patients with insurance coverage increases in the future.

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Suggested citation: Davis, Matthew M.; Udow-Phillips, Marianne; Riba, Melissa; Young, Danielle; Royan, Regina. Primary Care Capacity and Health Reform: Is Michigan Ready? January 2013. Center for Healthcare Research & Transformation. Ann Arbor, MI.

Special thanks to the Michigan State Medical Society and the Michigan Osteopathic Association in survey development, and to Krishna Davis, Seetha Davis, Lakshmi Halasyamani, Brandon List and Rose Kenitz for data entry.