Primary Care Archives

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

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

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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Access to health care in Michigan: Results from CHRT’s latest Cover Michigan Survey

The Center for Health and Research Transformation’s (CHRT) 2018 Cover Michigan Survey asked Michigan residents about their experiences in accessing health care, specifically how easy or difficult it was to get appointments with different providers.

The Cover Michigan Survey found that two factors—the presence of primary care providers (PCP), and whether or not people had a medical home—figured prominently in reported ease of access to care.

Additionally, ease of access to health care can vary and is not uniform for all populations. Over time, the percentage of respondents reporting ease of access or access challenges has been relatively consistent, but uninsured people continue to face challenges in accessing care, and access to some critical services like specialty and mental health care continues to be a problem for key groups. The 2018 Cover Michigan Survey report examines important indicators of access: self-reported ease of accessing primary, specialty, mental health, and dental care, and forgoing necessary medical and mental health care.

People in Michigan have varying experiences in accessing care. The 2018 Cover Michigan Survey
examined those variations by a number of factors and found important disparities. Key findings
include:

Variations in access to care exist: Primary and dental care were the least difficult services to access while specialty and mental health care were reported to be the most difficult. One in five people reported not seeking necessary medical care in the last six
months and one in ten reported not seeking necessary mental health care in the last year.
Connection to primary care matters: In comparison to Michiganders who had a PCP, people without a PCP were more likely to forgo medical and mental health care, and report difficulty accessing all types of care. Nearly half of those without a PCP had difficulty accessing specialty care and mental health care.
Having a medical home matters: People who relied on hospital ER/urgent care and clinic settings as their routine location of care reported more difficulty accessing care, and were more likely to report forgoing medical and mental health care, in comparison to those whose usual source of care was at a doctor’s office. The largest gaps were seen in mental health care, with hospital ER/urgent care and clinic users being twice as likely to report difficulty accessing care compared to people who typically access care through a doctor’s office.
Differences in access by type of insurance are evident: People with Medicaid and individually purchased plans were more likely to report difficulty accessing specialty and dental care, in comparison to those with Medicare or employer-sponsored plans. However, Medicaid beneficiaries were least likely to report difficulty in accessing mental health care. People who remain uninsured reported the greatest difficulty accessing all types of care, and were also most likely to report forgoing medical and mental health care they believed they needed.

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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.

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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Creating Sustainability through Public-Private Partnerships: The Future of New Primary Care Models

Cartoon drawing of several hands stacked over each other, symbolizing the public-private partnership behind Patient-Centered Medical Homes

As the U.S. health care system places a growing emphasis on improving the value of health care, many states and the federal government have increasingly invested in primary care to improve health outcomes and lower health care costs. Unlike “traditional” primary care settings, newer primary care models strengthen primary care providers’ role in expanding access to care and providing comprehensive, coordinated services to help improve patients’ experiences. In recent years, states have used federal funding to test new approaches to primary care through Patient-Centered Medical Home (PCMH) and other such initiatives.

Many of these efforts were originally funded through time-limited Centers for Medicare and Medicaid Services (CMS) demonstration projects that encouraged or required commitments from commercial payers and/or state Medicaid programs. As these initial demonstration grant periods end, public-private partnerships and other creative funding approaches are emerging to continue and/or expand Patient-Centered Medical Home efforts. New leadership at CMS appears poised to move the focus toward local solutions and governance that leverage private sector partnerships.

This brief, developed with support from the Commonwealth Fund, describes the major elements of PCMH initiatives and sustainability efforts in four states—Michigan, Vermont, Colorado, and Arkansas. The efforts undertaken by these four states provide valuable learnings for all states considering the future of their own initiatives.

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Primary care capacity in Michigan: How are physicians responding?

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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