Publications

CHRT Michigan Physician Survey – Perspectives on opioid prescribing policies and medication assisted treatment

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). Get the facts about opioids.

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). Michigan opioid laws: Frequently asked questions.

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.

Whether these 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 primary care providers (PCPs) about their views on these initiatives.

To see the full brief, click here.

Michigan Physician Survey – Primary Care Physicians in Michigan

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 latest survey also asked physicians about care continuity and Medicaid work requirements legislation (a full analysis can be found here).

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 healthcare 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.

To review the full report, click here.

EHR Interoperability and Patient-Centered Care

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.”

For more, read Electronic Health Record Interoperability and Patient-Centered Care.

Changes in Primary Care Physicians’ Patient Characteristics Under the ACA

 

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. 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.

To learn more, read Changes in Primary Care Physician Patient Characteristics Under the Affordable Care Act.

Primary Care Teams in Michigan

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. 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.

Read more in Primary Care Teams in Michigan.

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

After 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.

Data from the Center for Healthcare Research and Transformation’s (CHRT) Physician Survey show that the proportion of 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. Policy changes related to Medicaid should take into account the breadth of impact on physician practices as well as on beneficiaries.

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

Primary Care Capacity in Michigan: How are Physicians Responding?

primary-care-capacity-in-michigan-cover2014 Michigan Physician Survey

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.(1)The Henry J. Kaiser Family Foundation. April 7, 2014. How Will the Uninsured Fare Under the Affordable Care Act?. (accessed 11/20/14). As of December 2014, over 470,000 Michiganders had enrolled in the expanded Medicaid program, known as Healthy Michigan,(2)Michigan Department of Community Health. December 2014. Healthy Michigan Plan Enrollment Statistics. (Accessed 12/15/14). and over 270,000 Michiganders had enrolled in coverage through the Affordable Care Act’s Individual Marketplace.(3)U .S. Department of Health and Human Services. May 2014. Profile of Affordable Care Act Coverage Expansion Enrollment in Medicaid/CHIP and the Health Insurance Marketplace, 10-1-2013 to 3-31-2014: Michigan. (accessed 11/19/14). After Massachusetts expanded health insurance coverage in 2006, demand for primary care exceeded supply,(4) S.K. Long and P. Masi. 2009. Access and Affordability: An Update on Health Reform in Massachusetts, Fall 2008. Health Affairs 28(4): w578–w587. 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.(5)M.M. Davis et al. 2013. Primary Care Capacity and Health Reform: Is Michigan Ready? (Ann Arbor, MI: CHRT).

Key Findings

  • 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).

 

Capacity for New Patients

As more Michiganders become insured, the demand for primary care is likely to rise. The 2014 Michigan Physician Survey found that Michigan providers have the capacity to accept new patients: almost nine out of ten primary care physicians (87 percent) reported that they were taking new patients. Physicians who had been practicing less than ten years were 18 percent more likely to report accepting new patients than those who had been in practice over 20 years. Figure 1 Characteristics such as region of the state, compensation, and practice arrangement were not significantly related to taking new patients.

FIGURE 1: Share of Physicians Accepting New Patients, by Time in Practicefigure-1

Source: 2014 Michigan Physician Survey

Capacity for New Medicaid Patients

Compared to 2012, the proportion of physicians who reported accepting new Medicaid, military, or self-pay patients rose significantly. This increase was most marked for Medicaid patients: in 2014, 19 percent more physicians reported accepting Medicaid patients than did so in 2012. Figure 2

FIGURE 2: Change in Proportion of Physicians Accepting New Patients, by Insurance Type
figure-2

Source: 2012 Michigan Physician Survey and 2014 Michigan Physician Survey

Compared to current patient mixes, more physicians expected to see a high volume of Medicaid patients in the year following the survey. At the time of the 2014 survey, 52 percent of physicians reported seeing a low volume (<10 percent) of Medicaid patients, 33 percent reported seeing a moderate volume (10–30 percent) of Medicaid patients, and 15 percent reported seeing a high volume (>30 percent) of Medicaid patients. When asked about their expectations for the next year, 22 percent fewer physicians expected to see a low volume of Medicaid patients and 45 percent more physicians anticipated a high volume of Medicaid patients. Figure 3

FIGURE 3: Present and Anticipated Patient Volume, by Type of Insurance
figure-3

Source: 2014 Michigan Physician Survey

Conclusion

Michigan primary care physicians’ actions and expectations have changed dramatically in the past two years. Compared to 2012, far more physicians in 2014 reported seeing Medicaid patients or expecting the Medicaid portion of their practice to grow over time. This change may reflect both the considerable increase in the state’s population covered by Medicaid as well as the reality that health care utilization has declined coincident with the recession,(6)D. Altman. April 2012. Pulling It Together: The Falloff in Utilization: “There’s Something Happening, Here, What It Is Ain’t Exactly Clear” (Washington, D.C.: Kaiser Family Foundation). (accessed 11/20/14). freeing more room in physician panels and allowing these physicians to accept more new patients.

Methodology

2014 Michigan Physician Survey:

The survey data presented in this brief were produced from a mail survey of 1,000 primary care physicians practicing in Michigan, conducted between December 2013 and April 2014. Potential respondents received up to three mailings, with $5 included in the first mailing to encourage response. The physician sample was randomly generated from the American Medical Association (AMA) Physician Masterfile, a comprehensive list that includes both AMA members and non-members. The final sample included physicians from two primary care specialties: family medicine and internal medicine. They survey had a response rate of 36 percent (317 physicians) and has a margin of error of ±5.5 percent. Physicians who responded but reported they were no longer practicing primary care were removed from the analysis. Results were analyzed using SAS 9.3 software.

2012 Michigan Physician Survey:

Comparison data presented in this brief were produced from a mail survey of 1,500 primary care physicians practicing in Michigan, conducted between October and December 2012. Potential respondents received up to two mailings, with $5 included in the first mailing to encourage response. The physician sample was randomly generated from the AMA Masterfile. The final sample included 500 physicians each from three primary care specialties: pediatrics, family medicine, and internal medicine. Pediatricians were removed from this analysis to permit direct comparability among physicians who provide care for adults. Family physicians had a response rate of 53 percent and internal medicine physicians had a response rate of 45 percent. This analysis has a margin of error of ±4.6 percent. Results were analyzed using SAS 9.3 software. Statistical significance of bivariate relationships was tested using z tests or chi-square tests for independence. All reported differences are statistically significant at p ≤ 0.05 unless otherwise noted.

Survey Comparison:

Given the sampling methods used in the two physician surveys, some respondents may have been included in both the 2012 and 2014 surveys; because of the de-identified nature of responses, it was not possible to identify physicians who responded to both surveys. Response rates differed by medical specialties between surveys: internal medicine physicians were more likely to respond in 2012 than in 2014 and family medicine physicians were more likely to respond in 2014 than in 2012.


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.

References   [ + ]

1. The Henry J. Kaiser Family Foundation. April 7, 2014. How Will the Uninsured Fare Under the Affordable Care Act?. (accessed 11/20/14).
2. Michigan Department of Community Health. December 2014. Healthy Michigan Plan Enrollment Statistics. (Accessed 12/15/14).
3. U .S. Department of Health and Human Services. May 2014. Profile of Affordable Care Act Coverage Expansion Enrollment in Medicaid/CHIP and the Health Insurance Marketplace, 10-1-2013 to 3-31-2014: Michigan. (accessed 11/19/14).
4. S.K. Long and P. Masi. 2009. Access and Affordability: An Update on Health Reform in Massachusetts, Fall 2008. Health Affairs 28(4): w578–w587.
5. M.M. Davis et al. 2013. Primary Care Capacity and Health Reform: Is Michigan Ready? (Ann Arbor, MI: CHRT).
6. D. Altman. April 2012. Pulling It Together: The Falloff in Utilization: “There’s Something Happening, Here, What It Is Ain’t Exactly Clear” (Washington, D.C.: Kaiser Family Foundation). (accessed 11/20/14).

Primary Care Capacity and Health Reform: Is Michigan Ready?

policy-brief-2013-01-cover

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

Major Findings

Capacity to Serve New Patients By Specialty

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.

  • Among those physicians who anticipate having capacity for newly insured patients, more than 90 percent expected to have capacity for those newly covered by Medicaid (95 percent of pediatricians; 95 percent of family physicians; and 94 percent of internal medicine practitioners).
  • Fifty-five percent of primary care physicians in Michigan reported that they currently accept new Medicaid patients. Almost all of these physicians anticipate having capacity for newly enrolled Medicaid patients in the future (99 percent to 100 percent, depending on the type of primary care).
  • Even among physicians who do not currently take new Medicaid patients, most indicated that they would also take newly enrolled Medicaid patients (89 percent of family physicians; 88 percent of general medicine practitioners; and 84 percent of pediatricians).

FIGURE 1: Proportion of Primary Care Physicians Reporting Capacity to Accept Additional Patients with New Coverage in the Future

figure-1

Capacity to Serve New Patients by Geography

If the state decides to expand Medicaid coverage, five counties are expected to see the greatest increase in the numbers of those with Medicaid coverage: Wayne, Oakland, Macomb, Kent, and Washtenaw. Five counties are expected to see the greatest percentage increase in those with Medicaid coverage: Ottawa, Washtenaw, Kalamazoo, Oakland, and Grand Traverse. Overall, 75 percent of primary care physicians in these eight counties stated that they expect to have capacity for patients who would be newly covered by Medicaid (ranging from 56 percent in Kent County to 86 percent in Wayne County).

FIGURE 2: Capacity to accept new Medicaid participants in counties with the highest expected number of newly eligible Medicaid recipients

CountyExpected number of new Medicaid recipients in 2014*Percentage of primary care physicians who expect to have capacity for new Medicaid recipients
Wayne98,90386%
Oakland38,22080%
Macomb31,84382%
Kent23,59256%
Washtenaw16,96784%
* Unpublished data analysis conducted by CHRT in January 2013 using 2011 American Community Survey data (via census.gov). This data includes only newly eligible non-elderly adults, not the “woodwork” (currently eligible) population that can be attributed to the Medicaid expansion.

FIGURE 3: Capacity to accept new Medicaid participants in counties with the highest expected percentage increase in total Medicaid enrollment

CountyExpected percentage increase in new Medicaid recipients in 2014*Percentage of primary care physicians who expect to have capacity for new Medicaid recipients
Ottawa98%61%
Washtenaw56%84%
Kalamazoo51%71%
Oakland47%80%
Grand Traverse46%83%
* Unpublished data analysis conducted by CHRT in January 2013 using 2011 American Community Survey data (via census.gov). This data includes only newly eligible non-elderly adults, not the “woodwork” (currently eligible) population that can be attributed to the Medicaid expansion.

Conclusion

In 2011, 1.9 million Michigan residents had Medicaid coverage and 6.6 million had private coverage.(1)2011 American Community Survey. Under the Affordable Care Act, health insurance coverage will expand considerably starting in 2014. If Michigan chooses to expand Medicaid coverage, 289,388 Michigan residents are expected to newly enroll in Medicaid due to the expansion in 2014 (growing to 619,862 by 2020).(2)Udow-Phillips, Marianne; Fangmeier, Joshua; Buchmueller, Thomas; Levy, Helen. The ACA’s Medicaid Expansion: Michigan Impact. October, 2012. Center for Healthcare Research & Transformation. Ann Arbor, MI. An additional 369,000 residents will be tax credit eligible and expected to obtain private health insurance coverage through health insurance exchanges.(3)Ibid. A clear majority of primary care physicians throughout the state of Michigan responded to the CHRT-University of Michigan survey that they do anticipate having the capacity to welcome newly Medicaid enrolled patients in their practices. Based on these results, it does, indeed, appear that the state’s primary care system will have sufficient capacity to match the growing resource requirements of a state Medicaid expansion.

Survey Methodology

The survey data presented in this brief were produced from a mail survey of 1,500 primary care physicians practicing in Michigan, conducted between October 2012 and December 2012. Potential respondents received up to two mailings, with $5 included in the first mailing to encourage response.

The physician sample was randomly generated from the American Medical Association (AMA) Physician Masterfile, a comprehensive list that includes both AMA members and non-members. The final sample included 500 physicians each from three primary care specialties: pediatrics, family medicine and internal medicine. The survey had an overall response rate of 54 percent (714 physicians) and has a margin of error of +/- 3 percent. Physicians who responded but reported they were no longer practicing primary care were removed from the analysis. Final results were weighted to adjust for non-response in each of the three primary care specialty groups.

Figure 4 below summarizes the sample characteristics and response rates.

FIGURE 4: Survey Sample And Response Rates

Specialty*Response Rate^Respondents not practicing in primary care°Analytic sample size
Family Medicine53%15234
Internal Medicine45%5198
Pediatrics63%6282
Total54%26714
* Initial mailing consisted of 500 providers from each specialty
^ Adjusted for undeliverable surveys (family medicine = 35; internal medicine = 43; pediatrics = 36) and refusals (family medicine = 11; internal medicine = 7; pediatrics = 4)
° Self-reported

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.

References   [ + ]

1. 2011 American Community Survey.
2. Udow-Phillips, Marianne; Fangmeier, Joshua; Buchmueller, Thomas; Levy, Helen. The ACA’s Medicaid Expansion: Michigan Impact. October, 2012. Center for Healthcare Research & Transformation. Ann Arbor, MI.
3. Ibid.