A Two Headed Dragon: Two Tier Healthcare (Primary Care Appointments for Medicaid Beneficiaries With Advanced Practitioners)

Primary care practices may be relying on advanced practitioners (APs) to accommodate new Medicaid beneficiaries following the passage of the Affordable Care Act, according to a study published in the July/August issue of the Annals of Family Medicine (1).

            …….and this sets up a two-tiered healthcare system. One for the haves and the other rooted in Medicaid for the have-nots. The article reported on: “Primary care access in Medicaid improved after the Patient Protection and Affordable Care Act (ACA) despite millions of new beneficiaries.” They theorized that practices were scheduling more medicare/Medicaid appointments with APs. This theory was put to the test. They used data in which callers simulated new Medicaid patients and requested appointments with 3,742 randomly selected primary care practices in 10 states and documented whether it was with a physician or an AP. The proportion of primary care appointments scheduled with AP’s:

            Thus up to 28% of Medicaid patients will see an AP. Simulated Medicaid patients scheduled more appointments with APs after the implementation of the ACA. These findings suggest that practices may be relying on APs to accommodate new Medicaid beneficiaries. This is the plight of the have-notswho rely on Medicaid will see AP’s and those haveswith private insurance will see physicians. Medicaid beneficiaries are at particular risk of poor access due to lower reimbursement rates and less physician participation in Medicaid.  So those most vulnerable in our society with least resources will see those that are lessor trained. This blog will not discuss the studies comparing physician level care to that of AP’s. I will state that it is factual that AP’s have considerable less education and training than physicians. The clinical hours alone amount to about 3% of that of a residency trained physician (500 clinical hrs vs 15,000 clinical hrs). Thus now we have two tiers of health care: (1) physician level care, and (2) AP level care. Those in the lower socio-economic strata default to AP’s while those with higher-level resources will go to physicians. Perhaps an unintended consequence of the ACA as well as expanding utilization of AP’s in primary care. So now healthcare has become a two-headed dragon with two tiers. Ethics anyone…………….


  1. Lena Leszinsky andMolly Candon. Annals Journal Club: Primary Care Appointments for Medicaid Beneficiaries With Advanced PractitionersAnn Fam Med July/August 2019 17:363-366; doi:10.1370/afm.2399 http://www.annfammed.org/content/17/4/363.full

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Robert Duprey MD

Robert P. Duprey Jr studied medicine as a 2nd career medical student who went to medical school in his 40’s after honorable discharge and ‘retirement’ from 25 years in the US Military (USCG & US Army). He was a registered nurse (RN) with specialty training as a psychiatric RN in the US Army for 15 years. During this time he also became a Master’s level psychotherapist in 2002. While on US Army active duty he also became a Psychiatric Nurse Practitioner while working full time in 2011. He served as a Psych NP on active duty, to include a combat tour in Iraq, until his ‘retirement’ in 2014 and moved to Philippines with his 3 children. At this time he started medical school overseas at Oceania University of Medicine based out of Samoa accredited by Philippine Accrediting Association of Schools, Colleges and Universities (PAASCU). He continued to work as a Psych NP throughout medical school to support his children and to not have to take out loans for medical school tuition. Originally from Rhode Island, he completed medical school clerkship rotations throughout the USA with a graduation in May 2019 earning the esteemed credential of MD. He has successfully completed USMLE Steps 1, 2CS, and 2CK. He will take Step 3 this September as he applies for Psychiatry Residency. Having been and RN, NP and now MD, he is a believer of Physician led multidisciplinary healthcare teams 

  3 comments for “A Two Headed Dragon: Two Tier Healthcare (Primary Care Appointments for Medicaid Beneficiaries With Advanced Practitioners)

  1. August 14, 2019 at 5:48 pm

    Thank you for providing a link to the article. I was appalled at the lack of a vital statistic in this ‘study’: what was the overall increase in the use of APs for /ALL/ initial appointments, regardless of insurance.

    There is a reasonable possibility that the increase in APs for initial appointments had nothing whatsoever to do with Medicaid, and everything to do with physician overload from other causes. (And the ACA contributed to those other causes!)

    As presented, this could qualify for “Study of the Week”.

  2. Celia Entwistle MD
    August 1, 2019 at 3:27 pm

    And if we complain the feds will further bankrupt physicians by demanding that all medicaid patients be seen only by physicians! If 20 years ago, the feds had allowed physicians to consider some tax write off benefit (differences in reimbursement, charity care) this problem would have been lessened.

  3. Jesse Lee Belville,PA-C
    August 1, 2019 at 2:58 pm

    Yes! This is the outcome of Government involvement in health care. They twisted the market, health care costs went up, no competition, control of education with medicare paying for residencies in various specialities, Nursing Education, PA education.
    This will get worse before it gets better. Medicare goes broke in 7 years or less, and the socialists get more control. We will reap this coming disaster WE have sown. Enjoy. It will be messy.

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