Here come the 20-somethings

Young adults are the first added to insurance rolls under health reform, but few know how the health system works. How do physicians manage these new patients?

By — Posted Aug. 8, 2011

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Jeremy Byrd, MD, a pediatric internist in Simpsonville, S.C., has been on a quest to reach a traditionally elusive group of patients -- young adults.

During the past few years, Dr. Byrd has participated in a nearby Greenville Hospital System "speed-dating" event, in which young adults briefly interviewed physicians for five minutes before moving on to meet other doctors. He also has appeared on local television three times and has been quoted in newspaper articles.

"I'm trying to get out there," Dr. Byrd said, "trying to attract young adults and educating them on the importance of seeing an established doctor, and the importance of preventative care."

Part of the reason he is working so hard to attract younger patients is that, thanks to health system reform, there will be a whole lot more of them to attract.

One of the first provisions of the Patient Protection and Affordable Care Act allowed adults 26 and younger who do not have employer-sponsored health insurance to remain on or enroll in their parent's policy. Beginning in 2014, even young adults whose employer offers insurance will be eligible to join their parent's policy, and those without employer insurance also can buy coverage through an insurance exchange. In addition, single unemployed adults with limited income up to $15,000 per year (the income ceiling is higher for married young adults) will be eligible for health coverage through Medicaid.

Of the Americans who will gain insurance through health system reform, "we estimate that just over 7.5 million will be coming from the 19-26 segment," said Jean-Patrick Tsang, PhD, president of Bayser Consulting, a Wilmette, Ill.-based company that provides sales and marketing analysis for pharmaceutical, medical devices and diagnostics manufacturers. As a result, physician practices "will see a surge in patients age 26 and younger." A Commonwealth Fund report says 600,000 already had obtained new insurance coverage as of May.

Before the surge, however, physicians will need to convince this age group that they need a regular doctor and preventive care, and let them know that they are now eligible for insurance coverage. In addition, a tech-savvy generation comfortable with texting, social networking and online interaction will demand a certain level of service and technology to get them in the door and keep them coming back, experts said.

"What I kept hearing from [young adults] is that whenever they go to a physician, they feel like it's a formal, stiff interaction that focuses on their illness," said Dr. Byrd, who practices at four-physician Heritage Pediatrics & Internal Medicine. At the speed-dating event, "I think they enjoyed getting to know a doctor for a few minutes in a more casual, comfortable setting."

And they were open to discussions on preventive care, he said.

A new crop of insured

About a third of young adults ages 19 to 26 did not have health insurance before the health reform provision extending insurance to them went into effect, according to a study released in May by the Commonwealth Fund. In 2010, 45% of this age group could not afford the care they needed -- prescriptions, diagnostic tests, treatment and follow-up visits -- up from 32% who went without needed care because of cost in 2001.

The report authors say the 600,000 young adults already added to insurance rolls is certain to climb as young adults graduate from high school and college -- a time when they normally would drop off their parents' coverage -- and more employer-sponsored insurance plans open enrollment to this age group.

For physicians like Dr. Byrd, the challenge is how to educate and reach young adults who may not know about the insurance option and who have different expectations and habits in terms of preventive care, service, access and communication. Seventy-three percent of young adults have little to no familiarity with the recent changes in health care regulations that allow dependents 26 or younger to stay on a parent's or guardian's health care plan, according to a Harris Interactive poll released in June conducted on behalf of the American Academy of Family Physicians.

The new health system reform provision is boosting young adult health care purchasing power, "causing a shift in the way marketers [and physicians] assess, target and reach them," Tsang said.

Anthony Cirillo, a health care consultant in patient experience, marketing and physician wealth creation in the Charlotte, N.C., area, said that in general, "as 35 million people emerge from the shadows and access the health care system, the system may not be prepared. It is already hard enough to get in to see certain specialists, and emergency room wait times have always been an issue. Marketers may need to start educating the public on how to access the system. And [physicians] will have to pay attention to patient experience more than ever because it will become a market differentiator."

Cirillo said the challenges in boosting the number of insured young adults is significant, even with health system reform. "It's not like the insurance is free," he said. "There are many unknowns: Will [young adults] choose to purchase this insurance? Will they pay for it, or will their parents? Even if they have access to this new insurance, will they take advantage of preventative care?"

In his experience, Dr. Byrd said, preventive care is not valued. "If you have a chronic illness, you know you need a doctor. Generally, people age 20 to 40 are healthy."

Even if young adults are looking for medical care, it's not automatic that a physician's office will be the first place they go. According to a May 2011 report by PwC's Health Research Institute, 42% of consumers age 18 to 24 prefer to use an independent company, or one owned by a pharmacy, rather than a traditional doctor's office, compared with only 15% of consumers 55 and older who would go somewhere other than a physician practice.

Part of what Dr. Byrd does in his hospital system's speed-dating sessions is sell young adults on the merits of having a steady relationship with a physician.

"It's important for [young adults] to establish care and follow up with their pediatrician [or other physician] before, during and after college," Dr. Byrd said. For college-age people, vaccines, such as meningococcal, DTaP and varicella, may require boosters. Ongoing care also is important for young adults as they become more sexually active, he added.

Reaching a younger population

By using certain techniques to reach out to young adults, experts said, practices will have a better chance at capturing the population of new, young insureds that is coming. One way to reach out, they said, is to meet young adults where they live -- online.

At least two-thirds of young adults "are likely to use health care conveniences such as online scheduling and email communication with health care professionals," according to the Harris Interactive/AAFP study.

"I am not sure if the increase in the patient base would warrant a complete retooling of the physician's communication," Tsang said. "That said, it may not be a bad idea for the doctor to be on Facebook, have a follow-me account on Twitter, and put out some videos that address the most popular concerns of the younger folks."

Dr. Byrd says his practice has a website, and he regularly posts on Facebook and Twitter. These communications are primarily geared toward teens and young adults.

Tsang said the use of electronic medical records and practice management software are on the rise, and a doctor can score some points in a young patient's mind if he or she retrieves information electronically, as opposed to a paper dossier. "The doctor equipped with an EMR certainly comes across as cool and in the know."

In addition, online consultation continues to grow but remains "a very small" part of patient care, Tsang said. "For not-so-serious stuff, the young patient may want to reach out to a physician online."

"Having a secure online community is a big part of meaningful use," said Lindsay Horst, director of client services at Hostetler Management Group LLC, a physician practice consulting group in Marshallville, Ohio. "It's almost becoming a necessity." And practices can make simple changes, without adding software or infrastructure. "There are a lot of options with existing services."

For example, third-party companies will allow practices or clinics to set up portals to post lab results. These portals may allow doctors to provide online scheduling and other communications. EMRs also allow doctors to offer access to additional information through their infrastructure.

"You don't have to pay for, or even maintain, many of these additional services," Horst said.

Service enhancements -- online scheduling, bill payment, lab result access and physician communications, along with EMRs -- will be valued by younger patients, she said. So will the ability to get an appointment as quickly as possible. In the Harris/AAFP survey, 83% of respondents said they were very likely or likely to utilize same-day appointments, and 79% said they would be attracted to a practice with extended office hours.

"They're not just [living] 9 to 5," Horst said of young adults.

In general, "practices are going to have to pay more attention to patient experiences," Cirillo said. "All populations, except for the eldest, are demanding an experience that exceeds their expectations and actually surprises them. New technologies will help aid practices in handling demand and efficiency and will contribute to a better patient experience."

"The older generation may not change doctors" when enhanced services are not offered, Horst said. However, "when doctors put [these services and benefits] in place, you see usage across all groups."

Dr. Byrd said his practice gained at least one patient from the speed-dating event, and he is hopeful that the hospital will host more programs geared to young adults.

"Once we started talking, [young adults] realized pretty quickly that they needed to be plugged in to a regular doctor," he said.

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Creating more insured young adults

A May report estimated that 600,000 young adults have been added to insurance rolls in the early stages of the health reform law -- and that's just the tip of the iceberg. Of the 14.8 million uninsured ages 19-29, 12.1 million could gain subsidized coverage when health system reform goes into full effect into 2014. About 60% of the new coverage would come from Medicaid.

7.2 million: Medicaid, for those who earn less than 133% of the federal poverty level

3.4 million: Subsidized private coverage, for those between 133% to 249% of the federal poverty level

1.5 million: Subsidized private coverage, for those between 250% to 399% of the federal poverty level

0.9 million: Nonsubsidized private coverage, with possibility for those younger than 26 to stay on parents' plan, for those at 400% of the federal poverty level

Note: Those younger than 26 at 399% or below the federal poverty level also have the option of being on a parent's plan.

Source: "How the Affordable Care Act is Helping Young Adults Stay Covered," the Commonwealth Fund, May (link)

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Where young adults get care

An online survey of 1,273 people ages 18 to 26 looked at health care accessibility and utilization. Of the who said they have a regular place in which they receive care, more than three-quartersgo to a doctor's office.

76%: Physician practice
9%: Public clinic/health center
5%: VA/military hospital/clinic
5%: Campus clinic
4%: Hospital outpatient department
1%: Some other place

Source: "How the Affordable Care Act is Helping Young Adults Stay Covered," the Commonwealth Fund, May (link)

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Why 20-somethings don't see a doctor

A little more than a third of 1,273 people ages 18 to 26 said in a survey that they do not get regular medical care. Twenty-five percent of those did not have health insurance.

36%: I only go to the doctor if I'm extremely sick
25%: I don't have health insurance
21%: I'm healthy
5%: I prefer to treat myself naturally
4%: I don't like doctors
4%: I don't know of a good doctor in my area
2%: I don't have time to go to the doctor
1%: I am afraid of finding out something is wrong with me
2%: Other reason

Source: "How the Affordable Care Act is Helping Young Adults Stay Covered," the Commonwealth Fund, May (link)

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External links

"How the Affordable Care Act is Helping Young Adults Stay Covered," the Commonwealth Fund, May (link)

Young Adults Insurance Coverage Study, conducted by Harris Interactive for the American Academy of Family Physicians, June 2011 (link)

Website for the practice of Jeremy Byrd, MD, Heritage Pediatrics & Internal Medicine, Simpsonville, S.C. (link)

Heritage Pediatrics & Internal Medicine Facebook page (link)

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