Healthcare Business News

Reform Update: Can Medicaid beneficiaries find a doctor? The CMS wants to know

By Virgil Dickson
Posted: July 8, 2014 - 3:30 pm ET

The CMS is planning to conduct its first nationwide research effort to answer the question of whether adult Medicaid beneficiaries can find providers, and if factors such as being in managed Medicaid versus a fee-for-service offering aid or hurt the search. What it's likely to find, according to interviews conducted with state Medicaid officials and medical society officials in 20 states, is a mixed picture overshadowed by general concerns that reimbursement rates remain too low to entice many doctors to accept new Medicaid patients.

Many states already conduct such surveys annually, but the CMS' aim is to standardize the collection and analysis of data from state to state. The survey will begin this fall, with the goal of reaching roughly 29,000 adult Medicaid enrollees from each state for a total sample size of approximately 1.5 million, according to a bulletin circulated to state officials (PDF).

The CMS should brace itself for some bad news in terms of access to medical treatment for beneficiaries, though some bright spots exist.

Advertisement | View Media Kit


“Getting an insurance card does not ensure access to care,” said Mishael Azam, chief operating officer and senior manager of legislative affairs for the Medical Society of New Jersey, or MSNJ.

As many as 300,000 individuals became newly eligible to join Medicaid in New Jersey after Gov. Chris Christie decided to expand the program, with 60,000 of those applying for coverage as of Jan.1. Many of these individuals will likely struggle to find a physician, Azam said.

At issue is that many of the state's providers work in small private practices and face rising costs. Taking on Medicaid beneficiaries could add further financial strain for them because New Jersey has one of the lowest Medicaid reimbursement rates in the country at roughly 55% of Medicare fees versus the national average of 66%, according to the Kaiser Family Foundation.

Further, heavy administrative complexities are involved in getting certified to provide care to Medicaid beneficiaries, complexities that MSNJ is hoping the state will address. “It's a matter of reimbursement and reform that needs to take place here,” Azam said.

In South Dakota, a Medicaid non-expansion state, Dr. Mary Milroy, president of the state's medical association, is concerned about provider adequacy should lawmakers decide to expand Medicaid. As many as 25,000 new beneficiaries would qualify for the program should they decide to do so. Physicians in South Dakota already have begun to reduce their Medicaid patient load as their overhead costs continue to climb, Milroy said.

“Failure to find a solution to adequately fund the Medicaid program will worsen the disparity in access to care for those on Medicaid compared to those who are privately insured, forcing more physicians to limit the number of Medicaid patients they see or even from treating Medicaid patients all together,” she said.

Even if a Medicaid beneficiary can find a primary-care doctor, “primary-care physicians say it's hard to find specialists who will accept their Medicaid managed-care patients on referral,” said Dr. James Rish, president of Mississippi State Medical Association. Mississippi is another non-expansion state.

At issue is prior authorization requirements and other administrative burdens providers face as they attempt to treat patients, Rish said.

Other medical societies, including those in Connecticut, Iowa and New York, have heard similar concerns.

“I had one instance where the rate wouldn't even cover 20% of the cost,” said Dr. Andrew Kleinman, a plastic surgeon and president of the Medical Society of the State of New York.

Some states such as Pennsylvania for example could actually see Medicaid expansion increase access for beneficiaries. Republican Gov. Tom Corbett is awaiting CMS approval for an alternative plan to expand Medicaid using federal funds to buy people under 138% of the federal poverty level private insurance.

In hopes of enticing providers to participate, the plan has a loan forgiveness provision for doctors who agree to practice in rural and underserved areas where provider access is most lacking, said Kait Gillis, a spokeswoman for the state's Department of Public Welfare. Currently, 40% of physicians statewide do not participate in Medicaid in the state.

In Minnesota, most managed-care plans have contracts that link participation in their Medicaid business to participation in their commercial business, said Dan Hauser, a spokesman for the Minnesota Medical Association.

The state also has a policy that requires physicians and other providers to have an active caseload of up to 20% of new Medicaid patients if they want other state business such as the ability to treat public employees.

In Alaska, unlike in several other states, providers are actually pleased with the Medicaid reimbursement rate, the highest in the nation at nearly two and a half times the national average Medicaid fee level, according to Kaiser.

“There are some areas of the state where specialists do not exist and in that case, we pay for recipient travel to another community for care,” said Margaret Brodie, director of the Division of Health Care Services within the Alaska Department of Health & Social Services.

In Florida, currently transitioning a large chuck of Medicaid beneficiaries to managed care, plans are required to have robust provider networks to meet the needs of their enrollees.

“The network requirements are the most comprehensive ever required by the Florida Medicaid program,” said Shelisha Coleman, a spokeswoman for the state's Agency for Health Care Administration. “If a plan violates any portion of the contract, including network adequacy standards, it may be sanctioned or have liquidated damages imposed for lack of compliance.”

Officials from states such as Arizona, Arkansas and Oklahoma also say they are hearing no concerns about beneficiaries' ability to find a doctor.

For its national survey, the CMS and its contractor, independent research organization NORC at the University of Chicago, will draw samples from four types of Medicaid beneficiaries: those who are dually eligible for Medicare and Medicaid, adults who are disabled and those who are either in a managed-care or a fee-for-service offering.

The survey will track access, barriers to care, satisfaction with providers and the level of customer service. The findings will be used in determining future quality improvement efforts, the CMS said.

The study comes as Medicaid is undergoing a series of significant changes, both in terms of expansion in the number of individuals it covers because of the Patient Protection and Affordable Care Act and a steady migration of beneficiaries from a fee-for-service to managed care, a model that involves states paying a capitated rate to a private entity, such as an insurance company, to oversee the health needs of enrollees.

HHS estimates that 57% of Medicaid beneficiaries were enrolled in Medicaid managed-care organizations as of July 1, 2011, compared with 10% in 1991. The majority of the 6 million individuals the CMS believes joined Medicaid since October went into managed care.

“Post ACA-expansion and in recognition that many states already (conducts these surveys), CMS just wants to create a better national library of information on the topic,” said Matt Salo, executive director of the National Association of Medicaid Directors.

The CMS declined to comment on the research effort beyond what was in the bulletin.

Obama administration continues push to get states to expand Medicaid

Findings released by President Barack Obama's Council of Economic Advisers aim to highlight all that could be accomplished if the 24 states that have yet to expand Medicaid did so.

The report, titled “Missed Opportunities,” estimates the state-by-state impact, including access to care, financial security, overall health of residents and state economies.

If these states do not change course, 5.7 million people will be deprived of health insurance coverage in 2016, the report notes.

Illinois restores dental benefit for Medicaid beneficiaries

As of July 1, Illinois restored dental benefits for adults in the Medicaid system.

The benefit had been cut in 2012 in an effort to save funds. Removing those benefits didn't make financial sense in the long run because the lack of dental care could have produced a negative long-term impact on peoples' health, said Mike Claffey, spokesman for Illinois Medicaid.

Roughly 800 dentists in the state have continued to treat children in the Medicaid system, said Greg Johnson, executive director of the Illinois State Dental Society.

Follow Virgil Dickson on Twitter: @MHvdickson

What do you think?

Share your opinion. Send a letter to the Editor or Post a comment below.

Post a comment

Loading Comments Loading comments...



Switch to the new Modern Healthcare Daily News app

For the best experience of on your iPad, switch to the new Modern Healthcare app — it's optimized for your device but there is no need to download.