States not enforcing Medicaid physician access rules, report says

Federal and state officials have not done enough to ensure that Medicaid beneficiaries have adequate access to physicians and as a result Medicaid patients often must wait for months or travel far to see a doctor, HHS’ Office of the Inspector General says in a new report (PDF).

The report, released Monday, found that state standards for access vary widely and are infrequently enforced.

The inspector general, Daniel Levinson, said this is a particular problem because of the rapid growth of Medicaid enrollment due to eligibility expansion under the Patient Protection and Affordable Care Act to adults with incomes up to 138% of the federal poverty level. So far, 27 states have opted to expand their Medicaid programs, and the Obama administration says eight million people have signed up since last October.

To encourage more doctors to accept Medicaid patients, the healthcare reform law boosted Medicaid payments to primary-care doctors to Medicare levels for two years. But that payment hike will expire soon, and healthcare groups are urging Congress to extend the enhanced payments.

Under federal rules, Medicaid managed care plans must provide “adequate” access for all services, but states set the criteria for adequacy, such as travel distance, maximum waiting times, minimum number of providers in the network, and minimum ratios of primary-care doctors and specialists per enrollment volume.

Levinson said in the report that most states have not cited any insurers for access violations in the last five years, and the federal government has done little to oversee state enforcement, the Times reported. He said states usually rely on information supplied by Medicaid plans, which is often inaccurate or out of date concerning the provider networks.

In her response to the report, CMS Administrator Marilyn Tavenner generally agreed with Levinson's recommendations and wrote that she expected to provide additional guidance to the states on the issue, according to the Times.

Even so, newly enrolled Medicaid beneficiaries are generally happy with the coverage they have received despite some access-to-care issues, according to focus group findings recently prepared for the Medicaid and CHIP Payment and Access Commission. Since joining Medicaid, they report feeling less stressed about bills and about their health, researchers from PerryUndem Research/Communication said in their findings for the commission.

Those with chronic health conditions or mental health issues such as depression say their conditions are improving since joining Medicaid. Some have had health conditions diagnosed since enrolling which they previously were unaware of and are happy they can now afford treatment.

But some beneficiaries worry about finding a provider or accessing certain treatments. Concern also exists that care will be of lower quality, according to the report. Further, some have found that their pharmacy or Medicaid will not fill particular prescriptions.

Most focus group participants said they not heard about the process for renewing their enrollment in Medicaid, and are unaware of how to stay enrolled in Medicaid.

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