The federal government's proposed new regulations for Medicaid managed-care plans include the pledge that the program's beneficiaries will have adequate access to a doctor when they need one.
When have Medicaid beneficiaries ever had adequate access to doctors, especially specialists or dentists?
The core of the problem is pay, of course, although geography and the unspoken stigma associated with serving that clientele play a part. Medicaid rates in virtually every state are a fraction of what is paid by Medicare and private insurance companies. There are only so many hours in a day. How many should a physician practice devote to serving its lowest-paying patients?
In 2013, the last time Health Affairs published a physician survey on the question, the researcher found nearly 1 out of 3 doctors refused to see new Medicaid patients. That was compared to just 17% of physicians who refused to see new Medicare patients—and those were the ones who admitted it.
The situation has not gotten better now that the Affordable Care Act's bump in Medicaid pay to Medicare levels has expired. Just seven states kept the higher rates in place for 2015, according to the March Medicaid and CHIP Payment and Access Commission report, with another eight raising rates slightly. The rest reverted to the previous low rates.
Despite those realities, surveys of Medicaid beneficiaries have generally revealed a relatively high level of satisfaction with their access to care. In fact, their response is not much different from the perceptions of Medicare beneficiaries and the privately insured.
But closer examination, experts say, reveals that beneficiaries' satisfaction is boosted by the additional access that comes from visiting hospital emergency departments and government-subsidized community health centers.
If the government now proposes to hold Medicaid managed-care plans to the network adequacy of Medicare Advantage and exchange plans, will it also back that up with either adequate reimbursement for providers or a significant expansion of community clinics? In the current fiscal and political environment in Washington, the answer to that question is obviously not.
So it was interesting to read an Urban Institute report last week on the Medicaid expansion programs that have been adopted in six Republican-led states willing to cover families earning up to 138% of the federal poverty level as long as it is on the states' terms. The waivers granted in Arkansas, Indiana, Iowa, Michigan, New Hampshire and Pennsylvania, while differing in their particulars, have a number of common elements.
Each relies on private insurers, which are required to come up with qualified health plans that meet the standards of the ACA. While plan “purchasers” are almost totally subsidized, five of six states require some of these very low-income beneficiaries to make financial contributions that range as high as 2% of their income.
The plans also focus on setting up health savings accounts for beneficiaries and establishing wellness programs. While these are common features in many of today's corporate-sponsored plans (with only limited evidence to support claims that “more skin in the game” and wellness incentives hold down costs), these elements discourage enrollment by people who are scrambling to keep food on the table and a roof over their heads.
Still, the report was generally upbeat about the initial enrollment levels and the prospects of succeeding in providing adequate access to care—at least at the level of traditional fee-for-service Medicaid, if not better. ACA-qualified plans could give beneficiaries “a broader mix of providers” and promote “continuity of care when people move between eligibility for Medicaid and marketplace subsidies,” the report concluded.
The downside is that it might cost more than traditional Medicaid. But even that might not be the case.
As Modern Healthcare's Bob Herman reported last week, most of the major Medicaid insurers that now manage nearly 70% of all Medicaid beneficiaries are running non-medical expense ratios well below the 15% threshold set in the proposed regulation. Most are also offering higher-than-Medicaid rates to primary-care physicians to attract more of them to their networks. How they do that is a subject worth investigating. I suspect it starts by managing patients in ways that encourage them to visit the doctor's office instead of the ED.
But better management of patient expectations and behavior can only go so far. In the long term, better access will depend on Medicaid paying providers the same rates as Medicare. Until Congress acts, physician access for Medicaid patients will remain a problem.