Will access problems become a thing of the past?
Will access problems become a thing of the past?
While research shows that Medicaid does a good job of facilitating access to care, compared to those without coverage, there are some concerns about access under the program. "This is especially true for specialty care," says Rachel L. Garfield, PhD, an assistant professor in the Department of Health Policy and Management at the University of Pittsburgh's Graduate School of Public Health.
Inequity in payment rates is one reason. Barriers to access are linked to low provider participation levels, which in turn are linked to relatively low reimbursement rates, as well as administrative burdens and geographic distribution of providers.
Only about 40% of physicians accept all new Medicaid patients, compared with 58% for Medicare patients, according to a September 2009 study from the Center for Studying Health System Change. The report, which surveyed more than 4,700 physicians, found that percentage decreased to 31% for family doctors and general practitioners, and 28% of all physicians didn't accept any new Medicaid patients at all.
"In some areas, there is a severe shortage of specialists who accept Medicaid patients," says Dr. Garfield. "For example, access to dental care has been a chronic challenge in Medicaid." According to a 2007 survey by the American Dental Association, fewer than 27% of dentists treated Medicaid-insured patients. A recent study by the Pennsylvania Medicaid Policy Center found that only 26% of practicing dentists in the state treated at least one Medicaid patient over the past year.
"Medicaid is a part of an evolving, quality-focused, patient-centric marketplace, with many changes happening simultaneously," says Patricia MacTaggart, a lead research scientist at George Washington University's Department of Health Policy in Washington, DC. "Access to insurance coverage is the first step. Access to appropriate care from the appropriate provider in the appropriate setting at the appropriate time is the next."
"Having a Medicaid insurance card does not in and of itself ensure access to care," noted Joel Menges, a managing director at The Lewin Group in Falls Church, VA. "Medicaid's payment rates to front-line providers have often been extremely low rates, relative to other insurance coverage programs."
Many physicians, dentists, and therapists either do not accept Medicaid patients at all or significantly limit the number of Medicaid patients they will treat. "For beneficiaries, this can make it challenging to find a provider who will treat them. It can also lead to prolonged waiting time for appointments," says Mr. Menges.
Provider cuts are often the first place that states look to trim Medicaid spending when they are faced with budget problems, notes Dr. Garfield.
"Those cuts can certainly exacerbate this problem by making providers less likely to accept new Medicaid patients, or leading them to limit the number of Medicaid patients they will see," says Dr. Garfield.
Kathy Kuhmerker, also a managing director at The Lewin Group, notes that because enhanced federal funding support is tied to states not making any changes in eligibility, provider rate reductions are one of the few options available to states to achieve cost-containment.
"Most state policymakers face by far the largest state-level budget deficits they've seen in their lifetimes," says Ms. Kuhmerker. "While states are reluctant to impose Medicaid provider rate cuts that can worsen provider participation levels and exacerbate access problems, they feel forced to do so anyway."
In terms of how health care reform will affect access, there are many unknowns. Two certainties, however, are that the population of Medicaid/CHIP enrollees will be growing, and that there are workforce limitations in primary care.
"Added to that, states are still in a difficult financial situation with limited options to balance their budgets," says Ms. MacTaggart.
Ms. MacTaggart says "the good news" is that the Patient Protection and Affordable Care Act increases Medicaid payments in fee-for-service and managed care for primary care services provided by primary care doctors to 100% of the Medicare payment rates for 2013 and 2014 starting Jan. 1, 2013.
States will receive 100% federal financing for the increased payment rates. "The limitation of the language from a provider perspective is that it is only two years. The limitation from the state perspective is that the enhanced federal funding is only for two years," says Ms. MacTaggart. "This leaves both the state and providers questioning what happens at the end of two years."
For North Carolina and Washington, DC, there is no change, as they have already aligned with Medicare payments. For other states, the adjustment may be small or significant.
In order for the service delivery system to work for Medicaid, other publicly funded enrollees and privately funded enrollees, as the population to be served expands, the payments to providers must be adequate and the workforce issues must be addressed, says Ms. MacTaggart.
Dr. Garfield says that the increase in payment could address both the historical problem of low payment and participation, and the anticipated increase in participating providers needed to treat new Medicaid enrollees.
"The debate right now is whether the payment increase as structured in the law will fulfill these purposes," says Dr. Garfield. "It is targeted to primary care providers, so it does not address access to specialists." Also, it is specified only for 2013 and 2014, which is before the Medicaid expansion is implemented.
"Clearly the primary intention of the bill's massive Medicaid eligibility expansion is to facilitate access to care for those persons who are being made Medicaid-eligible," notes Ms. Kuhmerker.
The Lewin Group has estimated that more than 70% of the Medicaid expansion population will be comprised of persons who otherwise would have remained uninsured. "The increased payment rates for primary care services are another important access-enhancing piece of the reform bill," says Ms. Kuhmerker.
However, she adds that some Medicaid programs have already expressed skepticism that the two-year increase will be sufficient to convince currently non-participating providers to enroll in the program. Also, challenges accessing specialty care are likely to continue, given that states are unlikely to be able to increase those payment rates.
"On the more positive side, we estimate that the majority of new eligibles will be enrolled in managed care plans," says Ms. Kuhmerker. "These have historically been able to offer providers higher reimbursement rates than the fee-for-service program. This should also improve access to care."
Contact Dr. Garfield at (412) 383-7279 or [email protected], Ms. Kuhmerker at (703) 269-5592 or [email protected], Ms. MacTaggart at (202) 994-4227 or [email protected], and Mr. Menges at (703) 269-5598 or [email protected].
While research shows that Medicaid does a good job of facilitating access to care, compared to those without coverage, there are some concerns about access under the program. "This is especially true for specialty care," says Rachel L. Garfield, PhD, an assistant professor in the Department of Health Policy and Management at the University of Pittsburgh's Graduate School of Public Health.Subscribe Now for Access
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