Lower Medicaid fees linked to scarcer primary care appointments

(Reuters Health) - When the fees paid to healthcare providers by the Medicaid insurance program for the poor go up, appointments with primary care doctors suddenly become more available to Medicaid beneficiaries – and the opposite happens when fees go down, according to a recent U.S. study.

Researchers found that, overall, every $10 change up or down in the Medicaid fees paid to providers led to a 1.7 percent change in the same direction in the proportion of patients on Medicaid who could secure an appointment with a new doctor.

Based on these trends, reductions in Medicaid funding that lead to lower physician fees will compromise patient access to primary care providers, the authors conclude in JAMA Internal Medicine.

“As funding declines it threatens the breadth of provider participation in Medicaid,” said senior author Daniel Polsky, executive director of the Leonard Davis Institute of Health Economics at the University of Pennsylvania in Philadelphia.

“I don’t want to overestimate its result on patient welfare, but I think it’s a good thing to have broad choices of doctors when you’re looking to make a new patient appointment,” he said in a phone interview.

For the analysis, trained field workers posing as new Medicaid or privately insured patients called physician practices in 10 states to request a new-patient primary care appointment or an appointment for an urgent health care concern. In total, 12,092 calls were made and recorded to determine whether simulated Medicaid patients were able to get an appointment at all and, if so, how soon it could be scheduled.

The 10 states in the survey were Arkansas, Georgia, Illinois, Iowa, Massachusetts, Montana, New Jersey, Oregon, Pennsylvania and Texas.

An initial survey round was conducted in 2012 and early 2013, before the Affordable Care Act (ACA), commonly called Obamacare, was fully implemented. In 2014 and in 2016, the surveys were repeated to see whether the ACA’s initial, two-year hike in Medicaid reimbursement improved primary care availability for the more than 14.5 million adults newly enrolled in the program.

The Medicaid fee bump between the first two surveys was tied to 7.7 percentage-point increase in the availability of primary care appointments for Medicaid patients, the study found. Before the ACA increased Medicaid fees, 58.7 percent of callers pretending to be a new patient were able to get an appointment, compared to 66.4 percent in the second survey.

However, in the third survey, done in 2016 when Medicaid fees had already returned to lower levels, researchers found a substantial decrease in appointment availability.

Overall, when the mean Medicaid fee for a patient office visit went from $68.58 in 2012 to $107.38 in 2014 and then $75.67 in 2016, appointment availability tracked a similar pattern. In 2012, 56.2 percent of patients got an appointment while in 2012 it was 65.5 percent and then 61.5 percent in 2016. New Jersey, Georgia and Texas experienced the largest decreases in appointment availability, with 9.1, 10.9 and 10.1 percentage-point drops, respectfully.

In comparison, a total of 11,071 calls made by simulated patients with private insurance over the same periods showed no changes in appointment availability.

“The relationship is very strong between the proportion of providers who participate in a network and those that see patients with that particular insurance type,” Polsky told Reuters Health by phone.

One limitation of the study is that it only measured the impact of Medicaid funding in 10 states, the authors note.

“This study was very focused on what doctors offices were saying, but it doesn’t tell you what each patient was experiencing,” said Dr. Benjamin Sommers, an associate professor of health policy and economics at the Harvard T. H. Chan School of Public Health in Boston, who wasn’t involved in the research.

“If they didn’t get an appointment you have to wonder whether they will ultimately get the care they need. Is this just a slight inconvenience where they will have to make an extra call, or does this mean they were not being seen at all. There are different implications,” Sommers said in a phone interview.

One of the reasons the study results are important is their relation to the debate this year over whether to “block grant” Medicaid, Polsky said. That would mean less funding for the program, potentially leading providers to leave the Medicaid market.

SOURCE: JAMA Internal Medicine, online November 13, 2017.