Since the advent of the Affordable Care Act, there has been a nearly 26% increase in the number of individuals with Medicaid or CHIP as their source of health insurance. But a well–documented problem is the issue of referring patients to providers who will accept Medicaid or CHIP reimbursement for their services.
This is not to say that providers generally do not accept Medicaid or CHIP patients; in fact, nearly 83% of primary care providers (PCPs) accept Medicaid or CHIP. However, nearly 80% of those providers cite a preference for privately insured patients.
Among providers who do not accept Medicaid, factors include reimbursement rates and delays, administrative difficulties, and the specific requirements placed on providers who accept these programs. In fact, nearly three times as many physicians report difficulty referring children with CHIP insurance to specialty care as they do with their privately insured peers.
So, who treats Medicaid patients? And is the quality of care provided by these individuals the same as you might expect from a clinician who takes only private insurance? An article in the April 2016 issue of Medical Care sought to answer these questions.
More than 92% of Massachusetts physicians reported seeing at least one Medicaid patient in 2011. But the median proportion of Medicaid patients, for both PCPs and specialists, was less than 6%.
Geissler, Lubin, and Marzelli used data from the 2011 Massachusetts All-Payer Claims Database to examine the characteristics of clinicians submitting Medicaid claims. They analyzed the intensity of participation in Medicaid, board certification, location of physician training (US or abroad), and relative rank of the physician’s training site.
Intensity of participation in Medicaid was assessed by determining the percentage of the physician’s annual claims submitted to Medicaid. Influence of a physician within a network of providers was determined by quantifying the number of mutual patients shared between the physician in question and other physicians in their Boston Hospital Referral Region. This measure is important because the quality of a physician’s network can enhance their referral capacity, especially among patients with complex health conditions or multiple comorbidities.
The researchers included only claims for face-to-face visits and only physicians who saw >30 non-Medicare patients. Also included were data about the percentage of Medicaid enrollees by ZIP code, to understand Medicaid usage by geographical area. In terms of clinician training ranking, they grouped all international medical graduates (IMGs) together. For US medical graduates, they used each institution’s average ranking between 2012 and 2015 in US News and World Report. If a school did not report a ranking, they received the average of the bottom-ranked schools.
Regression analysis used factors such as board certification, training site, and rank of medical school to predict intensity of Medicaid participation. The goal was to determine whether physicians who possess qualities often deemed “more desirable” by patients are those who treat the most Medicaid patients.
Although more than 92% of physicians reported seeing at least one Medicaid patient in 2011, the median proportion of Medicaid patients, for both PCPs and specialists, was less than 6%. This suggests that a small group of providers is responsible for seeing the majority of patients with Medicaid coverage.
Among PCPs, higher Medicaid intensity was associated with: being an IMG; being in practice for fewer years; and not having a solo practice. Among specialists, higher Medicaid intensity was associated with: being in practice for fewer years; being an IMG; and not being board-certified.
Being a specialist with a high proportion of Medicaid patients was also associated with decreased rank of that physician’s medical school. In general, physicians who accept greater proportions of Medicaid patients tend to be less centrally located, and therefore have less extensive networks from which to draw.
Key limitations of this research include that it was limited to data from Massachusetts, limiting generalizability. The data do not include claims from Federally Qualified Health Centers, but they account for less than 6% of Medicaid spending in MA. This research was also conducted before the increases in Medicaid fees after ACA implementation.
As a current medical student, this research struck a nerve.
As a current medical student, this study struck a nerve, particularly because of the emphasis on IMGs and medical school ranking. While it is certainly important that physicians receive proper training and are equipped to address all patients, I do not support using institutional rankings to proxy physician quality, knowing first-hand that many factors come into play in selecting an institution — for me, they included cost, location, involvement in the community, and the availability of a network of physicians where I want to live when I graduate.
What is more important to me is to understand what I, as a future primary care provider, can do. How do I ensure that people with Medicaid coverage get timely and appropriate referrals to specialty care? How can I expand my provider network to better equip them with the tools they need to ensure their long-term, lasting health?
I hope that this research will continue to inform all physicians on the need to increase accessibility, not just to Medicaid, but to treatment facilities ranging from primary care to specialty care.