Medicaid fees and access to care

A new paper in NEJM by Daniel Polsky and colleagues sheds light on the impact of an increase in Medicaid payment rates to selected providers in 2013 and 2014. The increase of fees, which bumped up Medicaid payments to Medicare levels, was part of the ACA and designed to increase access to primary care for Medicaid enrollees. The fee increase expired on January 1, 2015.

The fee bump was substantial. On average it raised Medicaid reimbursement for primary care by 50%.

The investigators used the secret shopper method, calling providers to assess the availability and wait times for appointments for either new Medicaid or new privately insured patients in ten states. Their data spanned November 2012 through July 2014. They found that

[t]he availability of primary care appointments in the Medicaid group increased by 7.7 percentage points, from 58.7% to 66.4%, between the two time periods. The states with the largest increases in availability tended to be those with the largest increases in reimbursements, with an estimated increase of 1.25 percentage points in availability per 10% increase in Medicaid reimbursements (P = 0.03). No such association was observed in the private-insurance group. During the same periods, waiting times to a scheduled new-patient appointment remained stable over time in the two study groups.

Some comments:

  • One of the chief, longtime complaints about Medicaid, heard across the political spectrum, is that it pays too little, harming access and care. There’s even a big lawsuit about it.
  • This study is strong evidence that the bump down in payment that occurred at the start of this year will adversely affect access. “Currently, only 16 states plan to continue the reimbursement increases,” the authors wrote.  So, a problem has been identified (Medicaid pays too little), a solution tested (pay more), with clear outcomes (better access, by one measure). The policy implications are fairly clear.
  • There are a number of limitations discussed in the paper. I want to add or emphasize two:
    • I believe the observed effect is causal, at least in direction. It’s completely reasonable that higher payment begets greater access, as it was measured. It’s possible, though, that other factors also affected Medicaid access, even relative to privately insured patients. Perhaps greater education and outreach as part of coverage expansion played a role, differentially affecting providers’ willingness to offer care to Medicaid vs. privately insured patients. We can’t be sure. Still, a stronger study design for the policy as implemented is hard to develop. We didn’t randomize states to fee increases, for instance.
    • There are other, important ways to measure access, as I have discussed. It is possible that the degree of access as it was measured in this study (via secret shoppers) differs from that as measured in other ways (like surveying patients, both with new or continuing coverage). It’s important to examine both aspects of access, as well as consider access to specialists. This study only considered one type of access to primary care.

For all that, it’s a very good study. To be sure, we should continue to collect data and study access. Still, about the Medicaid fee bump, I’m ready to say to policymakers, it’s your move.

(See also Harold Pollack’s post, which makes some of the same points, only with a lot more style.)


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