Medicaid patients have better access to primary care than you might think

The following originally appeared on The Upshot (copyright 2014, The New York Times Company).

One longstanding concern about Medicaid is that too few doctors will accept it, because it tends to pay providers less generously than private plans do. This concern shows up in news articles about Medicaid, driven by evidence from doctors’ offices. But if you ask Medicaid enrollees directly, they reveal that access to primary care is comparable to that for private plans.

A report from the inspector general at the Department of Health and Human Services released in late September reinforced concerns about access to care for Medicaid enrollees. As my colleague Robert Pear reported, the inspector general found wide variation across states in access standards. For instance, the maximum travel distance states allow varies from five to 60 miles; the maximum appointment wait times vary from one to 60 days; and the minimum provider density varies from one in 100 to one in 2,500 enrollees, among other standards.

Worse, the inspector general found that only eight of the 33 states it examined conducted tests to assess whether Medicaid patients’ access to care met their standards.

Access problems could be exacerbated by the Affordable Care Act, which extends Medicaid coverage to millions more Americans, and expands coverage through private plans. To at least partly address this concern, the law includes an increase in funding for primary care training and in Medicaid payments for primary care visits through this year, and Congress is considering extensions. In its waiver application to allow residents eligible for Medicaid to participate in its state exchange, Arkansas argued thathigher payments to providers were necessary to encourage the supply of care to meet the new demand.

Medicaid enrollees may, in fact, have to work a bit harder to find a primary care doctor who will see them, but almost all are still able to find one. Using data from a large, nationally representative survey, Genevieve Kenney and colleagues did find that a substantial minority, 11 percent, of new Medicaid enrollees said that they had difficulty making an appointment. But only 2.8 percent said that they could not do so at all. To be sure, the program ideally would provide access for all its enrollees, but a 2.8 percent failure rate is probably a lot lower than most people think and suggests modest improvements may be sufficient to bring that number to zero.

The researchers also found that Medicaid enrollees who had been covered for at least a full year had no more difficulty obtaining care than those with employer-sponsored coverage. However, Medicaid enrollees were more likely to experience delays in care, but still at a fairly low rate — 8.4 percent, compared with 5.2 percent of low-income adults with employer-sponsored insurance. With one exception, Medicaid and employer-sponsored insurance enrollees were just as likely to receive key types of preventive care. (Those insured through work were five percentage points more likely to receive a flu shot.)

In 2012, the U.S. Government Accountability Office published similar findings. Based on a large survey of patients, not providers, Medicaid offered comparable access to care as private insurance for consumers with full-year coverage.

One reason people may think Medicaid primary care access is poor is because of the results of so-called secret shopper calls, the type of assessment the H.H.S. inspector general recommended. These are calls to doctors’ offices from people pretending to be patients, seeking to learn whether appointments can be made and, if so, how soon. Though secret shopper assessments are informative as to the breadth of provider choice Medicaid patients have — an important consideration — they can also mislead.

Publishing in JAMA Internal Medicine, Karin Rhodes and colleaguesconducted about 11,400 secret shopper calls in late 2012 through early 2013. Primary care offices in 10 states were contacted, accounting for one-third of the Medicaid population. On average, private plan callers were offered an appointment 85 percent of the time and Medicaid callers only 58 percent of the time, suggesting significantly worse access to primary care for Medicaid patients. However, the researchers also found that median wait times were five to eight days for private and Medicaid callers alike, with the exception of Massachusetts, where they were 13 days for private and 15 days for Medicaid callers.

A prior secret shopper study published in the New England Journal of Medicine by Joanna Bisgaier and Karin Rhodes examined specialty clinics in Cook County, Ill., in 2010. Callers pretended to be either insured by Medicaid or Blue Cross Blue Shield. On average, 66 percent of Medicaid callers were denied an appointment, compared with only 11 percent of privately insured callers. Other secret shopper studies also found worse access to care for Medicaid relative to private coverage.

But secret shopper studies have important limitations. One is that they tend to compare Medicaid to private plans with the most expansive networks, which may not be a representative standard. Many Americans are enrolled in private plans with more narrow networks, perhaps almost as narrow as that of Medicaid. Another limitation is that differences in the proportion of offices accepting patients do not, by themselves, tell us anything about differences in the quality of health care received or in health outcomes. Such results don’t even reveal the extent to which variations in providers’ willingness to make new appointments translate into patients’ ability to obtain them. This is a subtle, but important, distinction. Asking patients directly paints a more optimistic picture.

Though doctors may be less willing to accept new Medicaid patients than private patients in some plans, in general Medicaid patients seem to obtain nearly the same access to primary care. Perhaps they do so because they learn which providers to call or they make more calls. Assuming comparable quality, it’s not as worrisome that fewer doctors accept Medicaid if Medicaid patients can still reliably find some doctors who do in a reasonable amount of time.

Medicaid surely can be improved. It very likely pays some providers too little in some areas, and some of its patients probably experience access problems because of that. No doubt that’s true of some private plans as well. And the results I’ve written about here don’t address access to specialty care, which may be more difficult for Medicaid patients. But Medicaid is also a popular and valuable program, contributing to the health and well-being of many Americans who rely on it.

The secret shopper approach is undoubtedly the right strategy to assess compliance with state standards written in terms of proportion of doctors accepting patients within certain time and distance margins. But relying on secret shopper calls alone also understates access and provides a ready way to attack the program as woefully inadequate. The direct experience of patients needs to be considered as well.


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