Healthcare providers and patient advocates have long argued that access to services for low-income Medicaid patients is inadequate. Low doctor-payment rates, they argue, mean that few will serve Medicaid patients. According to the Kaiser Family Foundation, New Jersey has the sixth-lowest Medicaid payment rates for primary-care services and lowest payments for other services, such as obstetrics and specialty care.
There are reasons that those rankings don’t tell the whole story.
The Medicaid access question has been around for a long time, but it is of even greater importance today. Since New Jersey expanded Medicaid under the Affordable Care Act (ACA) last year, enrollment has increased by nearly a third to 1.67 million. If the Medicaid delivery system fell short before the expansion, imagine how hard it is to get care now with so many more people enrolled.
In recent years, several studies have shed light on the Medicaid access question for New Jersey, but at first look their results seem to conflict. Given the sharp growth in Medicaid enrollment, it is important to make sense of these numbers. Some findings raise red flags but others are more reassuring.
A 2013 study asked doctors whether they accept new Medicaid patients. In this study, New Jersey ranked rock bottom, with more than half of doctors not taking Medicaid patients.
Another study, conducted by my group, Rutgers Center for State Health Policy, used a 2012-2013 NJ Department of Health survey that asked patients about their access experiences. Here the story was not as bleak. Just over one-in-six Medicaid patients reported that a primary-care doctor’s office told them they would not accept their coverage. Surprisingly this statistic was nearly as high (one-in-seven) among privately insured patients. Medicare patients reported slightly better access, with only 10 percent saying a physician’s office would not take their coverage.
A new study published in the New England Journal of Medicine paints a favorable picture. In this study, actors posing as patients called primary-care offices to try to book appointments. The “secret shoppers” only called offices participating in Medicaid. This seems fair, since the first thing most people would do to find a doctors is look up their plan’s roster (although questions have been raised about the accuracy of rosters).
This study was conducted at two periods of time, once before the ACA Medicaid expansion, during late 2012 through early 2013, and again in the second quarter of 2014 after the eligibility expansion was well under way. The study was examining whether a temporary increase in payment rates for primary care led to improved access.
In the pre-ACA period, 70 percent of the offices called would book an appointment. In the later period, the share offering appointments rose to 80 percent. Of 10 states in this study, New Jersey had the lowest Medicaid doctor-payment rates, but surprisingly was among the top few in appointment availability during both periods. The study also found that the temporary rate increase did, in fact, improve appointment availability.
That brings me back to the question of how much payment rates matter. The payment data mentioned above measures amounts Medicaid pays for particular kinds of services under state fee-for-service (FFS) programs. Most states split their Medicaid programs between FFS and managed care, in which the state pays a fixed monthly fee to managed care organizations (MCOs) for enrolled patients. The MCOs, in turn, negotiate payment rates with providers, which can differ from the published FFS payments.
Over 90 percent of New Jersey Medicaid enrollees are assigned to MCOs, which have contractual obligations to make sure care is accessible. Moreover, whether through FFS or an MCO, federal rules require paying higher rates to certain clinics called Federally Qualified Health Centers. New Jersey has a robust network of these clinics. These factors may explain why the secret shopper study showed New Jersey is doing comparatively well in spite of its low provider rates. But this study also showed that increasing rates can be a tool for expanding access.
How do we reconcile the results of these different studies? They asked different questions. The first study asked representatives samples of doctors’ offices whether they accept new Medicaid patients. Only about half do, but if that half accepts large numbers of Medicaid patients, this statistic may be a poor marker of access.
The other two studies do show some access barriers, but not insurmountable ones. In the secret-shopper study, for instance, at least seven in 10 practices on Medicaid rosters were willing to take new patients. That means with calls to just a few offices, every patient should be able to find an appointment. Asking patients about their access experience, as in the Rutgers study, yields a similar result.
In spite of what I see as reassuring picture emerging from the recent research, there remain reasons to be vigilant about Medicaid access. The studies focus mainly on primary care, to the exclusion of detailed analysis of specialist access. The Medicaid population bears a very high burden of illness, especially complex chronic diseases, making specialty-care access very important.
None of the studies discussed here provides detailed information on access to mental health providers, endocrinologists (especially important for hard-to-control diabetes), or other vital specialties. For the most part, the Federally Qualified Health Centers do not offer specialty care. And the new Medicaid expansion population (mostly very-low-income adults without dependent children) is likely to have substantial need for specialty care.
The recent studies tell us that simple measures, like payment rates to providers, do not tell the full access story. Instead, close scrutiny of the actual availability of services across the state, especially specialty care, is needed. Conducting targeted audits of appointment availability among providers listed on Medicaid managed-care plan rosters would be a good start. If gaps are identified, the state’s Medicaid program and its managed-care plans need to take appropriate steps, which might include building stronger networks or raising provider payments in a targeted way.