Access to specialty care and medical services in community health centers

Although community health centers (CHCs) provide primary health services to the medically underserved and poor, limited access to off-site specialty services may lead to poorer outcomes among underinsured CHC patients. This study evaluates access to specialty health services for patients receiving care in CHCs, using a survey of medical directors of all federally qualified CHCs in the United States in 2004. Respondents reported that uninsured patients had greater difficulty obtaining access to off-site specialty services, including referrals and diagnostic testing, than did patients with Medicaid, Medicare, or private insurance.     

Commentary: Lessons from Medicaid--improving access to office-based physician care for the low-income population.

Medicaid offers important lessons about providing access to office-based physician services for the poor. First, differentials in physician fees between Medicaid and other payers compromise access to care and are difficult to reverse. Second, managed care alone is not enough to attain equity in access, especially if differentials in payment rates between Medicaid and private patients in managed care settings are allowed to grow. Finally, financing strategies alone are not sufficient to resolve the shortage of health care providers in medically underserved areas. In these areas, payment policy must be combined with resource development to ensure that vulnerable populations have access to care.     

Payment generosity and physician acceptance of Medicare and Medicaid patients

Using 2008 physician survey data, we estimate the relationship between the generosity of fees paid to primary care physicians under Medicaid and Medicare and his/her willingness to accept new patients covered by Medicaid, Medicare, or both programs (i.e., dually enrolled patients). Findings reveal physicians are highly responsive to fee generosity under both programs. Also, their willingness to accept patients under either program is affected by the generosity of fees under the other program, i.e., there are significant spillover effects between Medicare and Medicare fee generosity. We also simulate how physicians in 2008 would have likely responded to Medicaid and Medicare payment reforms similar to those embodied in the 2010 Affordable Care Act, had they been permanently in place in 2008. Our findings suggest that “Medicaid Parity” for primary care physicians would have likely dramatically improved physician willingness to accept new Medicaid patients while only slightly reducing their willingness to accept new Medicare patients. Also, many more primary care physicians would have been willing to treat dually enrolled patients.     

The influence of payer mix on electronic health record adoption by physicians

BACKGROUND: Numerous studies have examined the relationship between physician practice characteristics and electronic health record (EHR) adoption. Little is known about how payer mix influences physicians' decisions to implement EHR systems. PURPOSE: This study examines how different proportions of Medicare, Medicaid, and privately insured patients in physicians' practices influence EHR adoption. METHODOLOGY: Data from a large-scale survey of physician's use of information technologies in Florida were analyzed. Physicians were categorized based on their responses to questions regarding the proportion of patients in their practice that use Medicare, Medicaid, or private insurance products. The binary dependent variable of interest was EHR adoption among physicians. Adjusted odds ratios (ORs) were computed using logistic regression modeling techniques. The model examined the effect of changes in each payer type on EHR adoption, controlling for various practice characteristics. FINDINGS: Physicians with the highest percentage of Medicaid patients in their practices were significantly less likely to indicate using an EHR system when compared with those in the low-volume Medicaid group (OR = 0.690; 95% confidence interval [CI] = 0.50-0.95). No differences in EHR adoption were detected among physicians in the low, median, and high Medicare volume classifications. Among the private payer classifications, physicians whose practices were in the median group indicated significantly greater EHR use than those with relatively low levels of privately insured patients (OR = 1.62; 95% CI = 1.16-2.27). Those in the high-volume private payer group were also more likely than the low-volume group to have an EHR system, but this trend did not reach statistical significance (OR = 1.44; 95% CI = 0.96-2.16). PRACTICE IMPLICATIONS: Governmental insurance programs are either not influencing or negatively influencing EHR adoption among physicians in Florida. Given the quality and cost benefits associated with EHR use (particularly for health care payers), policymakers should consider strategies to incentivize or reward EHR adoption among doctors who care for Medicare and Medicaid patients.     

Exploring the potential for foreign-trained dentists to address workforce shortages and improve access to dental care for vulnerable populations in the United States: a case study from Washington State

Background  

To address dental workforce shortages in underserved areas in the United States, some States have enacted legislation to make it easier for foreign dental school graduates to become licensed dentists. However, the extent to which foreign dental school graduates will solve the problem of dental workforce shortages is poorly understood. Furthermore, the potential impact that foreign-trained dentists have on improving access to dental care for vulnerable patients living in dental Health Professional Shortage Areas (HPSAs) and those enrolled in public insurance programs, such as Medicaid, is unknown. The objective of this paper is to provide a preliminary understanding of the practice behaviors of foreign-trained dentists. The authors used Washington State as a case study to identify the potential impact foreign dental school graduates have on improving access to dental care for vulnerable populations. The following hypotheses were tested: a) among all newly licensed dentists, foreign-trained dentists are more likely to participate in the Medicaid program than U.S.-trained dentists; and b) among newly licensed dentists who participated in the Medicaid program, foreign-trained dentists are more likely to practice in dental HPSAs than U.S.-trained dentists.     

Prudence in international comparisons: insights for the United States from the Canadian health insurance experience.

Canadian social insurance for medical care started in the province of Saskatchewan in 1946, when conditions were very different from those in the United States today. The Cooperative Commonwealth Federation political party has no counterpart in the United States today. Voluntary insurance was weak in the Canadian priaries, but currently strong in the United States. The U.S. Medicare and Medicaid programs help elderly and poor people, but Saskatchewan lacked such programs. Separation of executive and legislative powers in the United States differs from unified powers in Canada. However, there are several similarities between the U.S. federation of states, and the Canadian provinces. The U.S. Democratic Party has a progressive wing. Voluntary insurance in the United States grew weaker in the 1980s. The U.S. health care crisis on costs today is equivalent to post-Depression conditions in Canada. Both countries are dominated by private fee-for-service medical care, but access to that care has been promoted by compulsory insurance laws in several U.S. states. Therefore, the United States could well emulate Canada by action of the states, which would lead eventually to federal action. Coverage should be universal, with limited benefits initially; gradually, benefits would be broadened.     

Shortcomings in public and private insurance coverage of diabetes self-management education and support

The objective of this study is to present preliminary data to characterize public and private insurance coverage for diabetes self-management education (DSM Education) and diabetes self-management support (DSM Support). Representatives from Medicaid and 2 private insurance providers in 10 states provided coverage information for their insurance plans. Two states (the most populous state from the East and West coasts) were sampled purposively and 8 additional states from 4 geographic regions (northeast, southeast, northwest, southwest) were sampled at random. Representatives from each private insurer described both a premium and basic coverage plan. Thus, 10 Medicaid programs and 40 private insurance plans were represented. Information about Medicare coverage was accessed from publicly available documents. Restricted by physician certification of patient eligibility, Medicare coverage included 10 hours of DSM Education plus 3 hours of medical nutrition therapy (MNT) within a continuous 12-month period, and 4 hours of follow-up (2 hours DSM Education and 2 hours MNT) for each subsequent year. Only 22 of 40 sampled private insurance and 5 of 10 Medicaid plans covered DSM Education, which ranged from 7 to 20 hours of education per year. Medicaid and private plans often limited the amount of DSM Education or required patients to obtain a physician certification of eligibility. Other than on-demand access features, coverage of DSM Support was minimal. Public and private insurance coverage of DSM Education was neither widespread nor uniform, while coverage of DSM Support was scarce.     

Visits to specialists under Medicare: socioeconomic advantage and access to care

This study examines the relationship between socioeconomic advantage and the likelihood of receiving specialty care in a nationally representative sample of older Americans participating in fee-for-service Medicare. In 1992, 62.9 percent of Americans aged 65 and older visited a specialist physician at least once. Being white, having more education, and having a higher income were each independently associated with a higher likelihood of visiting a specialist. Having insurance to supplement basic Medicare coverage was also independently associated with an increased likelihood of visiting a specialist; disadvantaged elders are less likely to have such supplemental insurance. Therefore, based both upon socioeconomic disadvantage and a lack of insurance to supplement the basic Medicare benefit, black, less educated and low-income elders are less likely to receive specialty services under fee-for-service Medicare. As the program evolves, it will be important to continue to monitor access to specialty care in vulnerable, socioeconomically disadvantaged populations.     

Medicaid in the inner city: the case of maternity care in Chicago

The growing concentration of lower-income groups, including Medicaid patients, in homogeneous inner-city areas such as Chicago casts considerable doubt on the effectiveness of expanding Medicaid eligibility and raising physician reimbursement to improve access to maternity care. There are few private office-based physicians providing prenatal care in these areas, and most pregnant women and infants are treated by private-office-based physicians in very high-volume practices, prompting concern about the quality of care. Increasing the supply of providers is required to enhance access to maternity services in inner cities. Expanding eligibility and raising reimbursement rates are more apt to benefit "near-poor" women, who are more spatially dispersed, than clustered-poor female populations.     

Alcohol,drug abuse,and mental health care for uninsured and insured adults

OBJECTIVE: To compare adults with different insurance coverage in care for alcohol, drug abuse, and mental health (ADM) problems. DATA SOURCES/STUDY SETTING: From a national telephone survey of 9,585 respondents. DESIGN: Follow-up of adult participants in the Community Tracking Study. DATA COLLECTION: Self-report survey of insurance plan (Medicare, Medicaid, unmanaged, fully, or partially managed private, or uninsured), ADM need, use of ADM services and treatments, and satisfaction with care in the last 12 months. PRINCIPAL METHODS: Logistic and linear regressions were used to compare persons by insurance type in ADM use. PRINCIPAL FINDINGS: The likelihood of ADM care was highest under Medicaid and lowest for the uninsured and those under Medicare. Perceived unmet need was highest for the uninsured and lowest under Medicare. Persons in fully rather than partially managed private plans tend to be more likely to have ADM care and ADM treatments given need. Satisfaction with care was high in public plans and low for the uninsured. CONCLUSIONS: The uninsured have the most problems with access to and quality of ADM care, relative to the somewhat comparable Medicaid population. Persons in fully managed plans had better rather than worse access and quality compared to partially managed plans, but findings are exploratory. Despite low ADM use, those with Medicare tend to be satisfied. Across plans, unmet need for ADM care was high, suggesting changes are needed in policy and practice.     

Effects of changes in incomes and practice circumstances on physicians' decisions to treat charity and Medicaid patients

CONTEXT: The decline over the past decade in the percentage of physicians providing care to charity and Medicaid patients has been attributed to both financial pressure and the changing practice environment. Policymakers should be concerned about these trends, since private physicians are a major source of medical care for low-income persons. This study examines how changes in physicians' practice income, ownership, and size affect their decisions to stop or start treating charity care and Medicaid patients. METHODS: This study uses panel data from four rounds of the Community Tracking Study Physician Survey. The dependent variables are the likelihood of physicians' (1) dropping charity care, (2) starting to provide charity care, (3) no longer accepting new Medicaid patients, and (4) starting to accept new Medicaid patients. The primary independent variables are changes in physicians' practice income, ownership, and practice type/size. Multivariate analysis controls for the effects of other physician practice characteristics, health policies, and health care market factors. FINDINGS: A decline in physicians' income increased the likelihood that a physician would stop accepting new Medicaid patients but had no effect on his or her decision to provide charity care. Those physicians who switched from being owners to employees or from small to larger practices were more likely to drop charity care and to start accepting Medicaid patients, and physicians who made the opposite practice changes did the reverse. CONCLUSIONS: Changes in their income and practice arrangements make physicians less willing to accept Medicaid and uninsured patients. Moreover, physicians moving into different practice arrangements treat charity and Medicaid patients as substitutes rather than as similar types of patients. To reverse these trends, policymakers should consider raising Medicaid reimbursement rates and subsidizing organizations that encourage private physicians to provide charity care.     

Inequality and access to health care.

Health services research has laid the groundwork for ongoing policy debates over the shortcomings of the American health care system and the need for the expansion of health insurance protection. In the early 1970s, studies of inequality in access to medical care provided the basis for proposals for national health insurance. The examination of the impact of Medicare and Medicaid demonstrated the critical role of these governmental efforts in reducing inequalities in access to care. By the 1980s the focus of investigation turned to the impact of policies designed to contain the cost of health care on access to medical services by vulnerable populations. Documentation of the negative health outcomes that followed from restrictions on access to care has set the stage for a renewed debate over universal health insurance.     

Do the Medicaid and Medicare programs compete for access to health care services? A longitudinal analysis of physician fees, 1998–2004

As the demand for publicly funded health care continues to rise in the U.S., there is increasing pressure on state governments to ensure patient access through adjustments in provider compensation policies. This paper longitudinally examines the fees that states paid physicians for services covered by the Medicaid program over the period 1998–2004. Controlling for an extensive set of economic and health care industry characteristics, the elasticity of states’ Medicaid fees, with respect to Medicare fees, is estimated to be in the range of 0.2–0.7 depending on the type of physician service examined. The findings indicate a significant degree of price competition between the Medicaid and Medicare programs for physician services that is more pronounced for cardiology and critical care, but not hospital care. The results also suggest several policy levers that work to either increase patient access or reduce total program costs through changes in fees.     

Insurance,competition and cost containment

Most economists have suggested that the growing presence of insurance, including Medicare, Medicaid, Blue Cross and the commercial insurers, is largely responsible for the rapid rise of health care costs in the United States. It is the contention of this paper, however, that the insurance industry in the private sector in the United States may help in the effort to contain costs rather than solely stimulating rapidly increasing costs. A number of methods that insurers have employed to contain costs, including monitoring provider behavior and prospective reimbursement, are identified. It is cautioned, however, that although health insurer cost containment efforts will continue to expand in the future, perversities in the U.S. tax laws, potential provider opposition and the complexities of medicine will continue to make cost containment a difficult task.     

The association between health insurance coverage and diabetes care; data from the 2000 Behavioral Risk Factor Surveillance System

OBJECTIVE: To describe the association between type of health insurance coverage and the quality of care provided to individuals with diabetes in the United States. DATA SOURCE: The 2000 Behavioral Risk Factor Surveillance System. STUDY DESIGN: Our study cohort included individuals who reported a diagnosis of diabetes (n=11,647). We performed bivariate and multivariate logistic regression analyses by age greater or less than 65 years to examine the association of health insurance coverage with diabetes-specific quality of care measures, controlling for the effects of race/ethnicity, annual income, gender, education, and insulin use. PRINCIPAL FINDINGS: Most individuals with diabetes are covered by private insurance (39 percent) or Medicare (44 percent). Among persons under the age of 65 years, 11 percent were uninsured. The uninsured were more likely to be African American or Hispanic and report low incomes. The uninsured were less likely to report annual dilated eye exams, foot examinations, or hemoglobin A1c (HbA1c) tests and less likely to perform daily blood glucose monitoring than those with private health insurance. We found few differences in quality indicators between Medicare, Medicaid, or the Department of Veterans Affairs (VA) as compared with private insurance coverage. Persons who received care through the VA were more likely to report taking a diabetes education class and HbA1c testing than those covered by private insurance. CONCLUSIONS: Uninsured adults with diabetes are predominantly minority and low income and receive fewer preventive services than individuals with health insurance. Among the insured, different types of health insurance coverage appear to provide similar levels of care, except for higher rates of diabetes education and HbA1c testing at the VA.     

Continuity of primary care: to whom does it matter and when?

BACKGROUND: Inconsistent findings on the value of continuity of care can stem from variability in its importance to different subsets of patients. We therefore examined the association among patient and visit characteristics and extent to which the patient valued continuity of care (PVC). We hypothesized that continuity would be more important to patients who are older, sicker, and female, who have established a relationship with their physician, and whose visit addresses more complex problems. METHODS: A study of 4,454 consecutive outpatient visits to 138 community-based family physicians used a 3-item measure (alpha = 0.67) of PVC. The patient's report of (1) the adequacy of primary care for the visit and (2) satisfaction with the physician on that visit was assessed with multiple measures. Analyses examined the associations among PVC and patient-reported satisfaction with the physician and adequacy of the visit. RESULTS: Extremes of age, female sex, less education, Medicare and Medicaid insurance, number of chronic conditions and medications, number of visits to the practice, and worse self-reported health status were associated with higher value placed on continuity (P < .001 for all except sex, where P = .015). Patients who value continuity and did not see a regular physician rated adequacy of the visit lower (for 7 attributes of the visit) than those seeing their own physician. Satisfaction with the physician for the visit was greatest among patients who value continuity and saw their regular physician. CONCLUSIONS: Continuity of physician care is associated with more positive assessments of the visit and appears to be particularly important for more vulnerable patients. Health care systems and primary care practices should devote additional effort to maintaining a continuity relationship with these vulnerable patients.     

Billing and payment of commercial and Medicaid health plan adult vaccination claims in Michigan since the Affordable Care Act

BackgroundProvider concern regarding insurance non-payment for vaccines is a common barrier to provision of adult immunizations. We examined current adult vaccination billing and payment associated with two managed care populations to identify reasons for non-payment of immunization insurance claims.MethodsWe assessed administrative data from 2014 to 2015 from Blue Care Network of Michigan, a nonprofit health maintenance organization, and Blue Cross Complete of Michigan, a Medicaid managed care plan, to determine rates of and reasons for non-payment of adult vaccination claims across patient-care settings, insurance plans, and vaccine types. We compared commercial and Medicaid payment rates to Medicare payment rates and examined patient cost sharing.ResultsPharmacy-submitted claims for adult vaccine doses were almost always paid (commercial 98.5%; Medicaid 100%). As the physician office accounted for the clear majority (79% commercial; 69% Medicaid) of medical (non-pharmacy) vaccination services, we limited further analyses of both commercial and Medicaid medical claims to the physician office setting. In the physician office setting, rates of payment were high with commercial rates of payment (97.9%) greater than Medicaid rates (91.6%). Reasons for non-payment varied, but generally related to the complexity of adult vaccine recommendations (patient diagnosis does not match recommendations) or insurance coverage (complex contracts, multiple insurance payers). Vaccine administration services were also generally paid. Commercial health plan payments were greater for both vaccine dose and vaccine administration than Medicare payments; Medicaid paid a higher amount for the vaccine dose, but less for vaccine administration than Medicare. Patients generally had very low (commercial) or no (Medicaid) cost-sharing for vaccination.ConclusionsAdult vaccine dose claims were usually paid. Medicaid generally had higher rates of non-payment than commercial insurance.     

Preventable hospitalizations in primary care shortage areas. An analysis of vulnerable Medicare beneficiaries

BACKGROUND: Health care outcomes among vulnerable elderly populations (defined in this study as Medicare beneficiaries who rated their overall general health as "fair" or "poor") are a growing concern. Recent studies suggest that potentially preventable hospitalizations may be useful for identifying poor ambulatory health care outcomes among vulnerable populations. OBJECTIVES: To determine if Medicare beneficiaries in fair or poor health are at increased risk of experiencing a preventable hospitalization if they reside in primary care health professional shortage areas. DESIGN: A survey of Medicare beneficiaries from the 1991 Medicare Current Beneficiary Survey. PATIENTS: Medicare beneficiaries living in the community. RESULTS: Medicare beneficiaries in fair or poor health were 1.82 times more likely to experience a preventable hospitalization if they resided in a primary care shortage area (95% confidence interval, 1.18-2.81). After controlling for educational level, income, and supplemental insurance, Medicare beneficiaries in fair or poor health were 1.70 times more likely to experience a preventable hospitalization if they resided in a primary care shortage area (95% confidence interval, 1.09-2.65). CONCLUSIONS: Medicare beneficiaries in fair or poor health are more likely to experience a potentially preventable hospitalization if they live in a county designated as a primary care shortage area. Provision of Medicare coverage alone may not be enough to prevent poor ambulatory health care outcomes such as preventable hospitalizations. Improving health care outcomes for vulnerable elderly patients may require structural changes to the primary care ambulatory delivery system in the United States, especially in designated shortage areas.     

SCHIP structure and children's use of care

This study explores the impact of program structure on children's use of care by comparing care use in State Children's Health Insurance Program (SCHIP) and Medicaid covered populations in a State where children share the same provider network and are both in a primary care case management system with the same Medicaid fee structure. We then compare care use in this system to care use in an SCHIP structured as a fee-for-service (FFS) system using a private insurance provider network and fee schedule. Where SCHIP and Medicaid Programs share a primary care case management (PCCM) system, we find more use of well-child care among Medicaid covered children, but more use of office-based physician care among SCHIP covered children. Across the Medicaid PCCM-based and the private insurance FFS-based system, we find more use of primary and specialty care in the FFS system, and more use of well-child care and less use of emergency departments for non-urgent care in the PCCM-based system.     

In 2011 nearly one-third of physicians said they would not accept new medicaid patients, but rising fees may help

When fully implemented, the Affordable Care Act will expand the number of people with health insurance. This raises questions about the capacity of the health care workforce to meet increased demand. I used data on office-based physicians from the 2011 National Ambulatory Medical Care Survey Electronic Medical Records Supplement to summarize the percentage of physicians currently accepting any new patients. Although 96?percent of physicians accepted new patients in 2011, rates varied by payment source: 31?percent of physicians were unwilling to accept any new Medicaid patients; 17?percent would not accept new Medicare patients; and 18?percent of physicians would not accept new privately insured patients. Physicians in smaller practices and those in metropolitan areas were less likely than others to accept new Medicaid patients. Higher state Medicaid-to-Medicare fee ratios were correlated with greater acceptance of new Medicaid patients. The findings serve as a useful baseline from which to measure the anticipated impact of Affordable Care Act provisions that could boost Medicaid payment rates to primary care physicians in some states while increasing the number of people with health care coverage.