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.     

New pathways for primary care: an update on primary care programs from the innovation center at CMS

Those in practice find that the fee-for-service system does not adequately value the contributions made by primary care. The Center for Medicare and Medicaid Innovation (Innovation Center) was created by the Affordable Care Act to test new models of health care delivery to improve the quality of care while lowering costs. All programs coming out of the Innovation Center are tests of new payment and service delivery models. By changing both payment and delivery models and moving to a payment model that rewards physicians for quality of care instead of volume of care, we may be able to achieve the kind of health care patients want to receive and primary care physicians want to provide.     

Behavioral Health and Health Care Reform Models: Patient-Centered Medical Home, Health Home, and Accountable Care Organization

Discussions of health care delivery and payment reforms have largely been silent about how behavioral health could be incorporated into reform initiatives. This paper draws attention to four patient populations defined by the severity of their behavioral health conditions and insurance status. It discusses the potentials and limitations of three prominent models promoted by the Affordable Care Act to serve populations with behavioral health conditions: the Patient-Centered Medical Home, the Health Home initiative within Medicaid, and the Accountable Care Organization. To incorporate behavioral health into health reform, policymakers and practitioners may consider embedding in the reform efforts explicit tools—accountability measures and payment designs—to improve access to and quality of care for patients with behavioral health needs.     

Policy makers should prepare for major uncertainties in Medicaid enrollment, costs, and needs for physicians under health reform

The Affordable Care Act of 2010 will expand Medicaid to millions of Americans by 2014. How many enroll will greatly affect health care access, demand for clinicians, and the federal budget, yet the precision and validity of enrollment estimates made to date is unknown. We created a simulation model using two nationally representative data sets to determine the range of reasonable projections, estimating eligibility, participation, and population growth using prior research and our data. Our model predicted that the number of additional people enrolling in Medicaid under health reform may vary by more than 10?million, with a base-case estimate of 13.4?million and a possible range of 8.5?million to 22.4?million. Estimated federal spending for new Medicaid enrollees ranged from $34?billion to $98?billion annually, and we projected that 4,500-12,100 new physicians will be needed to care for new enrollees. In the end, Medicaid enrollment will be determined largely by the extent to which federal and state efforts encourage or discourage eligible people from enrolling. Yet our results indicate that policy makers should prepare to handle a broad range of contingencies and uncertainty in Medicaid expansion under health reform.     

The Care Span: Medicaid savings resulted when community health workers matched those with needs to home and community care

The Affordable Care Act of 2010 builds on earlier efforts to expand home and community-based alternatives to institutional long-term care. Identifying people living in the community who have unmet long-term care needs and who may be at risk for entering nursing homes may be crucial to these efforts. The Arkansas Community Connector Program used specially trained community health workers to identify such people in three disadvantaged counties and connect them to Medicaid home and community-based services. The result was a 23.8?percent average reduction in annual Medicaid spending per participant during the period 2005-08. Net three-year savings to the Arkansas Medicaid program equaled $2.619?million. Similar interventions may help other localities achieve cost-saving and equitable access to publicly funded long-term care options other than institutional care.     

A new corps of trained Grand-Aides has the potential to extend reach of primary care workforce and save money

Because the Affordable Care Act will expand health insurance to cover an estimated thirty-two million additional people, new approaches are needed to expand the primary care workforce. One possible solution is Grand-Aides?, who are health care professionals operating under the direct supervision of nurses, and who are trained and equipped to conduct telephone consultations or make primary care home visits to patients who might otherwise be seen in emergency departments and clinics. We conducted pilot tests with Grand-Aides in two pediatric Medicaid settings: an urban federally qualified health center in Houston, Texas, and a semi-rural emergency department in Harrisonburg, Virginia. We estimated that Grand-Aides and their supervisors averted 62 percent of drop-in visits at the Houston clinic and would have eliminated 74 percent of emergency department visits at the Virginia test site. We calculated the cost of the Grand-Aides program to be $16.88 per encounter. That compares with current Medicaid payments of $200 per clinic visit in Houston and $175 per emergency department visit in Harrisonburg. In addition to reducing health care costs, Grand-Aides have the potential to make a substantial impact in reducing congestion in primary care practices and emergency departments.     

As roughly 700,000 prisoners are released annually, about half will gain health coverage and care under federal laws

During 2009, 730,000 prisoners were released from federal and state prisons--a 21 percent increase from the number of prisoners released in 2000. Poor health and poor health coverage have been major challenges for former prisoners trying to reintegrate into the community and find work. We discuss these challenges and the likely effect of recent federal legislation, including the Second Chance Act, the Mental Health Parity and Addiction Equity Act, and the Affordable Care Act. We estimated that with the implementation of health reform, up to 33.6 percent of inmates released annually--more than 245,000 people in 2009--could enroll in Medicaid. Similarly, we estimated that up to 23.5 percent of prisoners released annually-more than 172,000 people in 2009-could be eligible for federal tax credits to defray the cost of purchasing insurance from state health exchanges. This health insurance, combined with new substance abuse services and patient-centered medical home models, could dramatically improve the health and success of former inmates as they return to the community. States should consider several policy changes to ease prisoners' transitions, including suspending rather than terminating Medicaid benefits for offenders; incorporating corrections information into eligibility determination systems; aiming Medicaid outreach and enrollment efforts at prison inmates; and designing comprehensive approaches to meeting former prisoners' health care needs.     

Improving coverage for children under health reform will require maintaining current eligibility standards for Medicaid and CHIP

When the Affordable Care Act of 2010 is fully implemented, it will extend health insurance coverage to many adult Americans who currently lack it. It is not known, however, how the health reform legislation will affect children and parents who would otherwise be uninsured. Based on our analysis, the Affordable Care Act has the potential to cut the number of uninsured children by about 40 percent, from 7.4 million to 4.2 million, and the number of uninsured parents by almost 50 percent, from 12.7 million to 6.6 million. However, the actual impact will depend on increasing the share of children and parents who are enrolled in public coverage and on other implementation outcomes. Most strikingly, if the requirement that states continue their Medicaid and Children's Health Insurance Program (CHIP) coverage is rescinded and if Congress does not continue funding CHIP, the uninsurance rate of children could more than double, increasing from 4.2 million to 7.9-9.1 million children. In that case, the uninsurance rate among children would be higher than if the Affordable Care Act had not been adopted.     

National health expenditure projections: modest annual growth until coverage expands and economic growth accelerates

For 2011-13, US health spending is projected to grow at 4.0 percent, on average--slightly above the historically low growth rate of 3.8 percent in 2009. Preliminary data suggest that growth in consumers' use of health services remained slow in 2011, and this pattern is expected to continue this year and next. In 2014, health spending growth is expected to accelerate to 7.4 percent as the major coverage expansions from the Affordable Care Act begin. For 2011 through 2021, national health spending is projected to grow at an average rate of 5.7 percent annually, which would be 0.9 percentage point faster than the expected annual increase in the gross domestic product during this period. By 2021, federal, state, and local government health care spending is projected to be nearly 50 percent of national health expenditures, up from 46 percent in 2011, with federal spending accounting for about two-thirds of the total government share. Rising government spending on health care is expected to be driven by faster growth in Medicare enrollment, expanded Medicaid coverage, and the introduction of premium and cost-sharing subsidies for health insurance exchange plans.     

Expansion of coverage under the Patient Protection and Affordable Care Act and primary care utilization

Context: Provisions of the Patient Protection and Affordable Care Act of 2010 (PPACA) expand Medicaid to all individuals in families earning less than 133 percent of the federal poverty level (FPL) and make available subsidies to uninsured lower‐income Americans (133 to 400 percent of FPL) without access to employer‐based coverage to purchase insurance in new exchanges. Since primary care physicians typically serve as the point of entry into the health care delivery system, an adequate supply of them is critical to meeting the anticipated increase in demand for medical care resulting from the expansion of coverage. This article provides state‐level estimates of the anticipated increases in primary care utilization given the PPACA's provisions for expanded coverage. Methods: Using the Medical Expenditure Panel Survey, this article estimates a multivariate regression model of annual primary care utilization. Using the model estimates and state‐level information regarding the number of uninsured, it predicts, by state, the change in primary care visits expected from the expanded coverage. Finally, the article predicts the number of primary care physicians needed to accommodate this change in utilization. Findings: This expanded coverage is predicted to increase by 2019 the number of annual primary care visits between 15.07 million and 24.26 million. Assuming stable levels of physicians’ productivity, between 4,307 and 6,940 additional primary care physicians would be needed to accommodate this increase. Conclusions: The PPACA's health insurance expansion parameters are expected to significantly increase the use of primary care. Two strategies that policymakers may consider are creating stronger financial incentives to attract medical school students to primary care and changing the delivery of care in ways that lead to operational improvements, higher throughput, and better quality of care.     

Accountable care organizations: the case for flexible partnerships between health plans and providers

Under the Affordable Care Act, the new Center for Medicare and Medicaid Innovation will guide a number of experimental programs in health care payment and delivery. Among the most ambitious of the reform models is the accountable care organization (ACO), which will offer providers economic rewards if they can reduce Medicare's cost growth in their communities. However, the dismal history of provider-led attempts to manage costs suggests that this program is unlikely to accomplish its objectives. What's more, if ACOs foster more market concentration among providers, they have the potential to shift costs onto private insurers. This paper proposes a more flexible payment model for providers and private insurers that would divide health care services into three categories: long-term, low-intensity primary care; unscheduled care, including unscheduled emergency services; and major clinical interventions that usually involve hospitalization or organized outpatient care. Each category of care would be paid for differently, with each containing different elements of financial risk for the providers. Health plans would then be encouraged to provide logistical and analytic support to providers in managing health costs in these categories.     

An Analysis of Payment Mix Patterns of Preterm Births in a Post-Affordable Care Act Insurance Market: Implications for the Medicaid Program

BackgroundThe United States has a relatively high preterm birth rate compared with other developed nations. Before the enactment of the Affordable Care Act in 2010, many women at risk of a preterm birth were not able to access affordable health insurance or a wide array of preventive and maternity care services needed before, during, and after pregnancy. The various health insurance market reforms and coverage expansions contained in the Affordable Care Act sought in part to address these problems. This analysis aims to describe changes in the patterns of payer mix of preterm births in the context of a post-Affordable Care Act insurance market, explore possible factors for the observed changes, and discuss some of the implications for the Medicaid program.MethodsWe applied a repeated cross-sectional study design to explore payment mix patterns of all births and preterm births between 2011 and 2016, using publicly available National Vital Statistics Birth Data. We included an equal number of years with payment source available in the dataset before and after January 1, 2014, when the coverage expansions became effective.ResultsWe found a small relative change in payment mix during the study period. Private health insurance (PHI) paid for a higher percentage of all births and this rate increased steadily between 2011 and 2016. Preterm births paid by PHI increased by 1.4 percentage points between 2011 and 2016 and self-pay/uninsured preterm births decreased by 0.3 percentage points over the same time period. Medicaid had the highest, and a relatively stable, preterm birth coverage percentage (48.9% in 2011, 49.2% in 2014, and 48.9% in 2016). Medicaid was also more likely to pay for preterm births than PHI, but this likelihood decreased by more than one-half after 2014 (8.2% in 2013 vs. 3.8% in 2014).ConclusionsAfter the 2010 reforms, Medicaid remained a constant source of coverage for the most vulnerable women in society when faced with the high cost of a preterm birth. Nationwide, of the 64 million women ages 15 to 44, 4% gained PHI (directly purchased or employer sponsored) and another 4% Medicaid, with a concomitant 8% decrease in uninsured women of reproductive age between 2013 and 2017. More research is needed to conclude with certainty that the reforms worked as intended, but the important role of Medicaid as a financial safety net is undeniable.     

Projecting the impact of the Affordable Care Act on California

The Affordable Care Act is the most fundamental legislative transformation of the US health care system in forty years. This analysis estimates that the act will provide health insurance for an additional 3.4 million people in California in 2016. This will mean that nearly 96 percent of documented residents of California under age sixty-five will be insured. Enrollment in Medi-Cal, the state's Medicaid program, is expected to increase by 1.7 million people, while 4.0 million people are expected to enroll in the state's planned new health insurance exchange. Employer-sponsored insurance and spending on health insurance will decline slightly. Low-income households will experience substantial financial benefits, but families at the highest income levels will pay more.     

Rewarding family medicine while penalizing comprehensiveness? Primary care payment incentives and health reform: the Patient Protection and Affordable Care Act (PPACA)

Family physicians' scope of work is exceptionally broad, particularly with increasing rurality. Provisions for Medicare bonus payment specified in the health care reform bill (the Patient Protection and Affordable Care Act) used a narrow definition of primary care that inadvertently offers family physicians disincentives to delivering comprehensive primary care.     

Community Health Center Use After Oregon’s Randomized Medicaid Experiment

PURPOSEThere is debate about whether community health centers (CHCs) will experience increased demand from patients gaining coverage through Affordable Care Act Medicaid expansions. To better understand the effect of new Medicaid coverage on CHC use over time, we studied Oregon’s 2008 randomized Medicaid expansion (the “Oregon Experiment”).METHODSWe probabilistically matched demographic data from adults (aged 19–64 years) participating in the Oregon Experiment to electronic health record data from 108 Oregon CHCs within the OCHIN community health information network (originally the Oregon Community Health Information Network) (N = 34,849). We performed intent-to-treat analyses using zero-inflated Poisson regression models to compare 36-month (2008–2011) usage rates among those selected to apply for Medicaid vs not selected, and instrumental variable analyses to estimate the effect of gaining Medicaid coverage on use. Use outcomes included primary care visits, behavioral/mental health visits, laboratory tests, referrals, immunizations, and imaging.RESULTSThe intent-to-treat analyses revealed statistically significant differences in rates of behavioral/mental health visits, referrals, and imaging between patients randomly selected to apply for Medicaid vs those not selected. In instrumental variable analyses, gaining Medicaid coverage significantly increased the rate of primary care visits, laboratory tests, referrals, and imaging; rate ratios ranged from 1.27 (95% CI, 1.05–1.55) for laboratory tests to 1.58 (95% CI, 1.10–2.28) for referrals.CONCLUSIONSOur results suggest that use of many different types of CHC services will increase as patients gain Medicaid through Affordable Care Act expansions. To maximize access to critical health services, it will be important to ensure that the health care system can support increasing demands by providing more resources to CHCs and other primary care settings.     

Mounting pressures: physicians serving Medicaid patients and the uninsured, 1997-2001

The proportion of doctors providing any charity care decreased from 76.3 percent in 1997 to 71.5 percent in 2001, according to a new study by the Center for Studying Health System Change (HSC). The proportion of physicians serving Medicaid patients also decreased from 87.1 percent in 1997 to 85.4 percent in 2001. The small decrease in physicians serving Medicaid patients does not appear to have had any negative effects on access to physicians among Medicaid beneficiaries. On the other hand, the more sizable decrease in physicians providing charity care is consistent with other evidence showing decreased access to physicians by uninsured persons. New budget pressures could lead states to freeze or cut Medicaid provider payment rates, which could then trigger access problems.     

Do Medicaid benefit expansions have teeth? The effect of Medicaid adult dental coverage on the use of dental services and oral health

This article examines the effect of Medicaid adult dental coverage on use of dental care and dental health outcomes using state-level variation in dental coverage during 2000–2012. Our findings imply that dental coverage is associated with an increase in the likelihood of a recent dental visit, with the size of the effect increasing with Medicaid payment rates to dentists, and a reduction in the likelihood of untreated dental caries. We are among the first to detect an effect of Medicaid coverage on a clinical health outcome other than mortality. These findings may have implications for states expanding Medicaid coverage to adults with incomes of up to 138% of the federal poverty threshold under the Affordable Care Act as most of these states offer an adult dental benefit.     

Acceptance of New Medicaid Patients by Primary Care Physicians and Experiences with Physician Availability among Children on Medicaid or the Children's Health Insurance Program

Objective

To estimate the relationship between physicians'' acceptance of new Medicaid patients and access to health care.

Data Sources

The National Ambulatory Medical Care Survey (NAMCS) Electronic Health Records Survey and the National Health Interview Survey (NHIS) 2011/2012.

Study Design

Linear probability models estimated the relationship between measures of experiences with physician availability among children on Medicaid or the Children''s Health Insurance Program (CHIP) from the NHIS and state-level estimates of the percent of primary care physicians accepting new Medicaid patients from the NAMCS, controlling for other factors.

Principal Findings

Nearly 16 percent of children with a significant health condition or development delay had a doctor''s office or clinic indicate that the child''s health insurance was not accepted in states with less than 60 percent of physicians accepting new Medicaid patients, compared to less than 4 percent in states with at least 75 percent of physicians accepting new Medicaid patients. Adjusted estimates and estimates for other measures of access to care were similar.

Conclusions

Measures of experiences with physician availability for children on Medicaid/CHIP were generally good, though better in states where more primary care physicians accepted new Medicaid patients.     

Medicaid patients increasingly concentrated among physicians

Despite increases in Medicaid payment rates and enrollment, the proportion of U.S. physicians accepting Medicaid patients has decreased slightly over the past decade, according to a national study by the Center for Studying Health System Change (HSC). In 2004-05, 14.6 percent of physicians reported that they received no revenue from Medicaid, an increase from 12.9 percent in 1996-97. There were also small increases in the percentage of physicians who were not accepting new Medicaid patients. A more striking trend is that care of Medicaid patients is becoming increasingly concentrated among a smaller proportion of physicians who tend to practice in large groups, hospitals, academic medical centers and community health centers. Relatively low payment rates and high administrative costs are likely contributing to decreased involvement with Medicaid among physicians in solo and small group practices.     

Health Insurance Status and Eligibility Among Patients who Seek Healthcare at a Free Clinic in the Affordable Care Act Era

Free clinics provide care to over 1.8 million people in the United States every year and are a valuable safety net for uninsured and underinsured patients. The Affordable Care Act has resulted in millions of newly insured Americans, yet there is continued demand for healthcare at free clinics. In this study, we assessed health insurance status and eligibility among 489 patients who visited a free clinic in 2016. Eighty-seven percent of patients seen were uninsured, 53.1% of whom were eligible for health insurance (Medicaid or subsidized insurance premiums). The majority of these patients completed health insurance applications at their visit with the help of a navigator. A majority of patients who were not eligible for health insurance lacked citizenship status. This study highlights that a significant number of patients who visit free clinics are eligible for health insurance, and that free clinics are important sites for health insurance navigation programs.