Medicaid Expansion: Physician Participation May Vary

Leigh Page

July 08, 2013

About half the states are expected to expand Medicaid coverage on January 1, 2014, under the Affordable Care Act, bringing in millions of new patients looking for physicians who accept Medicaid.

However, enrollees' ability to find physicians could vary widely from state to state, according to a new analysis of recent Medicaid acceptance rates published in the July issue of Health Affairs.

Sandra L. Decker, PhD, a distinguished consultant in the Office of Analysis and Epidemiology at the National Center for Health Statistics in Hyattsville, Maryland, analyzed 2 years of data for 8158 physicians in the National Ambulatory Medical Care Survey.

Dr. Decker's findings suggest that physicians in Massachusetts and Arkansas, for example, will be more comfortable admitting new Medicaid patients than those in New Jersey and California. However, she cautioned that other variables, such as the availability of enhanced payments for treating Medicaid patients, might also influence physician participation.

The Affordable Care Act originally directed states to raise Medicaid coverage rates to 138% of the federal poverty line. This change was expected to bring 16 million new Medicaid patients into the program nationwide, but in June 2012, the US Supreme Court allowed states to opt out of the expansion. At last count, only about half of the states had agreed to the expansion and 18 states had rejected it. The rest are still deciding, but most of those with decisions outstanding are reportedly leaning toward opting out.

Looking for a baseline on which to predict physicians' 2014 Medicaid participation rates, Dr. Decker's study shows that about two thirds of primary care physicians across the country accepted new Medicaid patients in 2011 and 2012, with nonprimary care physicians having a slightly higher acceptance rate. (Newly enrolled Medicaid recipients will be looking mainly for primary care physicians, although they also will have access to specialists.)

Physicians' acceptance rates varied widely by state. Among the states that will expand Medicaid coverage, the percentage of physicians who refused to accept new Medicaid patients ranged from 54.0% in New Jersey to 8.9% in Minnesota.

New Jersey and California were the 2 states in the Medicaid expansion group in which physicians had higher-than-average rates of refusing new Medicaid patients. Seven states had lower-than-average refusal rates, coming in at or below 17.7%: Massachusetts, Arkansas, Nebraska, New Mexico, Iowa, North Dakota, and Minnesota. The rest of the expansion states had refusal rates of 18.7% to 37.1%, a range considered near the national average.

Dr. Decker cautioned that the rate might vary by region within the state: Areas with high concentrations of new Medicaid enrollees might have fewer available physicians. She also cautioned that physician participation in Medicaid could be affected by issues surrounding the planned payment enhancement, which brings evaluation and management services and vaccine administration up to Medicare levels.

These payments are meant to lure more physicians into Medicaid to treat the expected flood of new patients. Payments were supposed to start on January 1, 2013, but because of implementation problems, they will not go into effect in some states until the fall. The payments will be retroactive for physicians who notified their state Medicaid programs by a certain deadline, but many physicians did not meet that deadline and will not receive retroactive payments.

Dr. Decker noted that because the enhanced payments end after 2014, they might not be much of an incentive anyway. She added that physicians might also stay away because some Medicaid patients have had a reputation for missing appointments.

Health Aff. 2013;32:1183-1187. Abstract

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