Medicaid Fee Bump Did Not Increase Primary Care Participation

Diana Phillips

July 19, 2018

Physician participation in the Medicaid program was largely unaffected by Affordable Care Act–mandated payment increases to primary care providers or the expanded access programs established in some states, according to the findings of two studies reported in the July issue of Health Affairs.

In one study, Sandra L. Decker, PhD, senior fellow in the Agency for Healthcare Research and Quality's Division of Research and Modeling, Center for Financing, Access, and Cost Trends, Rockville, Maryland, examined the association between physician-reported measures of Medicaid participation and the Medicaid "fee bump," the Affordable Care Act requirement that states raise Medicaid payment rates for certain primary care services to the level of Medicare rates.

The fee increase was fully funded by the federal government from January 1, 2013, through December 31, 2014. Although the increase was not mandatory after 2014, some states elected to maintain it.

Using data from the National Electronic Health Records Survey, an annual, cross-sectional, nationally representative survey of physicians, Decker found no significant change in participation rates between 2012 and 2015. In 2012, before the fee increase, 65.1% of responding primary care physicians reported accepting new Medicaid patients, as did 67.3% in 2014, after the increase.

Becker notes that the results are consistent with prior studies and that the lack of increased participation may reflect the temporary nature of the increases. "Accepting new patients for whom payment levels were expected to decline to two-thirds of Medicare rates in 2015 could have been perceived as a less attractive option than a permanent increase," she writes.

There were a number of trends that remained consistent through the study period:

  • Pediatricians were more likely to report accepting new Medicaid patients (83.3% in 2011; 83.0% in 2014) compared with general or family practice physicians (60.2% in 2011 and 67.0% in 2014), whereas internists were less likely to do so (55.4% in 2011; 56.7% in 2014), although the differences were not significant.

  • Specialists were more likely than primary care physicians to report accepting new Medicaid patients (71.2% vs 64.3% in 2011; 72.4% vs 67.3% in 2014).

  • Primary care physicians reported a higher rate of acceptance of patients with Medicare (81.1% in 2011; 84.7% in 2014) or private insurance (87.9% in 2011l; 89.1% in 2014) compared with patients with Medicaid.

Across the study period, the percentage of physicians reporting that more than 1% of their patients were on Medicaid (75.3% in 2011 and 79.8% in 2014) was higher than the percentage reporting current acceptance of new Medicaid patients (64.3% in 2011 and 67.3% in 2014).

"While physician-reported acceptance of new Medicaid patients was higher in states that had had higher Medicaid-to-Medicare fee ratios, compared to those with lower ratios before the 2013–14 Medicaid primary care fee bump, the bump was not significantly associated with the overall acceptance rate or the percentages of primary care physicians' patients on Medicaid," Becker writes.

Physicians' response to the 2014 expansion of eligibility for Medicaid under the Affordable Care Act was similarly unremarkable, with most physicians maintaining or only slightly increasing their Medicaid participation and most Medicaid patients remaining concentrated among relatively few physicians, report Hannah T. Neprash, PhD, assistant professor of Health Policy and Management at the University of Minnesota School of Public Health, Minneapolis, and colleagues in a separate article published at the same time.

Using national claims-based data, the authors studied the distribution of Medicaid patients across primary care physicians before and after the 2014 Medicaid expansion and observed a slight but significant increase in the proportion of Medicaid patients in the average primary care physician's patient population.

The study sample included 3820 primary care physicians, approximately half of whom practiced in one of the states that expanded Medicaid eligibility in 2014. Medicaid participation was calculated on the basis of the annual count of distinct adult patients, ages 18 to 64 years, with Medicaid as their primary insurer, divided by the number of all distinct patients treated annually.

"Overall, primary care physicians increased their participation in Medicaid by 1.6 percentage points, with adult Medicaid patients accounting for 7.8 percent of the average primary care physician's panel in 2013 and 9.4 percent in 2015," the authors report. They note that the change was attributable to the 3.4 percentage point increase in Medicaid participation among physicians in expansion states. "We found no significant change in the proportion of Medicaid patients seen by primary care physicians in nonexpansion states," they write.

Medicaid participation before and after the expansion was highly concentrated, the authors explain. "In 2013, before expansion, about nine in ten primary care physicians nationwide treated at least one adult Medicaid patient. However, adult Medicaid patients represented less than 5 percent of the patient panel for half of the physicians in our sample," the authors explain. "Adult Medicaid patients represented more than 20 percent of the patient panel for one in ten physicians in our sample."

Although the number of adult Medicaid patients increased by approximately 20% from 2013 to 2015, these patients remained concentrated among a small number of primary care physicians, the authors report, noting that approximately 60% of them were treated by 20% of the physicians who participated in Medicaid. "This suggests that greater demand for primary care among newly insured Medicaid patients was accommodated by a small group of physicians with high proportions of Medicaid patients," they write.

In 2015, 72% of primary care physicians in nonexpansion states and 60% of those in expansion states maintained their 2013 level of Medicaid participation. However, physicians in nonexpansion states who did not maintain their participation levels were more likely to decrease participation, whereas those in expansion states were more likely to increase participation, the authors observe.

When they analyzed participation trends among pediatricans, "we found that Medicaid patients represented a much larger share of pediatricians' panels than of other primary care physicians' panels, with few differences by state expansion status or over time," the authors write.

A separate analysis comparing participation rates among primary care physicians in early (before 2014) and late (after 2014) Medicaid expansion states, those in early expansion states showed increases in participation similar to those in states that expanded Medicaid in 2014, whereas smaller increases were seen among those in late expansion states.

The fact that most primary care physicians made no or only slight changes to their Medicaid participation despite the influx of millions of newly Medicaid-covered patients across the country may be a reflection of low reimbursement rates, administrative burdens, or other considerations that make participation difficult or unappealing, the authors suggest. In addition, the observation that the largest increases in Medicaid participation were among primary care physicians who were participating in Medicaid before the expansion suggests "policy efforts to increase access to primary care services for Medicaid recipients may be most successful by targeting existing Medicaid providers," the authors conclude.

Research for the Neprash study was supported by a grant from the Robert Wood Johnson Foundation. The authors have disclosed no relevant financial relationships.

Health Aff. 2018;37(7):1087-1098. Decker abstract, Neprash abstract

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