Psychiatrists' Acceptance of Medicaid Patients Remains Low

Megan Brooks

June 06, 2019

Medicaid expansion hasn't led to improved access to office-based mental healthcare. On the contrary, a new trends analysis shows declines in psychiatrists' participation in Medicaid.

"Owing to declines in psychiatrist participation in Medicaid, patient gains in insurance coverage under Medicaid expansion may not translate into meaningful improvements in access to office-based treatment by psychiatrists," the investigators write.

The data are concerning, first author Hefei Wen, PhD, assistant professor, Department of Health Management and Policy, University of Kentucky College of Public Health, Lexington, told Medscape Medical News.

"Medicaid expansion can only effectively improve access to care for the newly enrolled where there are physicians willing to accept Medicaid patients. Our findings amplify concerns over significant deficits in access to mental health services for low-income and other vulnerable populations, even when they have Medicaid coverage," said Wen.

The study was published online June 5 in JAMA Psychiatry.

Chief Payer

Medicaid is the chief payer for behavioral health services in the United States and has been expected to play an increasing role in financing behavioral health services with Medicaid expansion. Yet little is known about recent trends in psychiatrists' acceptance of Medicaid, both before and after 2014, when most Medicaid expansions under the Affordable Care Act (ACA) went into effect.

To investigate, Wen and colleagues analyzed data from 2010–2015 from the National Ambulatory Medical Care Survey (NAMCS), a nationally representative survey of physicians who were not federally employed, were based in offices, and were primarily engaged in direct patient care.

They compared differences in trends in physician acceptance of new Medicaid patients for psychiatrists, primary care physicians (PCPs), and other nonpsychiatric specialists during three 2-year periods, 2010–2011, 2012–2013, and 2014–2015.

During the study periods, 11,521 NAMCS respondents (95% of the total sample) reported seeing new patients. These respondents included 584 psychiatrists, 4400 PCPs, and 6537 other specialists.

During each period examined, psychiatrists were less likely than PCPs and other specialists to accept new patients with Medicaid. Also, there was a significant decline in the likelihood of psychiatrists accepting new Medicaid patients. No significant change in Medicaid acceptance was found among PCPs or other specialists.

Accepting New Medicaid Patients 2010–2011 2012–2013 2014–2015
Psychiatrists 47.9% 44.9% 35.4%
PCPs 75.8% 71.7% 71.3%
Other specialists 77.0% 73.2% 73.3%

The authors say the adjusted difference-in-differences estimates suggest Medicaid expansion has not been associated with a discernible change in the likelihood of accepting new Medicaid patients among psychiatrists or PCPs but has been associated with an increase in Medicaid acceptance among other specialists.

Need for Better Incentives

Commenting on the analysis, Sandra Decker, PhD, a senior fellow from the Agency for Healthcare Research and Quality, Rockville, Maryland, said, "It is fairly well known that not too many psychiatrists accept Medicaid (or other insurance for that matter). Not sure I completely understand why ACA might be expected to affect that, but I guess it never hurts to draw attention to the fact that acceptance of Medicaid among psychiatrists is low."

Wen said policy makers may need to identify strategies that will "incentivize psychiatrists to participate in Medicaid, which may be critical for translating expanded coverage into meaningful improvements in access to mental health services."

One promising approach, she said, may be to encourage care coordination, such as collaborative chronic care models (CCMs), in mental health services.

"CCMs rely on primary care physicians to provide mental health services, with support from case managers and consultation from psychiatrists and other behavioral health specialists. Such models make more efficient use of psychiatrists' time by allowing psychiatrists to assist primary care teams with expert input and decision support while allocating direct care hours to patients with the most complex psychiatric care needs," said Wen.

Additionally, the ACA's provision regarding state innovation models promotes state initiatives such as Medicaid health homes, which may facilitate the development of team-based stepped-care approaches such as CCMs and help address the overall shortage and declining Medicaid participation of psychiatrists, said Wen.

The study received no specific funding. Wen and Decker have disclosed no relevant financial relationships.

JAMA Psychiatry. Published online June 5, 2019. Abstract

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