• Why do states control Medicaid expenditures through low reimbursement rates instead of using cost sharing? Do you think this affects the acceptance rate of Medicaid beneficiaries by health care providers?
• Why were there concerns that expanding Medicaid through the ACA would not help new Medicaid beneficiaries and would hurt existing Medicaid beneficiaries? Do you think those concerns were warranted?
• How does overall access to care for Medicaid beneficiaries compare to those with other types of insurance and the uninsured?

Physician Acceptance Of New Medicaid Patients: What Matters And What Doesnt

A key challenge for states in ensuring access to care for the 85.3 million Medicaid beneficiaries is having a sufficient number of providers. The Medicaid and CHIP Payment and Access Commission (MACPAC) recently found that higher Medicaid fees are associated with higher rates of physicians accepting new Medicaid patients. Even so, acceptance of new Medicaid patients differs across specialties.

Prior research has documented a number of factors affecting physician decisions to participate in Medicaid, including payment levels, Medicaid expansion, and use of managed care. Among these, low feesrelative to those of other payershave been consistently shown to be most important to providers. Given the many policy changes affecting Medicaid programs in recent years, including growth in use of managed care and expansion of the program in many states to non-disabled adults, we were interested in determining whether these findings remained true. Once the Affordable Care Act extended coverage to millions more people, did more physicians accept new Medicaid patients? Has the trend toward providing care via comprehensive Medicaid managed care plans increased physician acceptance rates? Do payment rates still affect provider willingness to accept patients?

While low Medicaid payment rates are the primary reason physicians indicate for lack of participation in the program, increasing payment did not always lead to increased participation. Medicaid expansion, on the other hand, has led to increases in appointment availability according to other studies, while managed care has often been shown not to increase beneficiary access to services.

MACPAC contracted with the State Health Access Data Assistance Center at the University of Minnesota to analyze the 201415 data from the National Ambulatory Medical Care Survey (NAMCS), an annual survey of nonfederal, office-based physicians. The NAMCS asks physicians if they accept new patients and, among those accepting new patients, whether they accept Medicaid as a payment source for these new patients.

Physician Acceptance Rates By Payer Source And Specialty

Among physicians accepting new patients, providers were less likely to accept new patients with Medicaid than new patients with Medicare or private insurance (Exhibit 1). A little more than one-third of psychiatrists seeing new patients accepted those with Medicaid, while almost two-thirds accepted new Medicare and privately insured patients. Physicians in general/family practice were also markedly less likely to accept new Medicaid patients than those with Medicare or private insurance.

Looking just at the group of physicians who take new Medicaid patients, we saw that pediatricians, general surgeons, and obstetrician/gynecologists (OB/GYNs) accepted new Medicaid patients at higher rates than the overall Medicaid acceptance rate.

Effects Of State Policies

We also looked at the effects of three state policies on physician acceptance of new Medicaid patients: payment rates, Medicaid expansion, and managed care.

Payment Rates

Higher payment continues to be associated with higher rates of accepting new Medicaid patients. On average, Medicaid paid 72 percent of what Medicare paid in 2016. Accordingly, physicians most commonly point to low payment as the main reason they choose not to accept patients insured by Medicaid.

We found that physicians in states that pay above the median Medicaid-to-Medicare fee ratio accepted new Medicaid patients at higher rates than those in states that pay below the median, with acceptance rates increasing by nearly 1 percentage point (0.78) for every percentage point increase in the fee ratio.

Medicaid Expansion

With Medicaid enrollment in expansion states increasing by 13.6 million people between 2013 and 2018, many raised concerns about whether enough doctors would be available to treat those newly enrolled and if there would be negative effects on those who already had Medicaid. Many studies have found that access to care did not decrease after this surge of enrollment, citing improvements in appointment availability as well as decreased wait times.

We found that there were no significant differences in overall acceptance rates following Medicaid expansion. Comparing states that expanded Medicaid to those that had not expanded as of January 1, 2015, there was no statistical difference in overall rates of accepting new Medicaid patients. An exception was that OB/GYNs accepted new Medicaid patients at higher rates in non-expansion states (89.6 percent compared to 73.9 percent).

We also looked at whether acceptance rates changed over time in expansion and non-expansion states. Among expansion states, we compared acceptance in 201213 (prior to expansion) to rates in 201415 (after they expanded). We did the same thing for the group of non-expansion states. Acceptance rates did not change over time among either group of states.

Managed Care Penetration

States are increasingly using managed care in their Medicaid programs. As of July 2016, more than two-thirds of beneficiaries were enrolled in a comprehensive managed care plan. One argument for this increased reliance on private plans is that managed care has the potential to improve physician participation, thereby improving access to care, especially as contracts often require plans to meet certain network standards.

Similar to previous studies, however, our research found that the rate of managed care in states was not associated with physicians decisions to accept new Medicaid patients.

We initially found that Medicaid acceptance in states with managed care penetration rates above the national median were lower (66.7 percent) compared to states with managed care penetration rates below the median (78.5 percent). However, once we controlled for other factors (such as the share of the state that is in poverty or uses Medicaid, how many physicians there are in the state, and the demographic characteristics of those physicians and their practices), there was no association between managed care penetration and physician acceptance of new Medicaid patients.

Moving Forward

Physicians acceptance of new Medicaid patients is only one measure of participation in the Medicaid program. Acceptance of new Medicaid patients does not tell us how many new patients will be accepted nor does it account for the number of Medicaid patients already in the physicians care. Even when physicians accept new patients, making an appointment may be difficult, and the wait times may be substantial.

In addition, Medicaid beneficiaries may be receiving care from other clinicians (for example, physician assistants, nurse practitioners, and clinical social workers) and in settings other than physician offices, such as community health centers, that are not captured in these data.

It is important to note that despite low physician participation in Medicaid, beneficiaries are still receiving services. Compared to individuals without insurance, Medicaid enrollees reported substantially better access to care, including having a usual source of care, visiting a physician in the past year, and having fewer delays in receiving care. Medicaid access was comparable to private insurance for certain measures, such as having a usual source of care and having an outpatient visit. Adults with Medicaid also reported delaying care at rates similar to rates among adults with employer-sponsored coverage, but their reasons for delaying care differed significantly. For example, Medicaid beneficiaries reported delaying care at higher rates than those with employer-sponsored insurance due to a lack of transportation, while those with employer-sponsored insurance delayed care at higher rates because of out-of-pocket costs.