D ATA D R I V E N . P O L I C Y F O C U S E D LDI ResearchBRIEF Research to Improve the Nation’s Health System 2017 . No. 10 DECLINING MEDICAID FEES AND PRIMARY CARE APPOINTMENT AVAILABILITY FOR NEW MEDICAID PATIENTS Molly Candon, Stephen Zuckerman, Douglas Wissoker, Brendan Saloner, Genevieve M. Kenney, Karin Rhodes, Daniel Polsky JAMA Internal Medicine, published online November 13, 2017. doi:10.1001/jamainternmed.2017.6302 KEYFINDINGS Primary care appointment availability for new Medicaid patients declined when Medicaid fees for providers decreased after the ACA-mandated “fee bump” expired. THE QUESTION between 2012 and 2014 to estimate the effect of the increase in fees. We repeated the analyses between 2014 and 2016 to estimate the effect of Medicaid reimburses physicians at a lower rate and fewer physicians the fee bump’s removal, partial removal, or retention. participate in Medicaid when compared to other insurance types. To encourage provider participation in Medicaid, the Affordable Care Act (ACA) increased Medicaid fees to Medicare levels for primary care providers in 2013 and 2014. As expected, the bump in fees resulted in THE FINDINGS an increase in primary care appointment availability for new Medicaid The average Medicaid fee for a new patient office visit increased from patients, with larger increases occurring in states with larger increases in $68.58 in 2012 to $107.38 in 2014 and decreased to $75.67 in 2016. fees. Despite the improvements in access, most states returned to lower Similarly, the appointment availability rate increased from 56.2 percent to reimbursement rates in 2015. The question is: did the gains in access in 65.5 percent, then fell to 61.5 percent. Except for Iowa and Oregon, each Medicaid erode once fees declined? state followed a similar pattern. Overall, we found that a $10 decrease in payments was associated with a 1.7 percentage point decline in We conducted a study in which callers simulated new patients with appointment availability (95% CI, 1.2 to 2.1; P < .001). Providers’ responses Medicaid and requested appointments from thousands of randomly- to the initial increase in fees did not differ significantly from their response sampled primary care physicians across ten states before the fee to the eventual decrease in fees. bump was fully introduced (2012 and early 2013) and again during its implementation (2014) and after the Medicaid fee bump expired (2016). Since these results may be driven by other changes during this period, We assessed the appointment availability rate, i.e., the percent of requests we also looked at appointment availability for the privately insured, which that resulted in a scheduled appointment. We used state-level Medicaid is unlikely to be driven by Medicaid reimbursement rates. Indeed, there fees to primary care providers for a level 3 new patient office visit, then was no relationship between changes in Medicaid fees and changes in measured the changes in fees and changes in appointment availability appointment availability for patients with private coverage. COLONIAL PENN CENTER | 3641 LOCUST WALK | PHILADELPHIA, PA 19104-6218 | LDI.UPENN.EDU | P: 215-898-5611 | F: 215-898-0229 | @PENNLDI ResearchBRIEF LDI MEDICAID NEW PATIENT VISIT FEES AND PRIMARY CARE APPOINTMENT AVAILABILITY, BY STATE Large Change in Fees (>$40) Medium Change in Fees ($20-$40) Small Change in Fees (<$20) IL AR IA $125 100% $125 100% $125 100% $100 85% $100 85% $100 85% $75 70% $75 70% $75 70% $50 55% $50 55% $50 55% $25 40% $25 40% $25 40% $0 25% 2012 2014 2016 $0 25% $0 25% 2012 2014 2016 2012 2014 2016 NJ $125 OR 100% MT $125 100% $125 100% $100 85% $100 85% $100 85% $75 70% $75 70% $75 70% $50 55% $50 55% $50 55% $25 40% Average $25 40% $25 40% $0 25% $0 25% 2012 2014 2016 $0 25% 2012 2014 2016 2012 2014 2016 $125 100% PA MA $125 100% $125 $100 100% 85% $100 85% $100 85% $75 70% Medicaid Fee ($) $75 70% $75 70% $50 55% $50 55% $50 55% Appointment $25 40% $25 40% Availability (%) $0 25% $0 $25 25% 40% 2012 2014 2016 2012 2014 2016 $0 25% TX GA2012 2014 2016 Average $125 100% $125 100% $125 100% $100 85% $100 85% $100 85% $75 70% $75 70% $75 70% $50 55% $50 55% $50 55% $25 40% $25 40% $25 40% $0 25% $0 25% $0 25% 2012 2014 2016 2012 2014 2016 2012 2014 2016 NOTES: Data collection in 2012 extended into 2013. Federally qualified health centers are excluded. Analyses are weighted at the county level to ensure the distribution of calls by insurance type matched the distribution of individuals by insurance type. Weights are scaled so that each state contributes equally to cross-state averages. THE IMPLICATIONS practices may have allowed physicians to care for more patients by relying on other health care personnel, while other trends such as increased data These results suggest that many of the gains in appointment availability sharing and retail clinics may have further expanded capacity. for new Medicaid patients associated with higher Medicaid fees were lost when the fee bump expired. Despite the end of the fee bump, Yet a large gap in access to primary care between Medicaid patients appointment availability in Medicaid was 5.4 percentage points higher in and the privately insured remains. With the possibility of a restructured 2016 than in 2012, suggesting that other changes to primary care delivery Medicaid program on the horizon, some are anticipating a reduction had a positive influence on physician participation in Medicaid. For of federal funding for Medicaid. If the financial burden faced by states instance, Illinois and Iowa shifted to capitated Medicaid managed care for worsens, it will likely place additional downward pressure on Medicaid non-disabled beneficiaries, while the ACA promoted patient-centered fees. Unfortunately, our findings suggest that an erosion of access to medical homes in Medicaid. A growing trend toward team-based primary care in Medicaid would follow. ResearchBRIEF LDI THE STUDY CITATIONS In the audit study, we measured appointment availability at primary care Polsky D, Candon M, Saloner B, Wissoker D, Hempstead K, Kenney practices in Arkansas, Georgia, Illinois, Iowa, Massachusetts, Montana, GM, Rhodes K. Changes in Primary Care Access between 2012 and New Jersey, Oregon, Pennsylvania, and Texas in three time periods: 2016 for New Patients with Medicaid and Private Coverage. JAMA before the fee bump (late 2012 and early 2013), during its implementation Internal Medicine. 2017, 177(4). DOI: 10.1001/jamainternmed.2017.6302 (2014), and after its expiration in most states (2016). Scripted staff posed as new patients with Medicaid and called in-network primary care practices with at least one physician who served working-age adults. A Polsky D, Richards M, Basseyn S, Wissoker D, Kenney GM, Zuckerman pre-audit survey and provider directories identified insurance carriers S, Rhodes KV. Appointment Availability after Increases in Medicaid for Medicaid calls, as plan names vary across carriers participating in Payments for Primary Care. New England Journal of Medicine. 2015, 373. Medicaid managed care. The practices receiving calls were representative DOI: 10.1056/NEJMsa1413299 of primary care offices serving working-age adults. ACKNOWLEDGEMENT Callers were trained staff with voices that varied by age, sex, race, and This study was conducted by a multiinstitutional investigative team ethnicity. They were also randomly assigned to a routine check-up or from University of Pennsylvania’s Leonard Davis Institute, Urban newly-diagnosed untreated hypertension. Callers requested the earliest appointment available with a randomly selected physician within the Institute, Johns Hopkins University, and Northwell Health. practice, but would accept an appointment with other providers, including nurse practitioners and physician assistants. A successful appointment required a specific date and time, even if the caller was told that the appointment could be scheduled pending additional information. All appointments were cancelled at the end of the call or immediately thereafter. If the appointment process could not be completed, often ABOUT LDI because scheduling software required an insurance number, the calls were excluded from the analysis. Since 1967, the Leonard Davis Institute of Health Economics (LDI) has been the leading university institute dedicated to data-driven, We face some limitations. Since this audit was restricted to in-network policy-focused research that improves our nation’s health and health offices, we were unable to document changes in the size of Medicaid care. Originally founded to bridge the gap between scholars in networks, nor could we assess whether changes in Medicaid fees affected business (Wharton) and medicine at the University of Pennsylvania, access for established patients, the elderly, or children. Some data LDI now connects all of Penn’s schools and the Children’s Hospital of collection in the first wave occurred in early 2013 when the fee bump was Philadelphia through its more than 250 Senior Fellows. first implemented, which may attenuate results. Finally, we only include LDI Research Briefs are produced by LDI’s policy team. For more 10 states and 27% of the national nonelderly population; while states were information please contact Janet Weiner at weinerja@mail.med.upenn.edu. selected to provide geographic, demographic, and health care-related variation, our results may not be generalizable to other states. LEAD AUTHOR MOLLY CANDON, PhD Molly Candon, PhD is a postdoctoral fellow at the Leonard Davis Institute of Health Economics and Center for Mental Health Policy and Services Research and a lecturer of Health Care Management at the University of Pennsylvania. Her research is focused on access to primary and mental health care and the implementation of evidence-based prescribing.