Market environment and Medicaid acceptance: What influences the access gap?

Medicaid prevalence and opioid use disorder treatment access disparities

OBJECTIVE

To examine how variation in the size of the local Medicaid population moderates Medicaid-to-private treatment access differentials for women with opioid use disorder (OUD).

DATA SOURCES

County-level information on total Medicaid enrollment combined with randomized field experiment data from 10 diverse states that used a simulated patient (audit) methodology to examine buprenorphine providers' appointment granting behavior.

STUDY DESIGN

We used multiple regression modeling approaches to capture the moderating influence of Medicaid prevalence on differences in the likelihood of receiving an insurance-covered appointment between Medicaid and privately insured female patients.

DATA EXTRACTION

Completed calls to buprenorphine treatment providers.

PRINCIPAL FINDINGS

We find a 0.37 percentage point (p value <0.01) narrowing of the Medicaid-to-private access gap with each one percentage point increase in the local insured population on Medicaid. There is effectively no difference in the likelihood of being granted an insurance-covered appointment across the two payer groups in the top tercile of Medicaid penetration.

CONCLUSIONS

When Medicaid is a common source of insurance within the local population, buprenorphine providers are much less likely to discriminate between Medicaid and privately insured prospective patients. Efforts to enhance equitable access across patient groups are perhaps best targeted where Medicaid prevalence is lower.

Association between physician practice Medicaid acceptance and employing nurse practitioners and physician assistants: A longitudinal analysis

BACKGROUND

Access to care is often a challenge for Medicaid beneficiaries due to low practice participation. As demand increases, practices will likely look for ways to see Medicaid patients while keeping costs low. Employing nurse practitioners (NPs) and physician assistants (PAs) is one low-cost and effective means to achieve this. However, there are no longitudinal studies examining the relationship between practice Medicaid acceptance and NP/PA employment.

PURPOSE

The purpose of this study was to examine the association of practice Medicaid acceptance with NP/PA employment over time.

METHODS

Using SK&A data (2009-2015), we constructed a panel of 102,453 unique physician practices to assess for changes in Medicaid acceptance after newly employing NPs and PAs. We employed practice-level fixed effects linear regressions.

RESULTS

Our results showed that, among practices employing both NPs and PAs, there was a roughly 2% increase in the likelihood of Medicaid participation over time. When stratifying our sample by practice size and specialty, the positive correlation localized to small primary care and medical practices. When both NPs and PAs were present, small primary care practices had a 3.3% increase and small medical practices had a 6.9% increase in the likelihood of accepting Medicaid.

CONCLUSION

NP and PA employment was positively associated with increases in Medicaid participation.

PRACTICE IMPLICATIONS

As more individuals gain coverage under Medicaid, organizations will need to decide how to adapt to greater patient demand. Our results suggest that hiring NPs and PAs may be a potential lower cost strategy to accommodate new Medicaid patients.

Treatment flows after outsourcing public insurance provision: Evidence from Florida Medicaid

While politics can determine what public goods are available, elected officials must decide on the method of allocation. Commonly, governments provide public health insurance directly or pay private parties to administer it on their behalf. Such contracting can leverage private sector expertise but also raises agency concerns. In particular, little is known about how private provision of public health insurance impacts medical decision-making and treatment flows for low-income populations. An example comes from the Medicaid program, which has increasingly relied on outside insurers to deliver health services to enrollees. We exploit a large legislative intervention in Florida to show that Medicaid managed care (MMC) organizations generally do not skimp on short-run treatment delivery in the inpatient setting. In fact, patients with severe and chronic illnesses receive more inpatient services under these contracts, especially in relation to managing care transitions. We also document increased competition in the MMC market following the state's policy intervention.

Geographic location of buprenorphine-waivered physicians and integration with health systems

Efforts are underway to expand buprenorphine treatment for opioid use disorder (OUD) in hospitals and affiliated health systems, yet we do not know whether physicians who prescribe buprenorphine are likely to be health-system affiliated. Our study draws upon SK&A data covering primary care physicians and psychiatrists in eight states (California, Florida, Georgia, Maryland, Ohio, Rhode Island, Wisconsin, and West Virginia), which were linked to a list of waivered buprenorphine prescribers from the U.S. Drug Enforcement Agency. We calculated waivered rates stratified by patient limits, physician type, health system affiliation, and area-level characteristics. We mapped the spatial relationship between hospitals and waivered physicians in four metro areas. We found that primary care physicians affiliated with hospital health systems were less likely to have waivers than unaffiliated physicians (3.6% versus 8.2%), but the reverse was true for psychiatrists (33.2% versus 26.2%). Waivered physicians affiliated with health systems were less likely to practice in high-poverty areas than unaffiliated counterparts, and affiliated physicians were also more likely to cluster near hospitals. Health systems may be able to improve access to buprenorphine treatment in their communities by creating either incentives or mandates for more affiliated physicians to obtain a waiver.

Primary Care Appointments for Medicaid Beneficiaries With Advanced Practitioners

Primary care access in Medicaid improved after the Patient Protection and Affordable Care Act despite millions of new beneficiaries. One possible explanation is that practices are scheduling more appointments with advanced practitioners. To test this theory, we used data from a secret shopper study in which callers simulated new Medicaid patients and requested appointments with 3,742 randomly selected primary care practices in 10 states. Conditional on scheduling an appointment, simulated patients asked whether the practitioner was a physician or advanced practitioner. From 2012 through 2016, the proportion of appointments scheduled with advanced practitioners increased from 7.7% to 12.9% (P <.001) across the 10 states.

Racial and Ethnic Differences in Medicaid Acceptance by Primary Care Physicians: A Geospatial Analysis

Physician acceptance is an important dimension of access to care, especially for Medicaid patients. We constructed two new measures to quantify primary care physician (PCP) acceptance of Medicaid patients using geocoded Virginia physician addresses and population data and geospatial methods. For each Census block group, we measured the shares of "accessible PCPs" accepting any Medicaid patients or new Medicaid patients. Accessible PCPs were defined as those located within 30-minute travel from patient locations and patient locations were proxied by Census block group geographic centroids. We found that the shares of accessible PCPs accepting Medicaid varied within Virginia, and were significantly lower in urban communities where larger fractions of the population were Hispanic, even controlling for unobserved market-level traits associated with Medicaid acceptance. Policy makers and Medicaid program officials should continue to improve nonfinancial access to primary care, especially by addressing access barriers in communities with high shares of minority residents.