Phantom Networks: Discrepancies Between Reported And Realized Mental Health Care Access In Oregon Medicaid

Rural-urban differences in out-of-network treatment initiation and engagement rates for substance use disorders

OBJECTIVE

To examine rural-urban disparities in substance use disorder treatment access and continuation.

DATA SOURCES AND STUDY SETTING

We analyzed a 2016-2018 U.S. national secondary dataset of commercial insurance claims.

STUDY DESIGN

This cross-sectional study examined individuals with a new episode of opioid, alcohol, or other drug use disorders. Treatment initiation and engagement rates, and rates of using out-of-network providers for these services, were compared between rural and urban patients.

DATA COLLECTION

We included individuals 18-64 years old with continuous employer-sponsored insurance.

PRINCIPAL FINDINGS

Patients in rural settings experienced lower treatment initiation rates for alcohol (36.6% vs. 38.0%, p < 0.001), opioid (41.2% vs. 44.2%, p < 0.001), and other drug (37.7% vs. 40.1%, p < 0.001) use disorders, relative to those in urban areas. Similarly, rural patients had lower treatment engagement rates for alcohol (15.1% vs. 17.3%, p < 0.001), opioid (21.0% vs. 22.6%, p < 0.001), and other drug (15.5% vs. 17.5%, p < 0.001) use disorders. Rural patients had higher out-of-network rates for treatment initiation for other drug use disorders (20.4% vs. 17.2%, p < 0.001), and for treatment engagement for alcohol (27.6% vs. 25.2%, p = 0.006) and other drug (36.1% vs. 31.1%, p < 0.001) use disorders.

CONCLUSIONS

These findings indicate that individuals with substance use disorders in rural areas have lower rates of initial and ongoing treatment, and are more likely to seek care out-of-network.

Access to Psychiatric Appointments for Medicaid Enrollees in 4 Large US Cities

This audit study examines availability of and wait times for Medicaid enrollee appointments with psychiatric prescribing clinicians across 4 of the most populous US cities.

Commercial Insurer Market Power and Medicaid Managed Care Networks

Over 70% of Medicaid beneficiaries are enrolled in Medicaid managed care (MMC). MMC provider networks therefore represent a critical determinant of access to the Medicaid program. Many MMC insurers also participate in commercial insurance markets where prices are high, and some insurers exercise considerable market power. In this paper, we examined the relationship between commercial insurer market power and MMC physician network breadth using linked national enrollment data and provider directory data. Insurers with more commercial market power had broader Medicaid physician networks. Insurers with over 30% market share had 37.3% broader Medicaid networks than insurers in the same county that had no commercial market share. These differences were driven by greater breadth among primary care providers, as well as other specialists including OB/GYNs, surgeons, neurologists, and cardiologists. Commercial insurance market power may have spillovers on access to care for MMC beneficiaries.

Inaccuracies in provider directories persist for long periods of time

A growing literature has identified substantial inaccuracies in consumer-facing provider directories, but it is unclear how long these inaccuracies persist. We re-surveyed inaccurately listed Pennsylvania providers (n = 5170) between 117 to 280 days after a previous secret-shopper survey. Overall, 19.0% (n = 983) of provider directory listings that had been identified as inaccurate were subsequently removed, 44.8% (n = 2316) of provider listings continued to show at least 1 inaccuracy, and 11.6% (n = 600) were accurate at follow-up. We were unable to reach 24.6% (n = 1271) of providers. Longer passage of time was associated with reductions in directory inaccuracies, particularly related to contact information, and to a lesser degree, with removal of inaccurate listings. We found substantial differences in corrective action by carrier. Together, these findings suggest persistent barriers to maintaining and updating provider directories, with implications for how well these tools can help consumers select health plans and access care.

Primary Care Physician Network Overlap Between Medicaid and the Patient Protection and Affordable Care Act Marketplace

This cross-sectional study quantifies Medicaid and the Patient Protection and Affordable Care Act (ACA) Marketplace overlap among primary care physicians.

Determinants of referral network size for screening colonoscopies in the Veterans Health Administration after the implementation of the MISSION Act

OBJECTIVE

To measure key characteristics of the Veterans Health Administration's (VHA) Community Care (CC) referral network for screening colonoscopy and identify market and institutional factors associated with network size.

DATA SOURCES

VHA electronic health records, CC claim data, and National Plan and Provider Enumeration System.

STUDY DESIGN

In this retrospective cross-sectional study, we measure the size of the VHA's CC referral networks over time and by VHA parent facility (n = 137). We used a multivariable linear regression to identify factors associated with network size at the market-year level. Network size was measured as the number of physicians who performed at least one VHA-purchased screening colonoscopy per 1000 enrollees at baseline.

DATA EXTRACTION

Data were extracted for all Veterans (n = 102,119) who underwent a screening colonoscopy purchased by the VHA from a non-VHA physician from 2018 to 2021.

PRINCIPAL FINDINGS

From 2018 to 2021, median network volume of screening colonoscopies per 1000 enrollees grew from 1.6 (IQR: 0.6, 4.6) to 3.6 (IQR: 1.6, 6.6). The median network size grew from 0.63 (IQR: 0.30, 1.26) to 0.92 (IQR: 0.57, 1.63). Finally, the median procedures per physician increased from 2.5 (IQR: 1.6, 4.2) to 3.2 (IQR: 2.4, 4.7). After adjusting for baseline market characteristics, volume of screening colonoscopies was positively related to network size (β = 0.15, 95% CI: [0.10, 0.20]), negatively related to procedures per physician (β = -0.12, 95% CI: [-0.18, -0.05]), and positively associated with the percent of rural enrollees (β = 0.01, 95% CI: [0.00, 0.01]).

CONCLUSIONS

VHA facilities with a higher volume of VHA-purchased screening colonoscopies and more rural enrollees had more non-VHA physicians providing care. Geographic variation in referral networks may also explain differences in the effects of the MISSION Act on access to care and patient outcomes.

Rural and frontier access to mental health prescribers and nonprescribers: A geospatial analysis in Oregon Medicaid

OBJECTIVE

Medicaid enrollees in rural and frontier areas face inadequate access to mental health services, but the extent to which access varies for different provider types is unknown. We assessed access to Medicaid-participating prescribing and nonprescribing mental health clinicians, focusing on Oregon, which has a substantial rural population.

METHODS

Using 2018 Medicaid claims data, we identified enrollees aged 18-64 with psychiatric diagnoses and specialty mental health providers who billed Medicaid at least once during the study period. We measured both 30- and 60-minute drive time to a mental health provider, and a spatial access score derived from the enhanced 2-step floating catchment area (E2SFCA) approach at the level of Zip Code Tabulation Areas (ZCTAs). Results were stratified for prescribers and nonprescribers, across urban, rural, and frontier areas.

RESULTS

Overall, a majority of ZCTAs (68.6%) had at least 1 mental health prescriber and nonprescriber within a 30-minute drive. E2SFCA measures demonstrated that while frontier ZCTAs had the lowest access to prescribers (84.3% in the lowest quintile of access) compared to other regions, some frontier ZCTAs had relatively high access to nonprescribers (34.3% in the third and fourth quartiles of access).

CONCLUSIONS

Some frontier areas with relatively poor access to Medicaid-participating mental health prescribers demonstrated relatively high access to nonprescribers, suggesting reliance on nonprescribing clinicians for mental health care delivery amid rural workforce constraints. Efforts to monitor network adequacy should consider differential access to different provider types, and incorporate methods, such as E2SFCA, to better account for service demand and supply.

Disparities in Access to Diagnostic Evaluation for Alzheimer's Disease in Individuals Dually Eligible for Medicare and Medicaid: A Modeling Study

Background

Individuals dually eligible for Medicare and Medicaid (duals) may face greater obstacles to access to disease-modifying Alzheimer's treatments in spite of their higher disease burden, because of clinicians' reluctance to accept Medicaid and the so-called "lesser of" policy, under which Medicaid may pay providers lower rates.

Objective

To project differential wait times for duals compared to Medicare-only beneficiaries by state.

Methods

We used State Medicaid payment policy and Medicare enrollment data and a Markov model to predict differential wait times for duals and non-duals from 2023 to 2050. We estimated available diagnostic appointments by state for both groups based on reluctance of clinicians to accept Medicaid and the "lesser of" policy for each year.

Results

We estimate overall average wait times of almost two years (22.9 months) but almost three times as long for duals (59.8 months) than non-duals (20.7 months) because of higher disease burden. The effects of Medicaid payment policy would increase average wait times for duals to 89 months with 20 states having wait times of 99 months or more, which would effectively deprive duals of access.

Conclusions

The added average wait times in many states would effectively deprive duals from access to treatment and translate into avoidable disease progression and mortality. Policy interventions to reduce financial and nonfinancial obstacles are dearly needed to avoid deepening disparities. Examples are coverage arrangements that integrate Medicare and Medicaid coverage, covering the co-payment for physician services in full, and stricter network adequacy requirements for Medicaid Managed Care plans.

New Opportunities to Strengthen Medicaid Managed Care Network Adequacy Standards

This Viewpoint discusses new standards proposed by the Centers for Medicare &amp;amp; Medicaid Services for ensuring that Medicare managed care networks meet enrollees’ needs.

State-Level Variation in Medicaid Managed Care Enrollment and Specialty Care for Publicly Insured Children

Importance

Medicaid and Children's Health Insurance Program cover almost 50% of children with special health care needs (CSHCN). CSHCN often require specialty services and have been increasingly enrolled in Medicaid managed care (MMC) plans, but there is a dearth of recent national studies on specialty care access among publicly insured children and particularly CSHCN.

Objective

To provide recent, nationwide evidence on the association of MMC penetration with specialty care access among publicly insured children, with a special focus on CSHCN.

Design, Setting, and Participants

This cross-sectional study used nationally representative data from the 2016 to 2019 National Survey of Children's Health to identify publicly insured children in 41 states that administered comprehensive managed care organizations for Medicaid. Data analysis was performed from May 2022 to March 2023.

Exposure

Form CMS-416 data were used to measure state-year level share of Medicaid-enrolled children who were covered by MMC (ie, MMC penetration).

Main Outcomes and Measures

Measures of specialty care access included whether, in the past year, the child had (1) any visit to non-mental health (MH) specialists, (2) any visit to MH professionals, and (3) any unmet health care needs and (4) whether the caregiver ever felt frustrated getting services for their child. Logistic regression models were used to examine the association of MMC penetration with specialty care access among all publicly insured children, and separately for CSHCN and non-CSHCN.

Results

Among 20 029 publicly insured children, 7164 (35.8%) were CSHCN, 9537 (48.2%) were female, 4110 (37.2%) were caregiver-reported Hispanic, and 2812 (21.4%) were caregiver-reported non-Hispanic Black (all percentages are weighted). MMC was not associated with significant changes in any visit to non-MH specialists and unmet health care needs. In addition, MMC penetration was positively associated with caregiver frustration among all children (adjusted odds ratio, 1.23; 95% CI, 1.03-1.48; P = .02) and was negatively associated with any visit to MH professionals among CSHCN (adjusted odds ratio, 0.75; 95% CI, 0.58-0.98; P = .04).

Conclusions and Relevance

In this cross-sectional study evaluating MMC and specialty care access for publicly insured children, increased MMC enrollment was not associated with improved specialty care access for publicly insured children, including CSHCN. MMC was associated with less access to specialties like MH and increased frustrations among caregivers seeking services for their children.

State Policy and the Breadth of Buprenorphine-Prescriber Networks in Medicaid Managed Care

Provider networks in Medicaid Managed Care (MMC) play a crucial role in ensuring access to buprenorphine, a highly effective treatment for opioid use disorder. Using a difference-in-differences approach that compares network breadth across provider specialties and market segments within the same state, we investigated the association between three Medicaid policies and the breadth of MMC networks for buprenorphine prescribers: Medicaid expansion, substance use disorder (SUD) network adequacy criteria, and SUD carveouts. We found that both Medicaid expansion and SUD network adequacy criteria were associated with substantially increased breadth in buprenorphine-prescriber networks in MMC. In both cases, we found that the associations were largely driven by increases in the network breadth of primary care physician prescribers. Our findings suggest that Medicaid expansion and SUD network adequacy criteria may be effective strategies at states' disposal to improve access to buprenorphine.

Psychiatrist Networks In Medicare Advantage Plans Are Substantially Narrower Than In Medicaid And ACA Markets

Medicare Advantage now covers twenty-eight million older adults, many of whom have mental health needs. Enrollees are often restricted to providers who participate in a health plan's network, which may present a barrier to care. We used a novel data set linking network service areas, plans, and providers to compare psychiatrist network breadth-the percentage of providers in a given area that are considered "in network" for a plan-across Medicare Advantage, Medicaid managed care, and Affordable Care Act plan markets. We found that nearly two-thirds of psychiatrist networks in Medicare Advantage were narrow (that is, they contained fewer than 25 percent of providers in a network's service area) compared with approximately 40 percent in Medicaid managed care and Affordable Care Act plan markets. We did not observe similar differences in network breadth for primary care physicians or other physician specialists across markets. Amid efforts to strengthen network adequacy, our findings suggest that psychiatrist networks in Medicare Advantage are particularly narrow, which may disadvantage enrollees as they attempt to obtain mental health services.

Ten health policy challenges for the next 10 years

Health policies and associated research initiatives are constantly evolving and changing. In recent years, there has been a dizzying increase in research on emerging topics such as the implications of changing public and private health payment models, the global impact of pandemics, novel initiatives to tackle the persistence of health inequities, broad efforts to reduce the impact of climate change, the emergence of novel technologies such as whole-genome sequencing and artificial intelligence, and the increase in consumer-directed care. This evolution demands future-thinking research to meet the needs of policymakers in translating science into policy. In this paper, the Health Affairs Scholar editorial team describes "ten health policy challenges for the next 10 years." Each of the ten assertions describes the challenges and steps that can be taken to address those challenges. We focus on issues that are traditionally studied by health services researchers such as cost, access, and quality, but then examine emerging and intersectional topics: equity, income, and justice; technology, pharmaceuticals, markets, and innovation; population health; and global health.

Medicaid Reimbursement For Psychiatric Services: Comparisons Across States And With Medicare

Medicaid is characterized by low rates of provider participation, often attributed to reimbursement rates below those of commercial insurance or Medicare. Understanding the extent to which Medicaid reimbursement for mental health services varies across states may help illuminate one lever for increasing Medicaid participation among psychiatrists. We used publicly available Medicaid fee-for-service schedules from state Medicaid agency websites in 2022 to construct two indices for a common set of mental health services provided by psychiatrists: a Medicaid-to-Medicare index to benchmark each state's Medicaid reimbursement with that of Medicare for the same set of services, and a state-to-national Medicaid index comparing each state's Medicaid reimbursement with an enrollment-weighted national average. On average, Medicaid paid psychiatrists at 81.0 percent of Medicare rates, and a majority of states had a Medicaid-to-Medicare index that was less than 1.0 (median, 0.76). State-to-national Medicaid indices for psychiatrists' mental health services ranged from 0.46 (Pennsylvania) to 2.34 (Nebraska) but did not correlate with the supply of Medicaid-participating psychiatrists. As policy makers look to reimbursement rates as one strategy to address ongoing mental health workforce shortages, comparing Medicaid payment across states may help benchmark ongoing state and federal proposals.

Early Impact of VA MISSION Act Implementation on Primary Care Appointment Wait Time

BACKGROUND

Through Community Care Networks (CCNs) implemented with the VA MISSION Act, VA expanded provider contracting and instituted network adequacy standards for Veterans' community care.

OBJECTIVE

To determine whether early CCN implementation impacted community primary care (PC) appointment wait times overall, and by rural/urban and PC shortage area (HPSA) status.

DESIGN

Using VA administrative data from February 2019 through February 2020 and a difference-in-differences approach, we compared wait times before and after CCN implementation for appointments scheduled by VA facilities that did (CCN appointments) and did not (comparison appointments) implement CCNs. We ran regression models with all appointments, and stratified by rural/urban and PC HPSA status. All models adjusted for Veteran characteristics and VA facility-level clustering.

APPOINTMENTS

13,720 CCN and 40,638 comparison appointments.

MAIN MEASURES

Wait time, measured as number of days from authorization to use community PC to a Veteran's first corresponding appointment.

KEY RESULTS

Overall, unadjusted wait times increased by 35.7 days ([34.4, 37.1] 95% CI) after CCN implementation. In adjusted analysis, comparison wait times increased on average 33.7 days ([26.3, 41.2] 95% CI, p < 0.001) after CCN implementation; there was no significant difference for CCN wait times (across-group mean difference: 5.4 days, [-3.8, 14.6] 95% CI, p = 0.25). In stratified analyses, comparison wait time increases ranged from 29.6 days ([20.8, 38.4] 95% CI, p < 0.001) to 42.1 days ([32.9, 51.3] 95% CI, p > 0.001) after CCN implementation, while additional differences for CCN appointments ranged from 13.4 days ([3.5, 23.4] 95% CI, p = 0.008) to -15.1 days ([-30.1, -0.1] 95% CI, p = 0.05) for urban and PC HPSA appointments, respectively.

CONCLUSIONS

After early CCN implementation, community PC wait times increased sharply at VA facilities that did and did not implement CCNs, regardless of rural/urban or PC HPSA status, suggesting community care demand likely overwhelmed VA resources such that CCNs had limited impact.

Maternity care clinician inclusion in Medicaid Accountable Care Organizations

BACKGROUND

Medicaid Accountable Care Organizations (ACO) are increasingly common, but the network breadth for maternity care is not well described. The inclusion of maternity care clinicians in Medicaid ACOs has significant implications for access to care for pregnant people, who are disproportionately insured by Medicaid.

PURPOSE

To address this, we evaluate obstetrician-gynecologists (OB/GYN), maternal-fetal medicine specialists (MFM), certified nurse midwives (CNM), and acute care hospital inclusion in Massachusetts Medicaid ACOs.

METHODOLOGY/APPROACH

Using publicly available provider directories for Massachusetts Medicaid ACOs (n = 16) from December 2020 -January 2021, we quantify obstetrician-gynecologists, maternal-fetal medicine specialists, CNMs, and acute care hospital with obstetric department inclusion in each Medicaid ACO. We compare maternity care provider and acute care hospital inclusion across and within ACO type. For Accountable Care Partnership Plans, we compare maternity care clinician and acute care hospital inclusion to ACO enrollment.

RESULTS

Primary Care ACO plans include 1185 OB/GYNs, 51 MFMs, and 100% of Massachusetts acute care hospitals, but CNMs were not easily identifiable in the directories. Across Accountable Care Partnership Plans, a mean of 305 OB/GYNs (median: 97; range: 15-812), 15 MFMs (Median: 8; range: 0-50), 85 CNMs (median: 29; range: 0-197), and half of Massachusetts acute care hospitals (median: 23.81%; range: 10%-100%) were included.

CONCLUSION AND PRACTICE IMPLICATIONS

Substantial differences exist in maternity care clinician inclusion across and within ACO types. Characterizing the quality of included maternity care clinicians and hospitals across ACOs is an important target of future research. Highlighting maternal healthcare as a key area of focus for Medicaid ACOs-including equitable access to high-quality obstetric providers-will be important to improving maternal health outcomes.