The Doctor Won’t See You Now
Provider access is a major challenge for Medicaid patients
https://www.medpagetoday.com/opinion/second-opinions/105876
Patients are increasingly alarmed by the health workforce shortages delaying care, reducing access, and in some cases harming patient safety and quality of care.
Policymakers usually rely on provider counts to estimate and address shortage areas. However, we know that not all providers accept all types of insurance.
More specifically, the greatest shortfall of available providers is experienced by some of the poorest and sickest among us. Nearly 94 million people are covered by Medicaid, and secret shopper studies and physician reported surveys show that doctors are less likely to accept patients with Medicaid compared to those with private insurance or even Medicare.
We know that simply having health insurance is not enough; we also need more healthcare providers willing to see Medicaid patients.
Newly available Medicaid claims data (T-MSIS) now allow us to systematically track providers that serve Medicaid patients, as well as those that don’t. The data on primary care providers is displayed on our Medicaid Primary Care Workforce Tracker, where consumers can view trends over time, by specialty type, at a national, state, and county level.
As we report in the forefront section of the journal Health Affairs, the Tracker reveals a mix of good and bad news for Medicaid patients across the nation. In 2019, the percent of primary care physicians who provided any appreciable care to Medicaid patients — seeing just 11 or more patients over the year — ranged from 84% in Wisconsin to as low as 61% in New Jersey, suggesting the variability in state Medicaid policies matters a great deal.
Overall, the number of any type of primary care provider who saw Medicaid patients rose 13% from 2016 to 2019. However, advanced practice nurses and physician assistants made up 95% of the increase. The increase in physicians was only 1%, and the number of ob/gyns seeing Medicaid patients actually dropped 2.5% over the 3-year period, with 24 states losing ob/gyns accepting Medicaid over this period.
In 2019, 44% of U.S. counties had no Medicaid ob/gyns at all. Given that access to pre- and post-natal care can prevent life-threatening complications, this statistic translates to women dying in childbirth and other shameful health outcomes.
Thirteen states also saw a loss of Medicaid family medicine physicians, 21 states saw a loss of Medicaid internal medicine physicians, and 11 states saw a loss of Medicaid pediatricians.
There are many reasons healthcare providers and practices refuse or limit Medicaid patients. Across the U.S., state Medicaid programs pay on average 72% the rate of Medicare, and on top of the low pay, many providers cite other barriers to participation including loads of paperwork.
The federal government does require states to establish access standards for Medicaid managed care programs. However, enforcement by state agencies is variable and historically, there has been little oversight
In 2020, CMS issued a rule requiring states to develop quantitative network adequacy standards. Earlier this year, the Biden-Harris administration proposed new rules to establish national standards for appointment wait times and to require states to conduct secret shopper surveys to verify state compliance. These are important steps forward, but will require vigilance to ensure enforcement.
Overall health workforce shortages also limit the number of providers Medicaid may draw from. These shortages are only getting worse due to burnout and moral injury. In communities with too few resources, there are too few healthcare providers. It’s always those with the least who suffer the most.
During the COVID-19 pandemic, health workforce programs saw increasing investments. Programs like the National Health Service Corps — which places primary care and mental health providers in underserved settings in exchange for loan repayment — and the Teaching Health Centers program — which supports community-based physician and dental residency training programs — received American Rescue Plan Act funding. The federal government and states passed emergency policies to support telehealth and to allow advanced practice nurses and physician assistants to practice at their full scope. However, with the end of the COVID-19 public health emergency and the recent debt ceiling deal claw-back of unspent COVID relief funds, these programs are at risk again.
Among the lessons of COVID-19 is the importance of caring for America’s essential workers who keep our society functioning. These workers are often poorly paid and therefore rely on programs like Medicaid. It was also this population that (on top of pre-existing disparities) faced the brunt of COVID illness and death.
To ensure access to healthcare for women, children, essential workers and others, we need more providers willing to see Medicaid patients. Policymakers can help make that happen with better pay and a reduction in the administrative burdens associated with the program.
Such action would be a small price to pay for a healthier population — and a much stronger workforce.
Patricia Pittman, PhD, is the director of the Fitzhugh Mullan Institute for Health Workforce Equity, which is based at the George Washington University Milken Institute School of Public Health, and a professor of health policy and management. Candice Chen, MD, MPH, is a member of the Mullan Institute, and an associate professor of health policy and management at the George Washington University and a board-certified pediatrician.
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