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Fewer Docs Taking Medicaid Compared With Other Plans

WASHINGTON — Psychiatrists’ lack of acceptance of new patients who have Medicaid is “alarming,” Sheldon Retchin, MD, MSPH, said Thursday at a meeting of the Medicaid And CHIP Payment And Access Commission (MACPAC).

“I found this very alarming, that 65% of psychiatrists do not take new Medicaid patients at a time when we just expanded Medicaid and the nation is paralyzed by substance use disorder and mental health problems,” said Retchin, who is a MACPAC commissioner and professor of medicine and public health at Ohio State University, in Columbus. “I can’t tell if this is leading to a significant barrier or an access-to-care problem for this population, but it certainly suggests that. This is really impacting this population.”

Retchin was commenting after MACPAC staff members presented research that MACPAC had contracted to find out how often physicians were accepting new Medicaid patients, and what might influence their decision. The study was performed by the State Health Access Data Assistance Center at the University of Minnesota, in Minneapolis; researchers there analyzed data from the annual National Ambulatory Medicare Care Survey (NAMCS). That survey, conducted by the National Center for Health Statistics, uses information collected from office-based physicians nationwide. Results were based on data from 1,410 physicians.

Survey researchers asked each practice whether they were currently taking new patients and, if so, which insurers they accepted payment from. The researchers found that 70.8% of respondents were taking new patients covered by Medicaid, compared with 85.3% who were taking new patients with Medicare and 90.0% who were taking new patients with private insurance. Family physicians and general medicine doctors were less likely to accept new patients with Medicaid, at 68.2%, than to accept patients with Medicare (89.8%) or private insurance (91.0%), they found. Psychiatrists had markedly lower acceptance rates: 35.7% accepted new patients with Medicaid, while 62.1% accepted new Medicare patients and 62.2% accepted new privately insured patients.

There was no difference in overall acceptance of new Medicaid patients based on the Medicaid expansion status of the state in which the physician was practicing, or based on the rate of managed care penetration in the area. The only factor that appeared to influence acceptance rates, the researchers found, was the Medicaid fee — as the Medicaid fee grew closer to the amount paid by Medicare, which reimburses at a higher rate, more physicians would accept Medicaid patients.

These results “say something about psychiatry; we just tend not to value it,” said commission member Fred Cerise, MD, MPH, of Parkland Health and Hospital System in Dallas. “That’s particularly worrisome to me.”

Some commissioners offered possible explanations for the low Medicaid acceptance rates. “In a lot of rural communities, primary care in particular is provided by nurse practitioners and physician assistants; that has to factor in here somewhere,” said commissioner Martha Carter, DHSc, CNM, founder and CEO of FamilyCare Health Centers in Scott Depot, West Virginia. As for the psychiatrists, low payment rates from Medicaid and other insurers may be one reason why psychiatry residency programs have a hard time filling their slots, she said.

Commissioner Bill Scanlon, PhD, an independent consultant in Oak Hill, Virginia, noted that managed care plans also may play a role. “How are managed care plans managing physician access? They may have strategies to say, ‘I’m going to deal with fewer physicians and get a better response rather than having it open to everybody’ … it could result in what seemingly are lower participation rates but be a deliberate strategy.”

Commissioner Kisha Davis, MD, a family physician in Gaithersburg, Maryland, noted that in her own practice, “The reason our practice takes Medicaid is because in our state there is Medicare/Medicaid [rate] parity; that was a big [impact on the] financial decision on whether or not we would take Medicaid.”

Other types of practice settings also may play a role, said commissioner Christopher “Kit” Gorton, MD, MHSA, former president of public plans at Tufts Health Plan, in Boston. “At a broader level, there might be data in the NAMCS dataset about employment … groups, employed physicians, private practice physicians. In some cases these doctors [may say], ‘I never worked for myself; I never decided which patients I took or didn’t take; somebody else decided that,'” he said. “I think that may be a [data] slice that is illuminating.”

MACPAC chairwoman Penny Thompson, MPA, a consultant from Ellicott City, Maryland, said the commission would continue working on the issue. “There have been a fair amount of good ideas for expanding on this [in an] issue brief with additional information,” she said. “We ought to think about where this takes us and some areas where we want to dive deeper, whether it is psychiatry or [other] areas we want to find out more about. Payment policy is something Medicaid agencies can do something about; workforce supply they could maybe have an impact on, although not so directly.”

One possible idea is that “if a state paid at the Medicare rate … maybe it would excuse them from doing more reporting,” Thompson said. “That may be a recommendation for scrutinizing accessibility and access, focusing on areas of the country where the payment rates are substantially below Medicare. Maybe that’s something we can give some thought to as well.”