Build primary care capacity now for Medicaid's new eligibles, expert says

When you consider the newly eligible population coming onto your state's Medicaid program in 2014, remember that "those 32 million people out there are already being seen somewhere. They are being seen by a range of safety net providers," says Georges C. Benjamin, MD, FACP, FNAPA, FACEP(E), executive director of the American Public Health Association in Washington, DC.

Some are getting great care, some are getting little or no primary care, while others are being seen for episodic care only in emergency departments, says Dr. Benjamin. "The important point is that many of those 32 million people are probably being seen in the most inefficient manner possible," he says.

With that in mind, says Dr. Benjamin, state Medicaid directors need to take a good, comprehensive look at what the program's primary care capacity actually is. "If we just let the market do it, it won't work," he says. "You have to do some serious planning and work in a proactive way with the medical and nursing community."

Address maldistribution

Dr. Benjamin recommends working with the state's medical, nursing and physician's assistant schools to build capacity. Maldistribution is a problem both in the nation and within states, he says, and can be addressed with incentives such as reimbursement policies or scholarships.

Some practitioners cap the number of Medicaid patients they will accept due to poor reimbursement, notes Dr. Benjamin. "It's obviously better financially to have a person in a private plan that is going to pay more, than someone in Medicaid or Medicare," he says. "By increasing reimbursement for the primary care providers in public plans, they can offset some of that."

Reducing payment delays and required paperwork can help prevent the "churning" of patients, says Dr. Benjamin. "One of the challenges we have in the Medicaid program today is the patients who go on and off the rolls," he says. "That not only involves the patient, it also impacts the physician when the patient shows up, and they are no longer in the program but actually are still eligible. That affects reimbursement."

There also is no reason why a patient's cardiologist, pulmonologist, or endocrinologist could not be designated as the patient's primary care practitioner in selected cases, according to Dr. Benjamin. He gives the example of a patient with severe heart disease, mild diabetes, and mild pulmonary disease, whose major problem is cardiovascular.

"You have to look at the fact that the patient probably spends more time in the cardiologist's office than they ever would spend in their primary care physician's office," he says.

Absorbing additional patients

Dr. Benjamin notes that as a result of Massachusetts' implementation of health care reform, the volume of patients seen in Federally Qualified Health Centers (FQHCs) in the state grew. "Not only has their reimbursement gotten better, because they get paid for many patients they weren't getting paid for before, but they also have a really phenomenal capacity to grow and expand," he says.

With good management and continued fiscal support, says Dr. Benjamin, FQHCs can continue to absorb additional numbers of patients.

"I'm not saying we don't have a physician shortage, or that it won't be a problem going forward," says Dr. Benjamin. "But I don't think we should let it become an excuse for not covering people. All we are really doing is creating a system where people are getting seen in a more efficient way."

The most important thing for state Medicaid directors to do right now, advises Dr. Benjamin, is to sit down with other health planners in the state, including medical and nursing societies. "Get a good feel for where people are really being seen today, and how that might change in an environment where everyone has an insurance card," he says. "The assumptions are often not obvious."

Link patients to services

Dr. Benjamin says that in his former role as Secretary of the Maryland Department of Health and Mental Hygiene, there were some significant barriers to getting practitioners into the health plan when the state switched to mandatory Medicaid. "We had to work very hard to get all of their providers into an acceptable health plan. It required a proactive approach to do that," he says.

A large percentage of Medicaid patients was already being seen in the state's mental health system, says Dr. Benjamin, and were receiving their primary care and episodic health services inefficiently.

These Medicaid patients were relatively young and healthy, says Dr. Benjamin, but they had a significant mental health problem that needed to be addressed. "You've got to sit back and look at where everybody is being taken care of," he says. "Sometimes, you have to craft new systems to take care of them."

Other times, says Dr. Benjamin, it's a matter of linking patients to existing services. "You may need to create wraparound services or provide case managers so these folks can get their appointments and be seen," he says. "The public health system is very good at doing that."

Contact Dr. Benjamin at (202) 777-2742 or georges.benjamin@apha.org.