Signs of improved access to Medicaid providers

With an estimated 16 million additional Americans coming onto the Medicaid program as of 2014, having enough providers to ensure good access to care is certainly a legitimate concern. However, Judy Solomon, a senior fellow specializing in Medicaid and the Children's Health Insurance Program at the Washington, DC-based Center on Budget and Policy Priorities, says that "a couple of things raise my hopes."

First, reimbursement for certain primary care services will be increased to Medicare rates. This will be fully funded by the federal government. "Hopefully that will set the stage for having more provider participation," says Ms. Solomon. "Since that kicks in in 2013, the hope is that provider panels will be expanded in advance of 2014."

Secondly, there are substantial increases in funding for community health centers, both in the stimulus package and the health reform legislation. "That will help them to expand and do some of the brick and mortar work needed to increase capacity," says Ms. Solomon.

Impact of provider cuts

Interestingly, despite some significant provider rate cuts, many Medicaid programs are not seeing marked increases of problems with their beneficiaries accessing care. Ms. Solomon says this is likely due to the type of providers who received cuts. "My sense is that states tend to look at institutional providers like hospitals and nursing homes, and sometimes home health," she says.

Instead of making cuts to rates of primary care providers, states were more likely to eliminate optional services altogether, such as dental coverage for adults. "A number of states have done this rather than cut the rates. The reason for that is there is not much margin to begin with. There is just not much money to be saved there," says Ms. Solomon. "You can only go so low."

While fewer people use hospital and nursing home care, these services are more costly, so states saw an opportunity for substantial savings. "Since they are more expensive, states tend to go there. Also, they don't foresee an access problem arising from cutting those services, certainly not on the hospital side," says Ms. Solomon.

For instance, when the governor of Tennessee proposed capping hospital payments at $10,000 earlier this year, "I don't think anyone thought that hospitals would throw people out when the cash register totaled $10,000. I think the assumption of hospitals was that this would represent a shift to uncompensated care," says Ms. Solomon.

The Center on Budget and Policy Priorities has been monitoring the impact of cuts made to Medicaid programs throughout the recession, such as the elimination of dental services. As for difficulties in accessing care, however, Solomon says that "I don't think anybody is systematically monitoring this."

Some states do secret shopper surveys as part of the oversight of their Medicaid managed care programs. This may include attempting to get timely appointments with providers. With fee-for-service programs, though, access to care isn't specifically tracked.

"There was a lot of pushback on expansion of Medicaid from people who asked why would we be expanding Medicaid when there are already such access problems," says Ms. Solomon. "We really tried to look for evidence of that. Anecdotally, people may say there are problems, but there really isn't a lot of research out there."

"Scalpel" approach taken

Ohio Medicaid reduced reimbursement for some CPT codes for community providers and also decreased the dispensing fee paid to pharmacists. "You might say we took a scalpel approach, rather than a hatchet approach, to our provider rate reductions," says Heather Burdette, MBA, assistant deputy director of Ohio Health Plans. "This certainly served to mitigate any impact on access."

Additionally, with the decrease in private insurance enrollment and the increase in Medicaid enrollment, providers have some incentive to enroll in the Medicaid program to maintain their patient panel. "Even with the difficult decisions we have already made, our provider panel continues to grow at a steady rate," says Ms. Burdette.

In addition to tracking access with the fee-for-service program, the department works closely with its home health care case management agency and managed care plans to monitor access. "We are not seeing anything suggesting access to care has become a problem as a result of the changes we have implemented this last year," says Ms. Burdette.

During the last legislative session, a 25% rate reduction for Utah Medicaid's pediatric dentists was proposed. However, as Utah's dental reimbursement rate is acknowledged to be one of the lowest in the nation already, further reductions caused a concern about access.

The Centers for Medicare & Medicaid didn't approve the proposed reduction, however. Instead, a 4.5% reduction was allowed. "That will appease a lot of the dental providers in our state," says Michael Hales, the state's Medicaid director. "There was a big concern that many of those providers were going to exit the program. If we can keep rates to a more modest reduction, I think we will be able to maintain the majority of existing providers."

Michigan's Medicaid providers received a 4% rate reduction in FY 2009 and an additional 4% reduction for FY 2010, for a total of an 8% rate reduction since July 1, 2009.

Additionally, coverage of several optional services, including dental, vision, hearing, podiatry, and chiropractic was eliminated for adult beneficiaries.

Approximately two-thirds of Michigan's Medicaid beneficiaries are enrolled in Medicaid HMOs. "While this somewhat mitigates the impact of provider rate cuts on access to care, provider rate reductions, in general, are a cause for concern relative to access to care," says Stephen Fitton, director of the state's Medicaid program.

Contact Ms. Burdette at (614) 466-4443 or hburdett@ohio.gov, Mr. Fitton at (517) 241-7822 or fittons@michigan.gov, Mr. Hales at (801) 538-6689 or mthales@utah.gov, and Ms. Solomon at (202) 408-1080 or solomon@cbpp.org.