While Medicaid and the State Children’s Health Insurance Program (SCHIP) have done much to bring health care services to people who need them, those efforts can be in vain if there aren’t enough physicians available and willing to participate in the programs.
Many states have reported difficulty in generating sufficient access to physician services for their Medicaid and SCHIP enrollees, at least in some geographic areas and for some specialties. Until now, there hasn’t been a systematic way to examine this problem. But a new report from Mathematica Policy Research Inc. in Washington, DC, provides a framework through which states can assess factors that promote or hinder physician access and also identify actions that can be taken to improve access.
The framework report is one of several commissioned by the California HealthCare Foundation’s Medi-Cal Policy Institute. Institute program officer Lucy Streett tells State Health Watch that anecdotal information has outlined a problem with physician access in California for some time, and the Institute wanted to quantify the situation. (Although much of the Institute’s work is California-specific, the Mathematica framework report is applicable to all states interested in systematically looking at the problem of physician access.)
Physician surveys in California have found that about 50% of all physicians are willing to accept Medi-Cal patients, and that there has been minimal increase in that percentage despite an increase in Medi-Cal payment rates.
In addition to low rates, doctors have complained about bureaucratic issues in dealing with Medi-Cal, Ms. Streett says.
The Mathematic framework report offers a way to assess the problem and then develop action steps (see chart), according to Mathematica senior fellow Marsha Gold, lead author of the report. "When any state looks at this issue," she says, "it’s useful to have a sense of all the factors that influence access. Priorities in terms of access issues may vary state by state or even market by market. The data suggest that while states often focus on one or two priorities, they occur in a context. For example, in California there has been an issue around payment rates but also around the attitudes of physicians, and it’s important to work on both issues."
The framework is intended to help states identify: 1) the sources of problems with physician access; 2) the interventions that may be effective for different types of problems; and 3) the major parties to be involved in implementing these interventions.
Ms. Gold says that the goal of equitable access to physician services in public insurance programs is more likely to be achieved if all critical parties share and commit themselves to this goal, each doing its part to advance it. According to Ms. Gold, previous research has identified six key factors that influence access to physician services in Medicaid:
1. Provider supply.
The number, mix, and location of physicians determine the geographic accessibility of care. Data typically are expressed in geographically based physician-to-population ratios. Potential options for enhancing supply include bonus payments or less geographically dependent ways of delivering care.
2. Provider participation in public programs.
The extent to which available providers participate in public programs will determine the actual (vs. theoretical) availability of care. In theory, Ms. Gold says, several types of policy levers are potentially available to states to influence participation, including payment policy and various other incentives or disincentives for participation such as bonuses and clinical or data requirements.
3. Financial accessibility.
Financial accessibility of care depends on the cost of care and the insurance coverage and/or income and other financial resources at an individual’s disposal to pay those costs. Medicaid and SCHIP provide insurance coverage and thus make care more financially accessible. But, Ms. Gold cautions, "the growing flexibility provided to states in structuring benefits and cost-sharing under SCHIP and for those Medicaid beneficiaries who are not categorically eligible could mean that financial accessibility may become a more important barrier now than in the past."
4. System accessibility.
The ways in which health care systems are designed and operated will influence the degree of accessibility of the available care. Important variables include: design of office hours; availability and ease of making appointments for urgent, routine, or preventive conditions; availability of transportation; and rules and processes that determine access to specialty services.
5. Patient knowledge, including subgroup accessibility.
Regardless of how system entry and flow work, according to Ms. Gold, accessibility depends on how well those covered by the program understand it. Patient knowledge is an issue, particularly when systems undergo change such as through introduction of managed care.
In some subgroups, knowledge may be especially important when individuals have characteristics, such as those who are sick or frail, that may make access more difficult and motivation to learn about the system higher. Racial or other ethnic subgroups, particularly those influenced by the customs of other locales or countries, may have expectations about how to access care that differ from systems in place in their communities.
6. Concordance between system design and patient preferences.
Ms. Gold maintains that even with sound health care systems in place, access to physician services could be a problem if the available care does not match beneficiaries’ preferences. An example she cites is of a situation in which appointments are timely, but patients want to be seen on an unscheduled basis and are willing to trade a wait in the office for the flexibility to seek care when it best fits with other demands on their time.
Ms. Gold discusses why each of the six factors is important and reviews some of the research that has been done on each factor.
With the six factors that influence access to physician services in Medicaid, she also has identified six tools potentially available to encourage effective collaboration among all parties in responding to diverse types of barriers to access.
They are contracting mechanisms, payment mechanisms, delivery system mechanisms, monitoring mechanisms, provider education mechanisms, and consumer education mechanisms.
Potential interventions to bolster participation in public programs include increasing payment rates, monitoring plan networks coupled with incentives for improvement, limiting administrative burden, prompt payment, and state mandates on participation. "Within the traditional Medicaid program," Ms. Gold writes, "the most common strategy for increasing participation has been to raise physician fees, either across the board or selectively in areas of perceived care shortage. Unfortunately, little research has specifically evaluated the effectiveness of these incentive payments."
Use of the framework allows a broader look at potential barriers and ways to address them. Specifically, according to Ms. Gold, states looking to address the issues will need to: 1) identify concrete measures of key barriers to physician access; 2) monitor performance against these measures regularly; and 3) when problems are identified, take action that is appropriate to the specific problem. "States that are proactive in anticipating problems may be able to avoid them or limit their scope," she declares.
Based on the analysis presented in the framework, Ms. Gold says that collaboration for success will be more likely if each party takes on responsibilities appropriate to its role. She identifies likely commitments as:
• Government. Responsible for equitable payment and good business practices to encourage stable and broad-based provider participation organized in ways that create access to beneficiaries. It means that payment levels are set by adopting appropriate standards that, to the extent feasible, result in predictable levels of payment over the years, regardless of budget pressures, and timely reimbursement of claims. It also means that government works to establish effective means of communication and two-way interchange among all parties.
• Providers. Responsible and willing to treat patients on a nondiscriminatory basis. They should be willing to provide effective feedback to plans and providers on what they need to make participation feasible, to take their fair share of publicly insured patients as long as reasonable conditions are met, and to educate themselves sufficiently to understand accurately the needs of their patients.
• Health plans. As agents of the state, plans are responsible for structuring payments and practices in an equitable way to encourage stable and broad-based provider participation and access. They assume many of the same responsibilities as states by serving as a substitute for the state or complementing state actions.
• Consumers. Responsible for being informed, assuming an appropriate system and infrastructure to support education and access. Consumers need to be willing to learn how to use systems, particularly when the systems aim to accommodate their needs and preferences and when appropriate education is provided.
Ms. Gold tells State Health Watch that she hopes that states will put monitoring systems in place to look at the barriers and potential solutions. "With state budget crises, the potential for the situation to get worse is growing," she says, "and it will be important to find resources to deal with these issues."
[Contact Ms. Streett at (570) 286-8976 and Ms. Gold at (202) 484-4227.]