Associations Between the Patient Protection and Affordable Care Act Medicaid Primary Care Payment Increase and Physician Participation in Medicaid

Abstract

Care Act (ACA) increased 2013 to 2014 Medicaid payment rates for qualifying primary care physicians (PCPs) and services to higher Medicare payment levels, with the goal of improving primary care access for Medicaid enrollees. OBJECTIVES To evaluate the payment increase policy and to assess whether it was associated with changes in Medicaid participation rates or Medicaid service volume among PCPs. DESIGN, SETTING, AND PARTICIPANTS This study used 2012 to 2015 IMS Health aggregated medical claims and encounter data from PCPs eligible for the payment increase practicing in all states except Alaska and Hawaii and included 20 723 PCPs with observations in each month from January 1, 2012, to December 31, 2015. Data are for professional services performed in ambulatory settings, including office, hospital outpatient department, and emergency department. Regression models were used to test whether outcomes differed in months subject to higher payment rates relative to months before the increase and after the expiration of the increase in some states. The models controlled for time-invariant physician characteristics and time-varying characteristics, such as Medicaid enrollment. Interaction terms were included to estimate differential associations in subgroups of states (eg, by Medicaid managed care penetration) and physicians (eg, by specialty). MAIN OUTCOMES AND MEASURES Physician-month records subject to higher Medicaid payment rates were flagged using state-specific implementation and end dates for the payment increase. Five outcomes were measured for each physician-month observation, including (1) an indicator for seeing any patients enrolled in Medicaid, (2) an indicator for seeing more than 5 patients enrolled in Medicaid, (3) the Medicaid share of total patients, (4) a count of new patient evaluation and management visits furnished to patients enrolled in Medicaid, and (5) a count of existing patient evaluation and management visits furnished to patients enrolled in Medicaid. RESULTS Among 20 723 PCPs, the payment increase had no association with PCP participation in Medicaid or Medicaid service volume. The estimated average marginal effects for all 5 outcomes were not statistically distinguishable from 0. This null result was robust to sensitivity analyses, including different time trend specifications and analyses focusing on the payment increase implementation and expiration time frames. Descriptively, the Medicaid share of patients increased by about 25% from 2012 to 2015, although the share did not increase differentially in states and months subject to higher payment rates. CONCLUSIONS AND RELEVANCE The limited duration and design of the payment increase may have dampened its effectiveness. Future efforts to improve access through payment changes or other means can benefit from better understanding of the outcomes of this policy.

Assessment of the Patient Protection and Affordable Care Act’s Increase in Fees for Primary Care and Access to Care for Dual-Eligible Beneficiaries

“…15 Existing studies on the impact of the ACA fee bump focus on Medicaid-only enrollees and have not found increases in PCPs’ participation in Medicaid, although 1 study found increases in appointment availability for Medicaid vs commercial enrollees during the fee bump. 16 , 17 , 18 , 19 These studies have not examined changes in beneficiary use associated with the fee bump, and those examining PCPs’ Medicaid participation exclude nurse practitioners (NPs) and physician assistants (PAs), who are increasingly providing primary care, especially in rural and low-income areas where Medicare beneficiaries are more likely to be dual. 20 , 21 NPs and PAs were eligible for the fee bump if working under the supervision of a physician.…”

Access to Primary, Mental Health, and Specialty Care: a Comparison of Medicaid and Commercially Insured Populations in Oregon

“…53 Other potential levers for improving the program may include alternative payment models that hold providers accountable for access; 24,26 changes in the supply, training, and mix of the health care workforce; or telemedicine. 45 Given the disparities observed in this study, a high priority should be placed on approaches with the potential to address differences in urban-rural access, as well as Medicaid-commercial disparities.…”

“…For example, studies of the ACA's 2013/2014 primary care fee Bbump^-which resulted in an average increase in primary care payments of more than 70%-found no association with primary care providers' participation in Medicaid or Medicaid service volume. 45,46 While reimbursement may matter, physicians may be more responsive to efforts to simplify Medicaid's administrative processes and increase the speed of reimbursement. 47 Recent network adequacy regulations, which require Medicaid managed care plans in every state to set standards for specialty care access, including limits on wait times and distance traveled, may also narrow existing disparities in access.…”

Primary Care Access to New Patient Appointments for California Medicaid Enrollees: A Simulated Patient Study

“…[6][7][8] Between 2013 and 2015, full-time equivalent physicians participating in Medi-Cal increased by only 9% while Medi-Cal beneficiaries increased by 60%, presenting challenges for enrollees seeking medical care. 9 Although studies of appointment availability from other states report that expansion of the Medicaid program has led to more, not less, access to PCCs, [10][11][12] payment increases have also been reported to have little effect on Medicaid clinician participation rates across states 13 despite increased 2013-2014 PCC reimbursement rates.…”