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Primary Care Appointment Availability and Nonphysician Providers One Year After Medicaid Expansion
Renuka Tipirneni, MD, MSc; Karin V. Rhodes, MD, MS; Rodney A. Hayward, MD; Richard L. Lichtenstein, PhD; HwaJung Choi, PhD; Elyse N. Reamer, BS; and Matthew M. Davis, MD, MAPP
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Primary Care Appointment Availability and Nonphysician Providers One Year After Medicaid Expansion

Renuka Tipirneni, MD, MSc; Karin V. Rhodes, MD, MS; Rodney A. Hayward, MD; Richard L. Lichtenstein, PhD; HwaJung Choi, PhD; Elyse N. Reamer, BS; and Matthew M. Davis, MD, MAPP
After Medicaid expansion in Michigan, appointment availability for new Medicaid patients stably increased-this is perhaps attributable to increasing proportions of appointments scheduled with nonphysician providers.
The unexpected increase in appointment capacity, despite a fixed clinic sample and declining reimbursement, may be partially explained by the increasingly prominent role of nonphysician primary care providers.15 Given the increasing proportion of appointments scheduled with nonphysician providers during the study period, we speculate that clinics may have either hired additional nurse practitioners or physician assistants, or transferred the work of new patient intakes to existing nonphysician providers. Prior literature also suggests that nonphysician providers are more likely than physicians to care for Medicaid patients.16,17 In spite of lower Medicaid reimbursement in 2015, it is possible that practices were able to continue accepting new patients, as such providers often receive lower salaries than physicians.17

Limitations

The study design has certain limitations, which were also discussed in our previous article.9 These limitations include incomplete calls; however, these only occurred with less than 5% of sampled clinics. Additionally, the study was limited by our focus on accessibility of appointments to new, rather than established, patients and the focus on a single large Midwestern state. Due to our emphasis on evaluating Healthy Michigan’s appointment rule, we examined wait times only in clinics that accepted Medicaid. Appointment availability and wait times may differ for established patients, patients in clinics that do not accept Medicaid, and patients in other states.

CONCLUSIONS
One year following Medicaid expansion in Michigan, appointment availability for new Medicaid patients increased. This is perhaps attributable to increasing proportions of appointments scheduled with nonphysician providers. Future research should examine the evolving role of nonphysician providers and other team-based approaches to expanding primary care capacity and improving access for the newly insured.18

Acknowledgments

The authors would like to thank research assistants Jessica Landgraf, MA, Robyn Power, BS, Jessica Stallworth, MA, Lisa Fouladbash, MS, Jessica Chee, BS, and Rafael D. Nieves, MHSA, of the University of Michigan Robert Wood Johnson Foundation Clinical Scholars Program; and Sarah Mott, MPH, of the University of Michigan School of Public Health for their dedication to data collection, and Rekar Taymour, of the University of Michigan School of Public Health, for assistance with literature review. They are also grateful to the analytic support of Sonya DeMonner, MPH, of the University of Michigan Robert Wood Johnson Foundation Clinical Scholars Program, and Joshua Fangmeier, MPP, of the Center for Healthcare Research & Transformation. Lastly, they thank Lauren S. Hughes, of the Pennsylvania Department of Health, and Michelle H. Moniz, of the University of Michigan Department of Obstetrics and Gynecology, for thoughtful comments on earlier drafts of this manuscript.

Author Affiliations: Child Health Evaluation and Research Unit, Department of Pediatrics (MMD), and Division of General Medicine, Department of Internal Medicine (RT, RAH, HC, MMD), and Department of Health Management and Policy, School of Public Health (RLL, MMD), and Institute for Healthcare Policy & Innovation (RT, RAH, RLL, MMD), and Robert Wood Johnson Foundation Clinical Scholars Program (RAH, HC, ENR, MMD), University of Michigan, Ann Arbor, MI; Veterans Affairs Center for Clinical Management Research, Ann Arbor VA Healthcare System (RAH), Ann Arbor, MI; Care Management Design and Evaluation, Northwell Office of Population Health Management, Hofstra Northwell Medical School (KVR), Great Neck, NY.

Source of Funding: This study was supported by the Blue Cross Blue Shield of Michigan Foundation and the Robert Wood Johnson Foundation. Additional support to Dr Hayward was provided by the Methods Core of the Michigan Center for Diabetes Translational Research (NIDDK P60 DK-20572). The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and decision to submit the manuscript for publication.

Author Disclosures: Dr Tipirneni and Dr Davis are supported by a contract from the Michigan Department of Health and Human Services (MDHHS) to the University of Michigan to conduct an evaluation of the Healthy Michigan Plan, as required by CMS through a Section 1115 Medicaid waiver. The findings and conclusions described in this article are those of the authors and do not represent official positions of MDHHS or CMS. MDHHS and CMS had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and decision to submit the manuscript for publication. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (RT, KVR, RAH, RLL, MMD); acquisition of data (RT, ENR); analysis and interpretation of data (RT, HC, MMD); drafting of the manuscript (RT); critical revision of the manuscript for important intellectual content (RT, KVR, RAH, RLL, HC, ENR, MMD); statistical analysis (RT, HC); obtaining funding (RT); administrative, technical, or logistic support (ENR); and supervision (RT, MMD).

Address correspondence to: Renuka Tipirneni, MD, MSc, Clinical Lecturer, Department of Internal Medicine, Division of General Medicine, University of Michigan, North Campus Research Complex, Bldg 16, Rm 472C, 2800 Plymouth Rd, Ann Arbor, MI 48109-2800. E-mail: rtipirne@med.umich.edu.
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