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The American Journal of Managed Care March 2019
Fragmented Ambulatory Care and Subsequent Emergency Department Visits and Hospital Admissions Among Medicaid Beneficiaries
Lisa M. Kern, MD, MPH; Joanna K. Seirup, MPH; Mangala Rajan, MBA; Rachel Jawahar, PhD, MPH; and Susan S. Stuard, MBA
Incorrect and Missing Author Initials in Affiliations and Authorship Information
From the Editorial Board: Austin Frakt, PhD
Austin Frakt, PhD
Implications of Eligibility Category Churn for Pediatric Payment in Medicaid
Deena J. Chisolm, PhD; Sean P. Gleeson, MD, MBA; Kelly J. Kelleher, MD, MPH; Marisa E. Domino, PhD; Emily Alexy, MPH; Wendy Yi Xu, PhD; and Paula H. Song, PhD
Factors Influencing Primary Care Providers’ Decisions to Accept New Medicaid Patients Under Michigan’s Medicaid Expansion
Renuka Tipirneni, MD, MSc; Edith C. Kieffer, PhD, MPH; John Z. Ayanian, MD, MPP; Eric G. Campbell, PhD; Cengiz Salman, MA; Sarah J. Clark, MPH; Tammy Chang, MD, MPH, MS; Adrianne N. Haggins, MD, MSc; Erica Solway, PhD, MPH, MSW; Matthias A. Kirch, MS; and Susan D. Goold, MD, MHSA, MA
Did Medicaid Expansion Matter in States With Generous Medicaid?
Alina Denham, MS; and Peter J. Veazie, PhD
Currently Reading
Access to Primary and Dental Care Among Adults Newly Enrolled in Medicaid
Krisda H. Chaiyachati, MD, MPH, MSHP; Jeffrey K. Hom, MD, MSHP; Charlene Wong, MD, MSHP; Kamyar Nasseh, PhD; Xinwei Chen, MS; Ashley Beggin, BS; Elisa Zygmunt, MSW; Marko Vujicic, PhD; and David Grande, MD, MPA
Common Elements in Opioid Use Disorder Guidelines for Buprenorphine Prescribing
Timothy J. Atkinson, PharmD, BCPS, CPE; Andrew J.B. Pisansky, MD, MS; Katie L. Miller, PharmD, BCPS; and R. Jason Yong, MD, MBA
Specialty Care Access for Medicaid Enrollees in Expansion States
Justin W. Timbie, PhD; Ashley M. Kranz, PhD; Ammarah Mahmud, MPH; and Cheryl L. Damberg, PhD
Gender Differences in Prescribing of Zolpidem in the Veterans Health Administration
Guneet K. Jasuja, PhD; Joel I. Reisman, AB; Renda Soylemez Wiener, MD, MPH; Melissa L. Christopher, PharmD; and Adam J. Rose, MD, MSc
Cost Differential of Immuno-Oncology Therapy Delivered at Community Versus Hospital Clinics
Lucio Gordan, MD; Marlo Blazer, PharmD, BCOP; Vishal Saundankar, MS; Denise Kazzaz; Susan Weidner, MS; and Michael Eaddy, PharmD, PhD
Health Insurance Literacy: Disparities by Race, Ethnicity, and Language Preference
Victor G. Villagra, MD; Bhumika Bhuva, MA; Emil Coman, PhD; Denise O. Smith, MBA; and Judith Fifield, PhD

Access to Primary and Dental Care Among Adults Newly Enrolled in Medicaid

Krisda H. Chaiyachati, MD, MPH, MSHP; Jeffrey K. Hom, MD, MSHP; Charlene Wong, MD, MSHP; Kamyar Nasseh, PhD; Xinwei Chen, MS; Ashley Beggin, BS; Elisa Zygmunt, MSW; Marko Vujicic, PhD; and David Grande, MD, MPA
Nearby provider supply did not affect identification of usual sources of primary or dental care among new Medicaid enrollees. Strategies to improve access are needed.
ABSTRACT

Objectives:
Adequate access to primary and dental care is essential for population health, and some state Medicaid programs have expanded insurance coverage for both. However, there are few data on new Medicaid enrollees’ ability to access services. We examined the relationship between provider supply and enrollees’ identification of usual sources of care.

Study Design: Between November 2015 and February 2016, we surveyed low-income adults newly insured through Medicaid in Philadelphia, Pennsylvania, to determine if they had a usual source of care. Additionally, we used geospatial methods to calculate adult population per provider ratios by Census tract for primary and dental care providers who accepted Medicaid patients, then identified low-supply clusters.

Methods: We used multivariable logistic regression models to describe the odds of identifying usual sources of care based on being in low- or high-supply clusters, adjusting for patient demographics.

Results: Of 1000 contacted individuals, 312 completed the survey. Among respondents, 168 were previously uninsured and newly enrolled in Medicaid; 66.7% of this group identified a usual primary care provider and 42.3% identified a usual dental care provider. In adjusted analyses, individuals living in low- and high-supply areas had similar likelihoods of identifying a usual source of primary or dental care.

Conclusions: Many new Medicaid enrollees did not have usual sources of primary or dental care, regardless of nearby provider supply. Efforts to understand what improves access or engagement in healthcare among Medicaid enrollees are critical after low-income adults gain insurance.

Am J Manag Care. 2019;25(3):135-139
Takeaway Points
  • Even after low-income adults gained insurance, barriers to accessing care persisted.
  • Nearby provider supply did not affect identification of usual sources of primary or dental care among new Medicaid enrollees.
  • Further efforts to understand what improves access or engagement in healthcare among Medicaid enrollees are critical.
Recent expansions in Medicaid have renewed policy debates on how to improve access to primary and dental care among low-income populations. Access to primary care is essential because it provides an entry point to other forms of healthcare, delivers preventive services, and treats chronic diseases. Better primary care access is also associated with improved health outcomes at a lower cost, including reductions in heart disease and cancer mortality.1,2 Better dental care access is associated with lower rates of dental caries,3,4 diabetes,5 heart disease,6 and low-value emergency department utilization.7 Low-income populations in particular experience more access barriers to these 2 types of care than other populations.8-10

The Affordable Care Act (ACA) expanded coverage for primary and dental care services for low-income populations. As of 2016, when this study was conducted, 31 states and the District of Columbia had expanded Medicaid through the ACA, and 23 states included preventive dental service coverage for adults.11,12 However, in states that have expanded coverage, newly insured Medicaid enrollees still face access barriers. The ACA Medicaid expansion focused on addressing affordability13-16; however, health reforms have not equally prioritized provider availability17,18 and accessibility.18,19

The relationship between provider supply and the identification of a usual source of care among low-income populations for both primary and dental care is poorly understood. Therefore, the objective of this study was to examine the association between the supply of nearby Medicaid-accepting primary and dental care providers and the likelihood of identifying a usual source of care among newly enrolled Medicaid beneficiaries in an urban environment. Prior to our study, Pennsylvania began administering Medicaid to all of its expansion population through managed care organizations. In addition to covering primary care visits, these plans covered a limited set of dental visits for preventive, diagnostic, and minor restorative needs up to $1000.20,21 The population sampled resides in Philadelphia, a racially diverse city with a high density of providers and the fifth-largest population, but also the highest poverty rate among the 10 largest cities in the United States.22

STUDY DATA AND METHODS

The University of Pennsylvania Institutional Review Board approved this study.

Study Sample

We surveyed new Medicaid enrollees between November 2015 and February 2016. We identified Medicaid applicants through a partnership with Benefits Data Trust (BDT), a Philadelphia-based nonprofit organization that facilitates access to comprehensive public benefits and provides Medicaid application assistance. We randomly selected 1000 individuals to participate in a mailed survey if they received assistance from BDT within the year prior to November 2015, were aged 18 to 64 years, were able to read English, and had a Philadelphia mailing address. We excluded individuals who had not yet enrolled in Medicaid or had insurance before enrolling to focus on responses from newly insured adults. Individuals first received a letter informing them of the upcoming survey. One week later, we mailed the survey, consent information, a prepaid return envelope, and a $2 cash participation incentive. Nonrespondents received up to 2 additional reminders, then were called by phone to complete the survey. Respondents received an additional $10 gift card.

We developed the survey assessing usual sources of care based on questions used by the Agency for Healthcare and Research and Quality23 and our own pilot testing (see eAppendix [available at ajmc.com]). Specifically, the primary care question asked, “Is there a particular doctor’s office, clinic, health center, or other place that you usually go if you are sick or need advice about your health?” The dental care question asked, “A regular dentist is the one you would go to for check-ups and cleanings or when you have a cavity or tooth pain. Do you have a regular dentist or dental clinic?” The survey confirmed whether respondents had ultimately enrolled in Medicaid and captured demographic and self-reported health measures. We geocoded survey respondent addresses using ArcGIS 10.3 (Environmental Systems Research Institute; Redlands, California) to identify their Census tract (a close approximation to neighborhoods in Philadelphia), which is more relevant than larger geographic areas, such as zip code, for policy makers and planners in dense urban environments.17


 
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