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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
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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.
DISCUSSION

In this study of new Medicaid beneficiaries from Philadelphia, we report 3 key findings. First, only 66.7% of our respondents identified a usual source of primary care, whereas nationally 78% did in 2016.26 Second, only 42.3% identified a usual source of dental care, whereas nationally 64% did during a comparable time period. Third, the supply of nearby providers was not associated with a higher or lower likelihood of identifying a usual source of primary or dental care.

The high percentage of individuals without a usual source of primary or dental care could be due to lack of perceived need, difficulty finding a provider who accepts new Medicaid patients,27 costs not covered by insurance (eg, missed work to attend appointments), or lack of knowledge about the healthcare system.28 Although we hypothesized that individuals living in lower-supply areas would be less likely to find a source of care, Philadelphia is a uniquely high-supply market, potentially affecting our findings and limiting generalizability. For example, the Philadelphia hospital referral region has 87.5 primary care physicians per 100,000 residents compared with the national median of 73.5, and it is near the 90th percentile for physicians overall.29 Second, beneficiaries may seek sources of care that are not necessarily near their home,30 basing their decisions on convenience in relation to shopping centers, workplaces, or public transportation networks. Finally, the point estimates from our model suggest that a relationship between supply and having a usual source of care may exist and is worth exploring in larger data sets across multiple cities.

Limitations

Our study should be interpreted in the context of several limitations. First, given the observational nature of our study, our results are measures of association, not causation. Second, our supply measure does not utilize detailed accounts of provider effort, productivity, services offered, or acceptance of new Medicaid patients. Similarly, our demand measure (population counts) does not consider factors such as health status and healthcare-seeking preferences. Third, our approach assumes that most people prefer to obtain primary care or dental care near their home. The optimal distance to primary or dental care in urban areas is not known and may vary based on individual preference or travel patterns. Fourth, our study population was identified through a benefits outreach organization in a single urban area and may not be representative of all Medicaid enrollees in Philadelphia or other urban environments. Fifth, we were unable to determine which of 4 Medicaid managed care plans patients were enrolled in. Variations in plan types could lead to plan-level differences in provider availability, Census tract differences in plan-specific network adequacy standards, and different likelihoods of identifying a usual source of care. As a result, we may have overestimated access to care because not all nearby providers will participate in all Medicaid managed care plans. In addition, some individuals may have been assigned a provider by their insurance plan but may not have actually established a provider–patient relationship. Sixth, our generalizability is limited because we do not know the addresses or demographics of nonrespondents and cannot compare them with respondents. Finally, the modest response rate could lead to nonresponse bias. However, our response rate (31%) is an improvement compared with recent surveys of Medicaid patients, who are historically difficult to contact.31

CONCLUSIONS

Although we did not observe a relationship between nearby provider supply and the identification of a usual source of primary or dental care, there are several key issues moving forward. This relationship should be evaluated in other geographic areas (urban and rural) and in those with low provider supply. These evaluations may help determine whether characterizing access in terms of a population to provider ratio—a measure commonly used by policy makers and researchers—is useful.32 Our results ultimately suggest that policy makers and insurance plan managers should better understand what improves access or engagement in healthcare among Medicaid enrollees so that gains in insurance coverage can be translated into gains in health.

Acknowledgments

The authors thank Carolyn Cannuscio, ScD, for her critical input on survey development and Brittany Harrison, MA, for reviewing earlier versions of this manuscript. They also thank the staff at Benefits Data Trust for survey administration and for identifying individuals in Philadelphia whom they had helped apply for Medicaid.

Author Affiliations: Division of General Internal Medicine, Perelman School of Medicine (KHC, XC, AB, DG), and Leonard Davis Institute of Health Economics (KHC, DG), University of Pennsylvania, Philadelphia, PA; Department of Public Health (JKH), Philadelphia, PA; Department of Pediatrics (CW) and Duke-Margolis Center for Health Policy (CW), Duke University, Durham, NC; Health Policy Institute, American Dental Association (KN, MV), Chicago, IL; Benefits Data Trust (EZ), Philadelphia, PA.

Source of Funding: This work was supported by the American Dental Association (ADA). Two of the authors (Drs Chaiyachati and Hom) received training support from the Veterans Health Administration (VHA) and Robert Wood Johnson Foundation (RWJF) during data collection and initial drafts of the manuscript. The ADA, VHA, and RWJF had no role in the study design; collection, analysis, or interpretation of the data; writing the report; or the decision to submit the report for publication.

Author Disclosures: The 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 (KHC, JKH, CW, KN, EZ, MV, DG); acquisition of data (KHC, JKH, CW, EZ, MV, DG); analysis and interpretation of data (KHC, JKH, CW, KN, XC, MV, DG); drafting of the manuscript (KHC, CW, XC, AB, MV, DG); critical revision of the manuscript for important intellectual content (KHC, JKH, CW, KN, AB, MV, DG); statistical analysis (KHC, XC); obtaining funding (CW); administrative, technical, or logistic support (KHC, KN, AB, EZ); and supervision (MV).

Address Correspondence to: Krisda H. Chaiyachati, MD, MPH, MSHP, University of Pennsylvania, 423 Guardian Dr, 1313 Blockley Hall, Philadelphia, PA 19104. Email: kchai@pennmedicine.upenn.edu.
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