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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
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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
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
Medicare Annual Wellness Visit Association With Healthcare Quality and Costs
Adam L. Beckman, BS; Adan Z. Becerra, PhD; Anna Marcus, BS; C. Annette DuBard, MD, MPH; Kimberly Lynch, MPH; Emily Maxson, MD; Farzad Mostashari, MD, ScM; and Jennifer King, PhD
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

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
In the era after Medicaid expansion, primary care providers placed importance on practice capacity, specialist availability, and reimbursement when deciding whether to accept new Medicaid patients.
ABSTRACT

Objectives: Michigan expanded Medicaid under the Affordable Care Act (ACA) through a federal waiver that permitted state-mandated features, including an emphasis on primary care. We investigated the factors associated with Michigan primary care providers (PCPs)’ decision to accept new Medicaid patients under Medicaid expansion.

Study Design: Statewide survey of PCPs informed by semistructured interviews.

Methods: After Michigan expanded Medicaid on April 1, 2014, we surveyed 2104 PCPs (including physician and nonphysician providers, such as nurse practitioners and physician assistants) with 12 or more assigned Medicaid expansion enrollees (response rate, 56%). To guide survey development and interpretation, we interviewed a separate group of 19 PCPs with Medicaid expansion enrollees from diverse urban and rural regions. Survey questions assessed PCPs’ current acceptance of new Medicaid patients.

Results: Of the 2104 surveyed PCPs, 78% reported that they were currently accepting additional Medicaid patients; 58% reported having at least some influence on the decision. Factors considered very/moderately important to the Medicaid acceptance decision included practice capacity to accept any new patients (69%), availability of specialists for Medicaid patients (56%), reimbursement amount (56%), psychosocial needs of Medicaid patients (50%), and illness burden of Medicaid patients (46%). PCPs accepting new Medicaid patients tended to be female, minorities, nonphysician providers, specialized in internal medicine, paid by salary, or working in practices with Medicaid-predominant payer mixes.

Conclusions: In the era after Medicaid expansion, PCPs placed importance on practice capacity, specialist availability, and patients’ medical and psychosocial needs when deciding whether to accept new Medicaid patients. To maintain primary care access for low-income patients with Medicaid, future efforts should focus on enhancing the diversity of the PCP workforce, encouraging healthcare professional training in underserved settings, and promoting practice-level innovations in scheduling and integration of specialist care.

Am J Manag Care. 2019;25(3):120-127
Takeaway Points

In the era after Medicaid expansion, the factors considered important to Michigan primary care providers (PCPs) when deciding whether to accept additional Medicaid patients included the capacity to accept any new patients (69%), availability of specialists for Medicaid patients (56%), reimbursement amount (56%), psychosocial needs of Medicaid patients (50%), and illness burden of Medicaid patients (46%).
  • PCPs continuing to accept new Medicaid patients tended to be female, minorities, nonphysician providers, specialized in internal medicine, paid by salary, or working in practices with Medicaid-predominant payer mixes.
  • Policy makers should consider these factors in addition to reimbursement policies to ensure adequate PCP capacity in states with expanded Medicaid coverage.
As state and federal governments debate the future of the Affordable Care Act (ACA) and its Medicaid expansion, it seems likely that expanded Medicaid coverage will remain, but it will likely be modified by greater state flexibility in coverage and implementation.1 The impact of expanded Medicaid in any form depends on several factors, including, crucially, the acceptance of Medicaid by healthcare providers and systems.

Payment has long been emphasized as a driver of physician participation in Medicaid. Prior studies have found that reimbursement level is important to healthcare providers’ decisions to accept Medicaid.2-5 However, it is also important to carefully consider both the financial and nonfinancial factors that may influence providers’ participation in Medicaid and other programs.6

Since the 1980s, research has examined several nonfinancial factors associated with physician Medicaid acceptance, including characteristics of “high-share” Medicaid providers, such as younger age, female gender, and nonwhite race.4,5,7-10 However, few studies have comprehensively examined which provider characteristics and practice settings may be associated with provider willingness to accept new Medicaid patients after the 1990s, when this was last examined in depth following the rapid growth of managed care. Given that influences on healthcare providers’ willingness to see Medicaid patients may have changed in the era after ACA Medicaid expansion, this question is worth revisiting.

Because primary care providers (PCPs) deliver frontline access to care for patients, understanding the factors associated with an adequate supply of PCPs who accept Medicaid patients is critically important. Access to care for Medicaid patients depends on several dimensions, including (1) providers’ willingness to accept any Medicaid patients, (2) the geographic distribution of available providers in relation to patients’ location, and (3) providers’ capacity and willingness to accept a greater number of Medicaid patients as demand rises (eg, after insurance coverage expansion). In the setting of Michigan’s Healthy Michigan Plan (HMP)—which expanded Medicaid under the ACA through a federal section 1115 waiver that permitted state-mandated features, including an emphasis on primary care11—prior studies have examined the first 2 dimensions of provider Medicaid acceptance. With regard to whether primary care practices accepted any Medicaid patients, these studies demonstrated increased availability of PCP practices offering appointments to HMP patients after Medicaid expansion12,13 despite rapid enrollment in the program,14 which was consistent with trends observed in 10 other states.15,16 Regarding provider distribution, these increases in appointment availability appeared to be geographically concentrated in regions with lower pre-expansion Medicaid acceptance.17

The current study examines the third dimension of providers’ capacity and willingness to accept a greater number of Medicaid patients: whether PCPs who already have some Medicaid patients are willing to accept more in response to patient demand. In a recent study, Neprash and colleagues found that most physicians maintained or slightly increased their Medicaid participation rates after ACA Medicaid expansion, with greater increases observed in expansion states.18 Of note, approximately 20% of PCPs accounted for the care of 60% of Medicaid patients in that study. In other words, most increases in PCP Medicaid participation occurred among providers already caring for Medicaid patients. The authors of that study concluded that policy efforts to increase access to primary care should target existing Medicaid providers. Thus, focusing on PCPs already caring for Medicaid patients, we investigated what factors were associated with their continued acceptance of new Medicaid patients.

METHODS

Study Design

As part of a formal evaluation under contract with the Michigan Department of Health and Human Services (MDHHS) and required by CMS for a section 1115 waiver, we conducted a statewide survey of PCPs regarding their experiences with HMP enrollees, new practice approaches and innovations adopted or planned in response to HMP, and future plans regarding acceptance and care of HMP patients.19 As an evaluation of a public program, the University of Michigan and MDHHS institutional review boards deemed the study exempt.

Survey Sampling

The PCP sample was drawn from the MDHHS Data Warehouse, which stores data generated from encounters on all Medicaid and HMP enrollees and their providers, including provider demographics, specialty (assessed by linking National Provider Identifier [NPI] numbers from the Data Warehouse to each respondent’s National Plan and Provider Enumeration System profile), practice setting, and health plan participation. From the Warehouse, 7360 NPI numbers were identified as the assigned PCP for at least 1 HMP managed care enrollee (adult Medicaid expansion group) in April 2015, 1 year after the HMP launch. Nurse practitioners (NPs) and physician assistants (PAs) who were listed as the assigned PCP were also included in the sample. We considered PCPs with at least 12 assigned members (an average of 1 HMP enrollee per month) eligible for the survey in order to assess the perspectives of PCPs who had sufficient experience with HMP patients to provide informed input on the primary care–oriented features of the program for another related study.19 Thus, 2813 PCPs with fewer than 12 assigned members were excluded. Of the remaining 4547 PCPs, exclusions included 25 with an NPI entity code that did not reflect an individual provider (20 organizational NPIs, 4 deactivated, and 1 invalid), 161 with only pediatric specialty, 4 University of Michigan physicians involved in the HMP evaluation, and 35 with out-of-state addresses greater than 30 miles from the Michigan border. After exclusions, 4322 PCPs (3686 physicians and 636 NPs or PAs) remained in the survey sample.

Although we focused on a PCP sample that already had assigned Medicaid patients, we considered the representativeness of the sample relative to the typical PCP. As the average US primary care panel size is approximately 1200 to 1900 patients,20 the median number of assigned HMP members per PCP in our sample was 53; with HMP representing approximately one-third of all Michigan Medicaid enrollees, the estimated Medicaid proportion of the panel was approximately 6% to 15% of the total panel size. This is consistent with the national average Medicaid proportion of PCP panels, which has been reported to range from 9% to 20%.18,21


 
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