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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
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
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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
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

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
In a survey of community health center medical directors in 9 Medicaid expansion states and DC, nearly 60% reported difficulty obtaining new specialist visits and multiple access barriers on behalf of their patients.

Difficulty obtaining new patient specialty visits reported by CHCs varied by insurance type, with most respondents reporting difficulty for patients with no insurance (168 CHCs; 85.3%) or Medicaid (113 CHCs; 57.3%), and a lower share of respondents reporting difficulty for patients dually eligible for Medicaid and Medicare (69 CHCs; 35.0%), with only Medicare (47 CHCs; 23.9%), or with private insurance (28 CHCs; 14.4%).

CHCs identified a range of specialties to which they had difficulty referring their Medicaid patients, with visits to orthopedists reported as the most challenging by 16% of respondents who reported difficulty (Figure). Other specialties with commonly reported access problems included gastroenterology (12%), neurology (12%), psychiatry (12%), dermatology (11%), and cardiology (5%). CHCs also reported the greatest access problems for these same 6 specialties for their uninsured patients.

CHCs that reported difficulty obtaining specialty care for their Medicaid patients rated several barriers as often or always contributing to poor access. The most common barriers were related to payment, coverage, and availability of appointments, including low Medicaid payment rates for specialists (78%), few specialists in Medicaid managed care organization (MCO) networks accepting new patients (69%), lack of Medicaid coverage for telemedicine (49%), and Medicaid MCOs’ administrative requirements for obtaining specialist consults (49%) (Table). More than half of respondents also rated long distances or travel times required to reach specialists (60%) and patients’ out-of-pocket cost burden associated with specialty care (56%) as contributors to poor access. More than one-third of CHCs reporting access problems cited difficulty establishing referral agreements with specialists (38%) and finding specialists that met the cultural or linguistic needs of their patients (38%).

CHCs reported difficulty with specialty referrals even though they deployed strategies that sought to improve access, either directly or indirectly (Table). Nearly two-thirds of CHCs reporting access problems had established agreements with specialists relating to the terms of referrals. More than 80% of CHCs reporting access problems provided at least some specialty care on-site, whereas nearly half reported using e-consults (45%) and less than one-third reported using telemedicine (27%) to interact with specialists. Most CHCs made specialist appointments on behalf of patients (61%), although fewer CHCs regularly reminded patients about upcoming appointments (40%). CHCs reported moderate levels of data sharing with specialists, including 43% that consistently shared health information electronically with specialists. By contrast, only 13% of CHCs were able to implement systems permitting real-time “read” access to the medical records of specialty practices. More than half of CHCs reported some form of collaboration with specialists, including participation in health promotion initiatives (66%) or quality improvement projects (57%) with local specialty practices.


Consistent with past reports of significant access problems,2 85% of CHCs reported difficulty obtaining specialist visits for their uninsured patients. Despite the ACA’s expansion of Medicaid eligibility, which led to nearly 12 million adults across the United States becoming newly eligible to gain Medicaid coverage,17 almost 60% of CHCs in our sample of Medicaid expansion states reported difficulty accessing new specialty visits for their Medicaid patients. Although insurance expansions may facilitate access to specialty care by reducing some financial barriers to care, other barriers remain outside of CHCs’ control. In particular, the impact of insurance expansions will ultimately depend on the degree to which payment and delivery systems are aligned to ensure that patients gain access to appropriate and timely specialty care. Data available as of July 2016 suggest that Medicaid pays only 72% of Medicare’s rates for specialty services,18 and these payment differentials are likely to persist as the federal share of funding for the expansion population decreases over time. Thus, specialists face strong disincentives to treat patients insured by Medicaid compared with other payers.

Most Medicaid enrollees in most states included in the study receive their insurance coverage via comprehensive Medicaid MCOs,19 which means that both MCOs and the states play a large role in determining access to specialty care for the majority of Medicaid enrollees. CHCs in our study, in which 7 of 9 states plus DC had a Medicaid MCO penetration rate exceeding 70%,19 commonly reported narrow MCO networks as a challenge to obtaining specialty care for patients. Although the Medicaid and CHIP Managed Care Final Rule of 2016 required new minimum standards for ensuring the adequacy of Medicaid MCO networks, it remains unclear whether states will define standards for individual specialties, go beyond time and distance standards to include appointment or office wait times, or begin to rigorously enforce the new standards.11 For sponsors and administrators of MCOs, our results suggest that Medicaid MCO networks in our sample of 9 states and DC may lack a sufficient number of specialists to care for Medicaid patients, which may reflect specialists’ reluctance to accept referrals for Medicaid patients. As such, administrators may want to consider reassessing both the number and type of specialists available for new patient visits and encouraging the use of strategies that can promote more efficient use of specialists.

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