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.
Objectives: With insurance enrollment greater than expected under the Affordable Care Act, uncertainty about the availability and timeliness of healthcare services for newly insured individuals has increased. We examined primary care appointment availability and wait times for new Medicaid and privately insured patients before and after Medicaid expansion in Michigan.
Study Design: Simulated patient (“secret shopper”) study.
Methods: Extended follow-up of a previously reported simulated patient (“secret shopper”) study assessing accessibility of routine new patient appointments in a stratified proportionate random sample of Michigan primary care practices before versus 4, 8, and 12 months after Medicaid expansion.
Results: During the study period, approximately 600,000 adults enrolled in Michigan’s Medicaid expansion program, representing 57% of the previously uninsured nonelderly adult population. One year after expansion, we found that appointment availability remained increased by 6 percentage points for new Medicaid patients (95% CI, 1.6-11.1) and decreased by 2 percentage points for new privately insured patients (95% CI, —0.5 to –3.8). Over the same period, the proportion of appointments scheduled with nonphysician providers (nurse practitioners or physician assistants) increased from 8% to 21% of Medicaid appointments (95% CI, 5.6-20.2) and from 11% to 19% of private-insurance appointments (95% CI, 1.3-14.1). Median wait times remained stable for new Medicaid patients and increased slightly for new privately insured patients, both remaining within 2 weeks.
Conclusions: During the first year following Medicaid expansion in Michigan, appointment availability for new Medicaid patients increased, a greater proportion of appointments could be obtained with nonphysician providers, and wait times remained within 2 weeks.
Am J Manag Care. 2016;22(6):427-431
During the first year following Medicaid expansion in Michigan:
Access to care depends, in large part, on states’ unique healthcare environments, which have varying population demographics and healthcare workforces. After the 2012 Supreme Court decision made Medicaid expansion under the Affordable Care Act (ACA) optional, 19 states decided not to expand Medicaid and the remaining 31 states expanded Medicaid in a variety of ways.1 For this reason, ongoing state-level evaluations are critically important to evaluate the consequences of Medicaid expansions in order to inform other states facing similar expansion challenges.
Although most primary care providers were accepting new patients on the eve of ACA-sponsored coverage expansions in 2012 and 2013,2 there was widespread concern that primary care capacity would be insufficient to meet the growing demand for care by newly insured individuals3,4—many of whom are establishing care with a primary care provider for the first time. Higher than expected enrollment in Medicaid5-7 has heightened this concern.8
In order to provide timely estimates of changes in primary care access in the era of healthcare reform, we previously reported preliminary results from a simulated patient study examining primary care appointment availability and wait times for new patients with Medicaid and private insurance before and 4 months after implementation of Medicaid expansion in Michigan on April 1, 2014.9 We found an initial increase in primary care appointment availability for new Medicaid patients with no lengthening of wait times 4 months after expansion.
Since then, the number of enrollees in the state’s Medicaid expansion program—or Healthy Michigan Plan—has nearly doubled, from approximately 350,000 to 600,000.10 Each new Healthy Michigan Plan beneficiary is required to obtain a primary care appointment within 90 days of enrollment. With the expanding number of enrollees and the mandate to schedule early appointments, there was increasing uncertainty as to whether the initial increase in primary care appointment access for new Medicaid patients would endure following continued coverage expansion. To monitor ongoing trends in appointment accessibility, we now present longitudinal data through the first 12 months after Medicaid expansion, regarding primary care appointment availability and wait times for new patients with Medicaid and private insurance.
We conducted a simulated patient (“secret shopper”) study, in which trained research staff called a stratified proportionate random sample of primary care practices (N = 295) to request a new patient appointment before (March 17-31, 2014) and, serially, after Medicaid expansion implementation in Michigan on April 1, 2014 (July 21-August 11, 2014; November 17-December 12, 2014; and March 20-April 15, 2015). Details of our study methodology, including sampling, practice classification, and simulated patient call protocols, were reported in our previous article.9 Briefly, we conducted a telephone survey of Michigan primary care clinics caring for adult patients February 24 to March 7, 2014, to confirm study eligibility and acceptance of new Medicaid patients, as well as other practice characteristics. Given the study’s focus on assessing appointment accessibility for new Medicaid patients, we placed simulated patient calls to clinics that accepted Medicaid in order to assess appointment wait times.
Trained research assistants called primary care clinics as simulated prospective patients with Medicaid or private coverage every 4 months up to 1 year after Medicaid expansion (see eAppendix A for a timeline of study calls and enrollment [available at www.ajmc.com]). Callers requested the next available routine new-patient appointment for a patient with well-controlled hypertension. Calls with each insurance scenario were separated by at least 1 week and appointments were canceled at the end of each call. The University of Michigan Institutional Review Board considered the study “not regulated,” as we did not collect information about individual patients or clinic staff.
Our main outcome was availability of appointments to simulated patients, which we defined as a specific appointment date and time offered during the call. For clinics that accepted Medicaid and offered appointments, we calculated wait times as the difference in calendar days between the call date and appointment date. We also noted whether the appointment was made with a physician or nonphysician provider (eg, nurse practitioner, physician assistant).
We compared changes in appointment availability across the same clinics between pre- and postexpansion periods using logistic regression with time indicators. To compare changes in the skewed distribution of wait times over time and between Medicaid and private insurance, we conducted paired testing with the Wilcoxon signed rank-sum test. In sensitivity analyses, we used linear regression with time indicators after log-transforming the wait time variable, but results did not differ. Because our analyses were based on clinic-level longitudinal data, each clinic could contribute multiple observations to each regression analysis over the 4 waves of data collection. We therefore clustered the residual structure at the clinic level to obtain robust standard errors.11,12
To assess differences across varying categories of clinics (eg, urban vs rural practices) at a given time period, we used 2 testing for appointment availability and the Wilcoxon rank sum test for wait time differences. We considered a 2-sided P <.05 statistically significant. All analyses were performed using Stata version 13 (StataCorp, College Station, Texas).
Full details of clinic characteristics have been published previously.9 We found in the current study that approximately half of the 295 study clinics were small practices with 1 to 2 providers (eAppendix B) and that 42% of clinics employed nonphysician providers, such as nurse practitioners or physician assistants. Although only 9% were traditionally defined as safety net clinics, 74% had established patients with Medicaid coverage. Clinics were located mostly in urban locations. During the study period, approximately 600,000 individuals enrolled in the state’s Medicaid expansion program10 and 340,000 enrolled in Marketplace plans,13 together representing approximately 10% of the state’s total population and 90% of the previously uninsured nonelderly adult population (eAppendix A).
Availability of Appointments
The proportion of clinics with appointments available to new Medicaid patients increased from 49% before expansion to 55% by 12 months after expansion (+6 percentage points; 95% CI, 1.6-11.1) (). Appointment availability for new privately insured patients decreased from 88% of clinics to 86% by 12 months after expansion (—2 percentage points; 95% CI, –0.5 to –3.8). Changes in appointment availability for both Medicaid and privately insured groups at 12 months post expansion remained stable compared with the 4-month postexpansion findings.
We also examined the proportion of appointments scheduled with nonphysician providers versus physicians, and found that there was an increasing proportion of appointments scheduled with nonphysician providers over the study period (). For Medicaid appointments, 8% were scheduled with nonphysician providers before expansion, and this increased to 21% by 12 months post expansion (+13 percentage points; 95% CI, 5.6-20.2). For private insurance appointments, 11% were scheduled with nonphysician providers before expansion, and this increased to 19% by 12 months post expansion (+8 percentage points; 95% CI, 1.3-14.1).
In clinics that accepted patients with Medicaid, median wait times for new Medicaid patients remained stable over the 12-month period (). In these same clinics, median wait times for new privately insured patients increased slightly by 12 months post expansion, from 7 to 10 days (P = .02). However, there was no significant difference between wait times for new Medicaid and new privately insured patients throughout the study period. Furthermore, median new patient wait times remained within 2 weeks, with more than 95% falling within the 90-day requirement of the Healthy Michigan law.
Variation by Practice Characteristics
Larger practices (≥3 providers) were more likely to accept new Medicaid patients pre-expansion and initially experienced significantly increased appointment availability 4 and 8 months post expansion (P = .002 and P = .02 , respectively) (eAppendix C); however, this increase was no longer significant by 12 months post expansion (P = .14). Safety net clinics were much more likely than non—safety net clinics to accept new Medicaid patients at baseline; however, only non–safety net clinics had significantly increased appointment availability after expansion (P = .005 at 12 months post expansion). Clinics in urban locations were less likely to accept new Medicaid patients than clinics in nonurban locations at baseline, but only urban clinics had increased Medicaid appointment availability post expansion (P = .006 at 12 months post expansion).
In this extended longitudinal follow-up of a simulated patient (“secret shopper”) study, we found that the proportion of primary care clinics accepting new Medicaid patients increased 12 months post-Medicaid expansion in Michigan. During the study period, there was also a steady increase in the proportion of appointments scheduled with nonphysician providers. Despite the large number of newly insured individuals, median new patient wait times remained within 2 weeks and were similar for Medicaid and privately insured patients. Although there was a statistically significant increase in wait times for new privately insured patients 12 months post expansion, the 3-day difference in wait times is likely not clinically meaningful for a patient scheduling an initial primary care appointment.
Notably, although the ACA-associated rate bump in Medicaid reimbursement to primary care providers expired at the end of 2014, the increased availability of appointments to new Medicaid patients persisted into 2015 despite Medicaid payments returning to pre-ACA levels. Prior literature suggested that states with larger increases in reimbursement during the rate bump had larger increases in Medicaid appointment availability.14 Consequently, many feared that primary care appointment access would decline soon after the rates dropped. Our observation of stable increases in Medicaid appointment availability suggests that this has not happened. Nevertheless, continuous careful attention to this issue is warranted, as primary care practice policies on acceptance of new Medicaid patients may continue to change over time.
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
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.
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
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: firstname.lastname@example.org.
1. Current status of state Medicaid expansion decisions. Kaiser Family Foundation website. http://kff.org/health-reform/slide/current-status-of-the-medicaid-expansion-decision/. Published May 14, 2016. Accessed May 2016.
2. Rhodes KV, Kenney GM, Friedman AB, et al. Primary care access for new patients on the eve of health care reform. JAMA Intern Med. 2014;174(6):861-869. doi: 10.1001/jamainternmed.2014.20.
3. Colwill JM, Cultice JM, Kruse RL. Will generalist physician supply meet demands of an increasing and aging population? Health Aff (Milwood). 2008;27(3):w232-w241. doi: 10.1377/hlthaff.27.3.w232.
4. Council on Graduate Medical Education. Sixteenth report: physician workforce policy guidelines for the United States, 2000-2020. Health Resources and Services Administration website. http://www.hrsa.gov/advisorycommittees/bhpradvisory/cogme/Reports/sixteenthreport.pdf. Published January 2005. Accessed August 18, 2015.
5. Cassidy CA. Medicaid enrollment surges, stirs worry about state budgets. The Associated Press website. http://bigstory.ap.org/article/c158e3b3ad50458b8d6f8f9228d02948/medicaid-enrollmentsurges-stirs-worry-about-state-budgets. Published July 19, 2015. Accessed August 18, 2015.
6. Ayanian JZ, Clark SJ, Tipirneni R. Launching the Healthy Michigan Plan—the first 100 days. N Eng J Med. 2014;371(17):1573-1575. doi: 10.1056/NEJMp1409600.
7. Medicaid and CHIP: May 2015 monthly applications, eligibility determinations and enrollment report. Medicaid.gov website. https://www.medicaid.gov/medicaid-chip-program-information/program-information/downloads/may-2015-enrollment-report.pdf. Published July 28, 2015. Accessed August 18, 2015.
8. Lin J. Accessing care especially difficult for Latinos on Medi-Cal. The Associated Press website. http://bigstory.ap.org/article/dcc1603f875a4f54ba5aeaad27b37801/accessing-careespecially-difficult-latinos-medi-cal. Published Accessed August 18, 2015.
9. Tipirneni R, Rhodes KV, Hayward RA, Lichtenstein RL, Reamer EN, Davis MM. Primary care appointment availability for new Medicaid patients increased after Medicaid expansion in Michigan. Health Aff (Milwood). 2015;34(8):1399-1406. doi: 10.1377/hlthaff.2014.1425.
10. Gov. Rick Snyder: Healthy Michigan Plan has enrolled more than 600,000 people in first year [press release]. Lansing, MI: State of Michigan; March 31, 2015. http://www.michigan.gov/snyder/0,4668,7-277-57577_57657-351257--,00.html. Accessed August 18, 2015.
11. Rogers W. Regression standard errors in clustered samples. Stata Technical Bulletin. 1994;3(13).
12. Wooldridge JM. Econometric Analysis of Cross Section and Panel Data. 2nd edition. Cambridge, MA: The MIT Press; 2010.
13. Health insurance marketplaces 2015 open enrollment period: March enrollment report. Office of the Assistant Secretary for Planning and Evaluation website. http://aspe.hhs.gov/sites/default/files/pdf/83656/ib_2015mar_enrollment.pdf. Published March 2015. Accessed August 18, 2015.
14. Polsky D, Richards M, Basseyn S, et al. Appointment availability after increases in Medicaid payments for primary care. N Eng J Med. 2015;372(6):537-545. doi: 10.1056/NEJMsa1413299.
15. Salsberg E. The nurse practitioner, physician assistant, and pharmacist pipelines: continued growth. Health Affairs blog website. http://healthaffairs.org/blog/2015/05/26/the-nurse-practitioner-physician-assistant-and-pharmacist-pipelines-continued-growth/. Published May 26, 2015. Accessed August 20, 2015.
16. Everett CM, Thorpe CT, Palta M, Carayon P, Gilchrist VJ, Smith MA. Division of primary care services between physicians, physician assistants, and nurse practitioners for older patients with diabetes. Med Care Res Rev. 2013;70(5):531-541. doi: 10.1177/1077558713495453.
17. Buerhaus PI, DesRoches CM, Dittus R, Donelan K. Practice characteristics of primary care nurse practitioners and physicians. Nurs Outlook. 2015;63(2):144-153. doi: 10.1016/j.outlook.2014.08.008.
18. Bodenheimer TS, Smith MD. Primary care: proposed solutions to the physician shortage without training more physicians. Health Aff (Milwood). 2013;32(11):1881-1886. doi: 10.1377/hlthaff.2013.0234.