Appointment availability after increases in Medicaid payments for primary care.

BACKGROUND: Providing increases in Medicaid reimbursements for primary care, a key provision of the Affordable Care Act (ACA), raised Medicaid payments to Medicare levels in 2013 and 2014 for selected services and providers. The federally funded increase in reimbursements was aimed at expanding access to primary care for the growing number of Medicaid enrollees. The reimbursement increase expired at the end of 2014 in most states before policymakers had much empirical evidence about its effects. METHODS: We measured the availability of and waiting times for appointments in 10 states during two periods: from November 2012 through March 2013 and from May 2014 through July 2014. Trained field staff posed as either Medicaid enrollees or privately insured enrollees seeking new-patient primary care appointments. We estimated state-level changes over time in a stable cohort of primary care practices that participated in Medicaid to assess whether willingness to provide appointments for new Medicaid enrollees was related to the size of increases in Medicaid reimbursements in each state. RESULTS: The availability of primary care appointments in the Medicaid group increased by 7.7 percentage points, from 58.7% to 66.4%, between the two time periods. The states with the largest increases in availability tended to be those with the largest increases in reimbursements, with an estimated increase of 1.25 percentage points in availability per 10% increase in Medicaid reimbursements (P=0.03). No such association was observed in the private-insurance group. During the same periods, waiting times to a scheduled new-patient appointment remained stable over time in the two study groups. CONCLUSIONS: Our study provides early evidence that increased Medicaid reimbursement to primary care providers, as mandated in the ACA, was associated with improved appointment availability for Medicaid enrollees among participating providers without generating longer waiting times. (Funded by the Robert Wood Johnson Foundation.).

Access to Primary Care Appointments Following 2014 Insurance Expansions.

PURPOSE: The Patient Protection and Affordable Care Act (ACA) expanded coverage to roughly 12 million individuals by mid-2014 and 20 million by 2016, raising concern about the capacity of the primary care system to absorb these individuals. We set out to determine how justified the concern was. METHODS: We used an audit design in which simulated patients called primary care practices seeking new-patient appointments in 10 diverse states (Arkansas, Georgia, Iowa, Illinois, Massachusetts, Montana, New Jersey, Oregon, Pennsylvania, and Texas) from November 2012 through March 2013 and from May 2014 through July 2014, before and after the major ACA insurance expansions. Callers were randomly assigned to scripts specifying either private or Medicaid insurance and called only offices identified as "in network" for each plan. RESULTS: We completed 5,385 private insurance and 4,352 Medicaid calls in 2012-2013 and 2,424 private insurance and 2,474 Medicaid calls in 2014. Overall appointment rates for private insurance remained stable from 2012 (84.7%) to 2014 (85.8%) with Massachusetts and Pennsylvania experiencing significant increases. Overall, Medicaid appointment rates increased 9.7 percentage points (57.9% to 67.6%) with substantial variation by state. Across all callers, median wait times for those obtaining an appointment were 7 days in 2012 and 5 days in 2014, but the difference was not statistically significant. CONCLUSIONS: Contrary to widespread concern, we find no evidence that the millions of individuals newly insured through the ACA decreased new-patient appointment availability across 10 states as shown by stable wait times and appointment rates for private insurance as of mid-2014.

Primary Care Appointment Availability and the ACA Insurance Expansions.

In the current debate in Congress over the Affordable Care Act (ACA), the issue of provider access is a major concern. Fortunately, our 10-state audit study published in JAMA Internal Medicine finds that primary care appointment availability for new patients with Medicaid increased 5.4 percentage points between 2012 and 2016 and remained stable for patients with private coverage. Over the same period, both Medicaid patients and the privately insured experienced a one-day increase in median wait times. Higher appointment availability for Medicaid patients is a surprising result given the increase in demand for care from millions of new Medicaid enrollees. In this Issue Brief, we summarize our study's findings, expand on possible explanations, and extend the analysis by examining the relationship between appointment availability and state-level Medicaid expansions. We find that access to primary care increased for Medicaid patients only in states that extended Medicaid eligibility to low-income, nonelderly adults. Combined, these results suggest coverage provisions in the ACA have not overwhelmed primary care capacity.

Primary Care Appointment Availability for Medicaid Patients: Comparing Traditional and Premium Assistance Plans.

BACKGROUND: Arkansas and Iowa received waivers from the federal government in 2014 to use federal Medicaid expansion funding to enroll beneficiaries in commercial insurance plans on the Marketplaces. One key hypothesis of these "private option" or "premium assistance" programs was that Medicaid beneficiaries would experience increased access to care. In this study, we compare new patient primary care appointment availability and wait-times for beneficiaries of traditional Medicaid and premium assistance Medicaid. METHODS: Trained field staff posing as patients, randomized to traditional Medicaid or Marketplace plans, called primary care practices seeking new patient appointments in Arkansas and Iowa in May to July 2014. All calls were made to offices that previously indicated being in-network for the plan. Offices were drawn randomly, within insurance type, based on the county proportion of the population with each insurance type. We calculated appointment rates and wait-times for new patients for traditional Medicaid and Marketplace plans. RESULTS: In Arkansas, Marketplace appointment rates were 27.2 percentage points higher than traditional Medicaid appointment rates (83.2% compared with 55.5%, P<0.001), while in Iowa, Marketplace appointment rates were 12.0 percentage points higher (86.3% compared with 74.3%, P<0.001). Conditional on receiving an appointment, median wait-times were roughly 1 week in each state without significant differences by insurance type. CONCLUSIONS: The experiences of Arkansas and Iowa suggest that enrolling Medicaid beneficiaries into Marketplace plans may lead to higher primary care appointment availability for new patients at participating providers. Further research is needed on whether premium assistance programs affect quality and continuity of care, and at what cost.

Home Health Use In Medicare Advantage Compared To Use In Traditional Medicare.

Medicare covers home health benefits for homebound beneficiaries who need intermittent skilled care. While home health care can help prevent costlier institutional care, some studies have suggested that traditional Medicare beneficiaries may overuse home health care. This study compared home health use in Medicare Advantage and traditional Medicare, as well as within Medicare Advantage by beneficiary cost sharing, prior authorization requirement, and plan type. In 2016 Medicare Advantage enrollees were less likely to use home health care than traditional Medicare enrollees were, had 7.1 fewer days per home health spell, and were less likely to be admitted to the hospital during their spell. Among Medicare Advantage plans, those that imposed beneficiary cost sharing or prior authorization requirements had lower rates of home health use. Qualitative interviews suggested that Medicare Advantage payment and contracting approaches influenced home health care use. Therefore, changes in traditional Medicare home health payment policies implemented in 2020 may reduce these disparities in home health use and spell length.

Home Health And Postacute Care Use In Medicare Advantage And Traditional Medicare.

This article compares patterns of postacute care-including care provided by skilled nursing facilities, inpatient rehabilitation facilities, and home health agencies-under Medicare Advantage and traditional Medicare. Overall, Medicare Advantage enrollees received less postacute care, both institutional and home health, than traditional Medicare enrollees did for three common conditions.

Changes in primary care access at community health centers between 2012/2013 and 2016.

OBJECTIVE: To compare access at community health centers (CHCs) vs private offices (non-CHCs) under the Affordable Care Act. DATA SOURCE: Ten state primary care audit conducted in 2012/2013 and 2016. STUDY DESIGN: CHCs and non-CHCs were called. We calculated difference in differences comparing CHCs vs non-CHCs by caller insurance type. PRINCIPAL FINDINGS: In both rounds, Medicaid and uninsured callers had higher appointment rates at CHC than non-CHCs. CHC appointment rates significantly increased between 2012/2013 and 2016 for both employer-sponsored and Medicaid callers, with no significant wait time changes. Appointment rates increased (13.5% points, P < 0.001) and wait times decreased (-5.7 days, P = 0.017) at CHCs relative to non-CHCs for employer-sponsored insurance. CONCLUSION: Appointment availability at CHCs improved after ACA implementation, without increased wait times.

Nursing home use by dual-eligible beneficiaries in the last year of life.

Research on health care at the end of life has focused on Medicare-financed acute care services. Much less information has been available on nursing home use in the last year of life, particularly for individuals who are dually eligible for Medicare and Medicaid. We used Medicare and Medicaid enrollment and claims data to examine nursing home admissions, odds of dying in nursing homes versus hospitals or the community, and variations in Medicare and Medicaid service use and costs by place of death. We found that, in the last year of life, 75% of dual-eligible people use nursing home care, increasing age is associated with greater likelihood of dying in nursing homes, and dual-eligible people who die in hospitals have notably higher costs than other beneficiaries.

Impacts on Emergency Department Visits from Personal Responsibility Provisions: Evidence from West Virginia's Medicaid Redesign.

OBJECTIVE: To examine the impact of a 2007 redesign of West Virginia's Medicaid program, which included an incentive and "nudging" scheme intended to encourage better health care behaviors and reduce Emergency Department (ED) visits. DATA SOURCES: West Virginia Medicaid enrollment and claims data from 2005 to 2010. STUDY DESIGN: We utilized a "differences in differences" technique with individual and time fixed effects to assess the impact of redesign on ED visits. Starting in 2007, categorically eligible Medicaid beneficiaries were moved from traditional Medicaid to the new Mountain Health Choices (MHC) Program on a rolling basis, approximating a natural experiment. Members chose between a Basic plan, which was less generous than traditional Medicaid, or an Enhanced plan, which was more generous but required additional enrollment steps. DATA COLLECTION: Data were obtained from the West Virginia Bureau for Medical Services. PRINCIPAL FINDINGS: We found that contrary to intentions, the MHC program increased ED visits. Those who selected or defaulted into the Basic plan experienced increased overall and preventable ED visits, while those who selected the Enhanced plan experienced a slight reduction in preventable ED visits; the net effect was an increase in ED visits, as most individuals enrolled in the Basic plan.

Trade-offs between public and private coverage for low-income children have implications for future policy debates.

Much of the discussion around the Affordable Care Act has focused on likely changes in coverage and access to care for adults. However, the law also alters coverage options for many low-income children. We used data from the new Health Reform Monitoring Survey Child Supplement to examine access to care and related outcomes for low-income publicly and privately insured children. We found that over 90 percent of low-income insured children had a usual source of care and had parents who were confident that their children could get the health care they need, regardless of their type of coverage. However, on a variety of cost-related measures, including difficulty paying the child's medical bills, out-of-pocket expenses, and satisfaction with health insurance premiums and copayments, children with Medicaid or the Children's Health Insurance Program (CHIP) fared better than those with employer-sponsored insurance. These results have implications for debates about the future of CHIP and other policies that affect public and private coverage options available to children and families.

Primary care access for new patients on the eve of health care reform.

IMPORTANCE: Current measures of access to care have intrinsic limitations and may not accurately reflect the capacity of the primary care system to absorb new patients. OBJECTIVE: To assess primary care appointment availability by state and insurance status. DESIGN, SETTING, AND PARTICIPANTS: We conducted a simulated patient study. Trained field staff, randomly assigned to private insurance, Medicaid, or uninsured, called primary care offices requesting the first available appointment for either routine care or an urgent health concern. The study included a stratified random sample of primary care practices treating nonelderly adults within each of 10 states (Arkansas, Georgia, Illinois, Iowa, Massachusetts, Montana, New Jersey, Oregon, Pennsylvania, and Texas), selected for diversity along numerous dimensions. Collectively, these states comprise almost one-third of the US nonelderly, Medicaid, and currently uninsured populations. Sampling was based on enrollment by insurance type by county. Analyses were weighted to obtain population-based estimates for each state. MAIN OUTCOMES AND MEASURES: The ability to schedule an appointment and number of days to the appointment. We also examined cost and payment required at the visit for the uninsured. RESULTS: Between November 13, 2012, and April 4, 2013, we made 12,907 calls to 7788 primary care practices requesting new patient appointments. Across the 10 states, 84.7% (95% CI, 82.6%-86.8%) of privately insured and 57.9% (95% CI, 54.8%-61.0%) of Medicaid callers received an appointment. Appointment rates were 78.8% (95% CI, 75.6%-82.0%) for uninsured patients with full cash payment but only 15.4% (95% CI, 13.2%-17.6%) if payment required at the time of the visit was restricted to $75 or less. Conditional on getting an appointment, median wait times were typically less than 1 week (2 weeks in Massachusetts), with no differences by insurance status or urgency of health concern. CONCLUSIONS AND RELEVANCE: Although most primary care physicians are accepting new patients, access varies widely across states and insurance status. Navigator programs are needed, not only to help patients enroll but also to identify practices accepting new patients within each plan's network. Tracking new patient appointment availability over time can inform policies designed to strengthen primary care capacity and enhance the effectiveness of the coverage expansions with the Patient Protection and Affordable Care Act.

The health reform monitoring survey: addressing data gaps to provide timely insights into the affordable care act.

The Health Reform Monitoring Survey (HRMS) was launched in 2013 as a mechanism to obtain timely information on the Affordable Care Act (ACA) during the period before federal government survey data for 2013 and 2014 will be available. Based on a nationally representative, probability-based Internet panel, the HRMS provides quarterly data for approximately 7,400 nonelderly adults and 2,400 children on insurance coverage, access to health care, and health care affordability, along with special topics of relevance to current policy and program issues in each quarter. For example, HRMS data from summer 2013 show that more than 60 percent of those targeted by the health insurance exchanges struggle with understanding key health insurance concepts. This raises concerns about some people's ability to evaluate trade-offs when choosing health insurance plans. Assisting people as they attempt to enroll in health coverage will require targeted education efforts and staff to support those with low health insurance literacy.

Reforming Medicare payments to skilled nursing facilities to cut incentives for unneeded care and avoiding high-cost patients.

Despite many changes made in 2010 and 2011 to Medicare's payment system for short-term stays in skilled nursing facilities, a flawed payment structure continues to underpay facilities for certain types of patients and overpay for others. The flaws in the payment structure create incentives to selectively admit or refuse patients based on the type and complexity of their conditions, while payments that vary with level of use encourage providers to furnish therapy services, such as rehabilitation care, that some patients might not need. We propose an alternative payment design and demonstrate that it would dampen such incentives by making payments that are more closely matched to costs and based on characteristics of the patients treated. We propose replacing the existing therapy component of payment with one that varies payments according to the expected care needs of the patient and adding a separate payment component that covers drugs and other nontherapy ancillary services, such as support for patients on ventilators. We also propose adding an outlier policy to provide additional reimbursement for patients requiring exceptionally high-cost care.