Boosting Medicaid payment levels did not incentivize primary care physicians (PCPs) to accept more patients with the government-sponsored health insurance, a longitudinal analysis of claims data for over 20,000 physicians revealed.
For 2013 and 2014 — the years payments were raised under the Affordable Care Act (ACA) to match those of Medicare — no increases in Medicaid participation or patient volume were seen in the study, reported Andrew W. Mulcahy, PhD, MPP, of the RAND Corporation in Arlington, Virginia, and colleagues.
“This finding is contrary to hypotheses informed by evidence from analyses of cross-sectional data from before the payment increase showing strong positive associations between Medicaid payment and participation rates,” they wrote in JAMA Internal Medicine.
Five outcomes were measured:
1. Seeing any Medicaid patient
2. Seeing more than five Medicaid patients
3. Share of total patients on Medicaid
4. Number of visits for new Medicaid patients
5. Number of visits for existing Medicaid patients
But no change for any of these, which in various models were marginal at best (1% to 2%), were associated with the increased reimbursement rate.
In 2012 to 2013, the years leading up to the period of Medicare pay-matching, the researchers found a 0.7% per-month increase in the proportion of PCPs seeing more than five Medicaid patients, but this then declined by the end of 2015, resulting in a 0.2% net decrease over the full study period. There were 13 states that had significant increases in the share of PCPs seeing more than five Medicaid patients (North Dakota, Nebraska, Connecticut, and others) and 13 with significant decreases (Vermont, Iowa, Mississippi, and others).
“This does not mean that a differently formulated payment policy could not have achieved more robust outcomes or that states spending some of their own funds to maintain higher payment rates are erring,” the authors cautioned. “The short duration of the ACA payment increase, its delayed implementation, and its complicated attestation process may have contributed to our results.”
Descriptively, the share of patients on Medicaid increased by about 25% from 2012 to 2015 (15.5% to 20.0%), but this was not necessarily tied to the higher payment rate period — the increase was sharpest after the 2014 eligibility expansion.
Interviews with state Medicaid officials are in line with the study’s findings, the authors noted, revealing that few of the physicians who enrolled to receive higher payments during the 2-year period were new to Medicaid.
In an accompanying commentary, Allan H. Goroll, MD, of Harvard Medical School in Boston, questioned whether an increase in fee-for-service (FFS) reimbursement is the appropriate way to incentivize Medicaid participation. “This is not to deny that an astronomical increase in evaluation and management valuations might have some result, but certainly not the aforementioned raising of FFS pay from an impossibly low Medicaid level to an undervalued Medicare level,” he wrote.
Goroll noted that methods meant to increase volume will have little effect on practices that are already overloaded or caught in the “hamster wheel.”
The current FFS payment model, he wrote, is derived from recommendations by the “specialty-dominated” American Medical Association’s Resource-Based Relative Value Update Committee, which “has routinely undervalued primary care evaluation and management services for decades, forcing primary care practices to maximize volume to stay in business.”
He pointed to other payment models, such as one he helped develop that substitute FFS with a prospective, risk-adjusted comprehensive payment for delivery of comprehensive care. While a base payment covers practice expenses, a bonus payment is tied to specific patient- and cost-related measures.
“We will need to overcome the fearful attitude of many primary care physicians that is hindering fundamental payment reform,” wrote Goroll. “The stakes are high, but the potential payoff is substantial for improving this foundational segment of our healthcare delivery system.”
Mulcahy’s group used 2012 to 2015 medical claims data from all states except Hawaii and Alaska, capturing 20,723 physicians from office-based settings, emergency departments, and outpatient departments in hospitals. This comprised about about 11% of all U.S. PCPs with a specialty or subspecialty who qualified for the payment increase. The samples were weighted to better match the nation’s distribution of PCPs.
The researchers noted that claims data captures the actual use of specific services targeted by the pay increase, offering an advantage over self-reported data on Medicaid participation.
To account for changes over time, regression models were used to test if outcomes differed prior to and following implementation of the 2013-2014 pay increase, and during that period of mandated increases. But these revealed no significant associations regarding Medicaid participation or volume.
Sensitivity analyses also revealed no significant associations. Fifteen states, as well as the District of Columbia, continued Medicaid payment increases after 2013-2014, though not all at the rates mandated during the 2-year period.
Source: MedPage Today