Access to Care in The Medicaid Program

transcript

Andrew B. Bindman, MD

Professor of Medicine, Health Policy, Epidemiology & Biostatistics

University of California San Francisco

Medicaid Expenditures by Service, 2006

Total = $304.0 billion

Urban Institute based on CMS Form 64 prepared for Kaiser Commission on Medicaid and the Uninsured.

Inpatient 14.1%

Physician/ Lab/ X-ray 3.8%

Outpatient /Clinic 6.8%

Drugs5.5%

Other Acute6.9%

Payments to MCOs 18.0%

Nursing Facilities

ICF/MR4.3%

Mental Health1.0%

Home Health and Personal Care

Payments to Medicare 3.3%

DSH Payments5.6%

AcuteCare

Long-TermCare

17%16%

Total HealthServices and

Supplies

Hospital Care ProfessionalServices

NursingHome Care

PrescriptionDrugs

CMS Office of the Actuary, National Health Statistics Group, National Health Expenditure Accounts, 2009.

Total National Spending (billions)

$2,098 $697 $702 $131 $228

Medicaid as Share of National Health Care Spending 2007

Access Problems by Insurance Status

2%3% 3% 1%

13%10%10%

Medicaid Private Uninsured

Adults Adults Children

No Usual Source of Care Needed Care but Did Not Get It

KCMU analysis of 2007 NHIS data

Children

State Budget Challenges Could Impact Medicaid Beneficiaries’ Access

• Reductions in Provider Payments

• Reductions in Enrollment

• Managed Care

Physician Participation by Insurance Type

71%75%

72% 73%

Medicaid Private Medicare

1996-97 2004-05

Cunningham, Peter and May, Jessica. “Medicaid Patients Increasingly Concentrated Among MDs.” 2006

Medicaid Private Medicare

1996-97 2004-05

% Accepting All New Patients % Accepting No New Patients

Factors Contributing to Physicians Participating in Care of Medicaid Patients

• Participation is voluntary

• Some avoid Medicaid patients due to• Patient characteristics and complexities• Concerns about being sued• Administrative hassles/payment delays

• Participation varies most strongly in association with state payment rates

• On average, Medicaid pays 70% of Medicare payments

Physicians’ Acceptance of Medicaid Patients and Fee Levels, 2001

Low-Fee States

High-Fee States

All Physicians (%) 62 52 68

Primary Care Physicians (%)

54 47 58

Specialist Physicians (%)

67 55 75

Zuckerman et al, Health Affairs, 2004

Medicaid Eligibility

• Any person who meets Medicaid eligibility criteria is entitled to benefit – no wait list

• Federal requirement of at least annual determination of eligibility

• Many states require or are considering more frequent determination of eligibility

• State determined frequency and ease of Medicaid eligibility process affects the number of beneficiaries with enrollment gaps

Children without Gaps in Medicaid Coverage in CA Before and After Eligibility Determination Increased

from 6 to 12 Months

Pre: 1999-2000 Post: 2001-2002

Years of Enrollment

Bindman, et al. Medical Care, 2008

Preventable Hospitalizations Increase with Interruptions in Medicaid Coverage

0 6 12 18 24 30 36 42 48 54 60

Interrupted

Continuous

Time (Months)Bindman et al, Annals of Internal Medicine, 2008

Medicaid Managed Care

• Delivery model used in most states

• Potential to improve access through requirement for a primary care provider

• Concern that access to high cost services (eg specialists) could be limited to save money

• Some states looking to expand mandatory Medicaid managed care for a larger proportion of their beneficiaries

Medicaid Managed Care Enrollees as a Percent of State Medicaid Enrollees, June 2007

0 - 60% (13 states)

81-100% (14 states)

61-70% (17 states including DC)71-80% (7 states)U.S. Average = 64.1% FPL

SOURCE: Medicaid Managed Care Penetration Rates by State as of June 30, 2007, CMS, HHS

Access to Care in The Medicaid Program

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