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Access to Care in The Medicaid Program Andrew B. Bindman, MD Professor of Medicine, Health Policy, Epidemiology & Biostatistics University of California San Francisco
Access to Care in The Medicaid Program
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
15.7%
ICF/MR4.3%
Mental Health1.0%
Home Health and Personal Care
14.8%
Payments to Medicare 3.3%
DSH Payments5.6%
AcuteCare
58.5%
Long-TermCare
35.8%
13%8%
42%
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
4%9%
2%3% 3% 1%
52%
32%
23%
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
51%
71%75%
52%
72% 73%
Medicaid Private Medicare
1996-97 2004-05
Cunningham, Peter and May, Jessica. “Medicaid Patients Increasingly Concentrated Among MDs.” 2006
19%
4% 3%
21%
4% 3%
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
US
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
49%
62%
0%
10%
20%
30%
40%
50%
60%
70%
Pre: 1999-2000 Post: 2001-2002
Years of Enrollment
Per
cent
age
Bindman, et al. Medical Care, 2008
Preventable Hospitalizations Increase with Interruptions in Medicaid Coverage
0%
5%
10%
15%
20%
25%
0 6 12 18 24 30 36 42 48 54 60
Interrupted
Continuous
Cum
ulat
ive
Pro
babi
lity
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
AZAR
MS
LA
WA
MN
ND
WY
ID
UTCO
OR
NV
CA
MT
IA
WIMI
NE
SD
ME
MOKS
OHIN
NY
IL
KY
TNNC
NH
MA
VT
PA
VAWV
CTNJ
DE
MD
RI
HI
DC
AK
SCNM
OK
GA
TX
IL
FL
AL
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
CA
