Medicaid provider networks overstate physician availability

A study from Yale and Cornell universities showed that Medicaid participation among physicians listed in provider networks may be overstated.

The study, published in the May issue of Health Affairs, looked at medical claims and Medicaid data from 2015-2017 in Kansas, Louisiana, Michigan, and Tennessee for more than 22,000 physicians.

The researchers found that 16% of adult primary care physicians listed in Medicaid managed care networks did not file any Medicaid claims in a year, and almost a third of outpatient primary care and specialist physicians contracted with Medicaid saw less than 10 Medicaid patients a year.

Medicaid covers more than 80 million Americans, but fewer office-based physicians participate in Medicaid than in Medicare and commercial plans. The researchers said they have concerns that insurers may be inflating their Medicaid managed care networks with physicians who may be unwilling to accept Medicaid patients.

The study authors said that while states set the standards for the number of physicians to ensure care access, new methods are needed to account for patient preferences and physician willingness to accept Medicaid patients. The majority of Medicaid beneficiaries are enrolled in private managed care plans that contract with the states to provide care and manage the physician networks.

The research showed that 25% of primary care physicians provided 86% of the care, with similar numbers for specialists – 25% providing 75% of care for Medicaid patients. Study authors said this could be a result of patient preference due to cultural competence of the physician, or may reflect that some doctors do not want to see significant numbers of Medicaid patients.

In fact, 16% of doctors listed in directories saw zero Medicaid beneficiaries over a year. Another 17% saw 10 patients or less. The report also notes that prior studies have shown that provider directories are often inaccurate and that relying on them to measure access is not sufficient.

The authors proposed that states regularly evaluate Medicaid managed care networks using audit studies and claims-based assessments and possibly fine plans that do not meet standards.

This article was originally published by sister publication Medical Economics.