- A study assessing the level of Medicaid participation among physicians listed in managed care provider networks has concluded that the directories may overstate the availability of doctors to see Medicaid patients.
- Yale and Cornell university researchers found that about 16% of adult primary care physicians listed in Medicaid managed care networks did not file any Medicaid claims in a year. About a third of outpatient primary care and specialist physicians contracted with Medicaid managed care plans saw fewer than 10 Medicaid patients a year.
- The findings, published in the May issue of Health Affairs, raise concerns that private insurers may be "padding" the Medicaid managed care networks with physicians, some of whom may be unwilling to treat program beneficiaries, the study authors said.
Adequate physician participation in Medicaid has long been a concern. The program is the largest source of health insurance in the U.S., now covering more than 80 million people, or almost one in four Americans.
Yet far fewer office-based physicians participate in Medicaid than in Medicare or commercial plans, the study authors said.
Most states have outsourced the delivery of Medicaid services to private insurers. More than 70% of Medicaid beneficiaries are now enrolled in managed care plans that contract with states to provide care and administer the physician networks from which Medicaid beneficiaries choose providers, the researchers said.
States typically set standards for the number of physicians in the network to ensure access to care. But the Health Affairs study found current state network adequacy standards may not reflect actual access and suggested new methods are needed that take into account beneficiaries' preferences and physicians' willingness to treat Medicaid patients.
The study examined 2015-2017 data from medical claims, Medicaid files and provider network directories for Medicaid managed care plans in four states: Kansas, Louisiana, Michigan and Tennessee. More than 22,000 physicians in adult primary care, pediatric primary care, cardiology and psychiatry were included in the sample.
The findings showed a small set of physicians provided most of the care to Medicaid beneficiaries. A quarter of primary care physicians provided 86% of the care, and a quarter of specialists provided 75% of the care for Medicaid beneficiaries.
The concentration of care could reflect patient preference due to factors such as cultural competence of the physician, or could be due to the unwillingness of some doctors to see significant numbers of Medicaid patients, researchers said.
The study found 16% of doctors listed in Medicaid managed care provider network directories qualified as "ghost" physicians, meaning they saw no Medicaid beneficiaries over a year in an outpatient setting. About 17% were classified as peripheral physicians, treating one to 10 Medicaid patients; 43% were classified as standard physicians, treating 11-150 beneficiaries; and 24% were classified as core physicians, treating more than 150 beneficiaries.
The report also noted prior analyses have documented that provider directories are often outdated or inaccurate.
"Our findings suggest that relying on the physicians listed in Medicaid managed care network directories to measure access is insufficient," study authors said.
They proposed that states devote resources to regularly evaluate Medicaid managed care networks using audit studies and claims-based assessments, noting states such as Florida have begun to fine plans that do not comply with network adequacy standards.