Douglas Wissoker

Appointment Availability after Increases in Medicaid Payments for Primary Care

BACKGROUND Providing increases in Medicaid reimbursements for primary care, a key provision of the Affordable Care Act (ACA), raised Medicaid payments to Medicare levels in 2013 and 2014 for selected services and providers. The federally funded increase in reimbursements was aimed at expanding access to primary care for the growing number of Medicaid enrollees. The reimbursement increase expired at the end of 2014 in most states before policymakers had much empirical evidence about its effects. METHODS We measured the availability of and waiting times for appointments in 10 states during two periods: from November 2012 through March 2013 and from May 2014 through July 2014. Trained field staff posed as either Medicaid enrollees or privately insured enrollees seeking new-patient primary care appointments. We estimated state-level changes over time in a stable cohort of primary care practices that participated in Medicaid to assess whether willingness to provide appointments for new Medicaid enrollees was related to the size of increases in Medicaid reimbursements in each state. RESULTS The availability of primary care appointments in the Medicaid group increased by 7.7 percentage points, from 58.7% to 66.4%, between the two time periods. The states with the largest increases in availability tended to be those with the largest increases in reimbursements, with an estimated increase of 1.25 percentage points in availability per 10% increase in Medicaid reimbursements (P=0.03). No such association was observed in the private-insurance group. During the same periods, waiting times to a scheduled new-patient appointment remained stable over time in the two study groups. CONCLUSIONS Our study provides early evidence that increased Medicaid reimbursement to primary care providers, as mandated in the ACA, was associated with improved appointment availability for Medicaid enrollees among participating providers without generating longer waiting times. (Funded by the Robert Wood Johnson Foundation.).

Primary Care Access for New Patients on the Eve of Health Care Reform

IMPORTANCE Current measures of access to care have intrinsic limitations and may not accurately reflect the capacity of the primary care system to absorb new patients. OBJECTIVE To assess primary care appointment availability by state and insurance status. DESIGN, SETTING, AND PARTICIPANTS We conducted a simulated patient study. Trained field staff, randomly assigned to private insurance, Medicaid, or uninsured, called primary care offices requesting the first available appointment for either routine care or an urgent health concern. The study included a stratified random sample of primary care practices treating nonelderly adults within each of 10 states (Arkansas, Georgia, Illinois, Iowa, Massachusetts, Montana, New Jersey, Oregon, Pennsylvania, and Texas), selected for diversity along numerous dimensions. Collectively, these states comprise almost one-third of the US nonelderly, Medicaid, and currently uninsured populations. Sampling was based on enrollment by insurance type by county. Analyses were weighted to obtain population-based estimates for each state. MAIN OUTCOMES AND MEASURES The ability to schedule an appointment and number of days to the appointment. We also examined cost and payment required at the visit for the uninsured. RESULTS Between November 13, 2012, and April 4, 2013, we made 12,907 calls to 7788 primary care practices requesting new patient appointments. Across the 10 states, 84.7% (95% CI, 82.6%-86.8%) of privately insured and 57.9% (95% CI, 54.8%-61.0%) of Medicaid callers received an appointment. Appointment rates were 78.8% (95% CI, 75.6%-82.0%) for uninsured patients with full cash payment but only 15.4% (95% CI, 13.2%-17.6%) if payment required at the time of the visit was restricted to

Disability and Medicare Costs of Elderly Persons

75 or less. Conditional on getting an appointment, median wait times were typically less than 1 week (2 weeks in Massachusetts), with no differences by insurance status or urgency of health concern. CONCLUSIONS AND RELEVANCE Although most primary care physicians are accepting new patients, access varies widely across states and insurance status. Navigator programs are needed, not only to help patients enroll but also to identify practices accepting new patients within each plans network. Tracking new patient appointment availability over time can inform policies designed to strengthen primary care capacity and enhance the effectiveness of the coverage expansions with the Patient Protection and Affordable Care Act.

Correction: Price and Quality in Child Care Choice: A Revision

Rapidly growing Medicare expenditures, which are already expected to exceed revenues by the year 2002, are likely to accelerate as a result of the increasing numbers of very old beneficiaries (85+ years), who are particularly at risk of being disabled. The concern for Medicare is that elderly persons with disabilities incur higher than average health care costs because of the underlying causes of their disability, which are usually chronic medical conditions (Manton and Stallard 1992). Such conditions often require long-term care, but they also tend to induce illnesses requiring acute care. This study analyzed data from the Medicare Current Beneficiary Survey to examine the relationship between disability and Medicare costs. It examined relations between levels of disability and costs, interactions between disability and other beneficiary characteristics, and changes in the level of disability and costs. (The Milbank Quarterly 1997 December; 75(4): 461-493).

Welfare Reform at Three Years: The Case of Washington State's Family Independence Program

In Hofferth and Wissoker (1992) we estimated the effects of price and quality on mode of child care chosen. We found large negative effects of price and quality on choice. This paper presents a revised version of our original model. The new results suggest negative price effects which are smaller than those in the original paper. The estimated effects of child/ staff ratios also become less negative and one becomes positive.

Nursing Home Use by Dual-Eligible Beneficiaries in the Last Year of Life

This paper reports the findings of an evaluation of the Family Independence Program (FIP), a welfare reform demonstration operated in Washington State between 1988 and 1993. Despite being designed to increase employment and reduce welfare recipiency, the analysis shows that FIP had the opposite effect: employment was lower and welfare participation higher than under the AFDC program. Since FIP shared many features of the federal Job Opportunities and Basic Skills Training (JOBS) program, which was implemented two years later, these findings raise concerns about the potential impacts of that program, as well as the impacts of future state and federal reform efforts.

Primary Care Appointment Availability for Medicaid Patients: Comparing Traditional and Premium Assistance Plans

Research on health care at the end of life has focused on Medicare-financed acute care services. Much less information has been available on nursing home use in the last year of life, particularly for individuals who are dually eligible for Medicare and Medicaid. We used Medicare and Medicaid enrollment and claims data to examine nursing home admissions, odds of dying in nursing homes versus hospitals or the community, and variations in Medicare and Medicaid service use and costs by place of death. We found that, in the last year of life, 75% of dual-eligible people use nursing home care, increasing age is associated with greater likelihood of dying in nursing homes, and dual-eligible people who die in hospitals have notably higher costs than other beneficiaries.

Declining Medicaid Fees and Primary Care Appointment Availability for New Medicaid Patients

Background:Arkansas and Iowa received waivers from the federal government in 2014 to use federal Medicaid expansion funding to enroll beneficiaries in commercial insurance plans on the Marketplaces. One key hypothesis of these “private option” or “premium assistance” programs was that Medicaid beneficiaries would experience increased access to care. In this study, we compare new patient primary care appointment availability and wait-times for beneficiaries of traditional Medicaid and premium assistance Medicaid. Methods:Trained field staff posing as patients, randomized to traditional Medicaid or Marketplace plans, called primary care practices seeking new patient appointments in Arkansas and Iowa in May to July 2014. All calls were made to offices that previously indicated being in-network for the plan. Offices were drawn randomly, within insurance type, based on the county proportion of the population with each insurance type. We calculated appointment rates and wait-times for new patients for traditional Medicaid and Marketplace plans. Results:In Arkansas, Marketplace appointment rates were 27.2 percentage points higher than traditional Medicaid appointment rates (83.2% compared with 55.5%, P<0.001), while in Iowa, Marketplace appointment rates were 12.0 percentage points higher (86.3% compared with 74.3%, P<0.001). Conditional on receiving an appointment, median wait-times were roughly 1 week in each state without significant differences by insurance type. Conclusions:The experiences of Arkansas and Iowa suggest that enrolling Medicaid beneficiaries into Marketplace plans may lead to higher primary care appointment availability for new patients at participating providers. Further research is needed on whether premium assistance programs affect quality and continuity of care, and at what cost.

The evaluation of the Washington State Family Independence Program

Appointment Availability for New Medicaid Patients Under the Affordable Care Act (ACA), Medicaid fees for primary care physicians were raised to Medicare levels in 2013 and 2014. The size of the federally funded increase varied widely, as Medicaid fees were close to Medicare levels in some states and Medicaid paid less than half for the same services in other states.1 A previous study found that higher Medicaid fees in 2014 were associated with increased primary care appointment availability for new Medicaid patients.2 Now that most states have returned to lower fee levels, it is time to examine whether declining Medicaid fees are associated with decreased primary care appointment availability for new Medicaid patients.

Access to Primary Care Appointments Following 2014 Insurance Expansions

This volume, the result of the Urban Institutes evaluation of the Washington State Family Independence Program (FIP), examines a states effort to implement a welfare reform program designed to help welfare families become more economically self-sufficient. The implementation of FIP was expected, relative to the regular Aid to Families with Dependent Children program, to increase participation in education, training, and employment, which would in turn reduce welfare participation. FIP did not achieve these results. Relative to traditional welfare in the comparison sites, FIP had little or no impact on education and training; it reduced employment and earnings a little; and it increased welfare participation sunstantially. The authors present the data gathered by the Urban Institute over the past five years and analyze the reasons for FIPs failure to meet its original goals.