Michael R. Richards

Appointment Availability after Increases in Medicaid Payments for Primary Care

BACKGROUNDnProviding 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.nnnMETHODSnWe 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.nnnRESULTSnThe 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.nnnCONCLUSIONSnOur 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.).

Access points for the underserved: primary care appointment availability at federally qualified health centers in 10 States.

Background:Federally Qualified Health Centers (FQHCs) are a vital source of primary care for underserved populations, such as Medicaid enrollees and the uninsured. Their role in delivering care may increase through new funding allocations in the Affordable Care Act and expanded Medicaid programs across many states. Objective:Examine differences in appointment availability and wait-times for new patient visits between FQHCs and other providers. Research Design:We use experimental data from a simulated patient study to compare new patient appointment rates across FQHC and non-FQHC practices for 3 insurance types (private, Medicaid, and self-pay). Trained auditors, posing as patients requesting the first available new patient appointment, were randomized to call primary care providers in 10 states in late 2012 and early 2013. Multivariate regression models adjust for caller-level, clinic-level, and area-level variables. Study Setting:The sample comprises 10,904 calls, including 544 calls to FQHCs. Results:FQHCs grant new patient appointments at high rates, irrespective of patient insurance status. Adjusting for caller, clinic, and area variables, the Medicaid appointment rate at FQHCs is 22 percentage points higher than other primary care practices. Although the appointment rate difference between FQHCs and non-FQHCs is somewhat smaller for the self-pay group, FQHCs are much more likely to provide a lower-cost visit to these patients. Conditional on receiving an appointment, wait-times at FQHCs are comparable with other providers. Conclusion:FQHCs’ greater willingness to accept new underserved patients before 2014 underscores their potential key roles as health reform proceeds.

Availability of New Medicaid Patient Appointments and the Role of Rural Health Clinics.

OBJECTIVEnTo examine the willingness to accept new Medicaid patients among certified rural health clinics (RHCs) and other nonsafety net rural providers.nnnDATA SOURCESnExperimental (audit) data from a 10-state study of primary care practices, county-level information from the Area Health Resource File, and RHC information from the Center for Medicare and Medicaid Services.nnnSTUDY DESIGNnWe generate appointment rates for rural and nonrural areas by patient-payer type (private, Medicaid, self-pay) to then motivate our focus on within-rural variation by clinic type (RHC vs. non-RHC). Multivariate linear models test for statistical differences and assess the estimates sensitivity to the inclusion of control variables.nnnDATA COLLECTIONnThe primary data are from a large field study.nnnPRINCIPAL FINDINGSnApproximately 80 percent of Medicaid callers receive an appointment in rural areas-a rate more than 20 percentage points greater than nonrural areas. Importantly, within rural areas, RHCs offer appointments to prospective Medicaid patients nearly 95 percent of the time, while the rural (nonsafety net) non-RHC Medicaid rate is less than 75 percent. Measured differences are robust to covariate adjustment.nnnCONCLUSIONSnOur study suggests that RHC status, with its alternative payment model, is strongly associated with new Medicaid patient acceptance. Altering RHC financial incentives may have consequences for rural Medicaid enrollees.

Influence of provider mix and regulation on primary care services supplied to US patients

Access to medical care and how it differs for various patients remain key policy issues. While existing work has examined clinic structures influence on productivity, less research has explored the link between provider mix and access for different patient types - which also correspond to different service prices. We exploit experimental data from a large field study spanning 10 US states where trained audit callers were randomly assigned an insurance status and then contacted primary care physician practices seeking new patient appointments. We find clinics with more non-physician clinicians are associated with better access for Medicaid patients and lower prices for office visits; however, these relationships are only found in states granting full practice autonomy to these providers. Substituting more non-physician labor in primary care settings may facilitate greater appointment availability for Medicaid patients, but this likely rests on a favorable policy environment. Relaxing regulations for non-physicians may be an important initiative as US health reforms continue and also relevant to other countries coping with greater demands for medical care and related financial strain.

Surgeon Participation in Early Accountable Care Organizations

Objective: We aimed to characterize the landscape of surgeon participation in early accountable care organizations (ACOs) and to identify specialty-, organization-, and market-specific factors associated with ACO participation. Background: Despite rapid deployment of alternative payment models (APMs), little is known about the prevalence of surgeon participation, and key drivers behind surgeon participation in APMs. Methods: Using data from SK&A, a research firm, we evaluated the near universe of US practices to characterize ACO participation among 125,425 US surgeons in 2015. We fit multivariable logistic regression models to characterize key drivers of ACO participation, and more specifically, the interaction between ACO affiliation and organizational structure. Results: Of 125,425 US surgeons, 27,956 (22.3%) participated in at least 1 ACO program in 2015. We observed heterogeneity in participation by subspecialty, with trauma and transplant reporting the highest rate of ACO enrollment (36% for both) and plastic surgeons reporting the lowest (12.9%) followed by ophthalmology (16.0%) and hand (18.6%). Surgeons in group practices and integrated systems were more likely to participate relative to those practicing independently (aOR 1.57, 95% CI 1.50, 1.64; aOR 4.87, 95% CI 4.68, 5.07, respectively). We observed a statistically significant interaction (P <0.001) between surgical specialty and practice organization. Model-derived predicted probabilities revealed that, within each specialty, surgeons in integrated health systems had the highest predicted probabilities of ACO and those practicing independently generally had the lowest. Conclusions: We observed considerable variation in ACO enrollment among US surgeons, mediated at least in part by differences in practice organization. These data underscore the need for development of frameworks to characterize the strategic advantages and disadvantages associated with APM participation.

Rural And Nonrural Primary Care Physician Practices Increasingly Rely On Nurse Practitioners

The use of nurse practitioners (NPs) in primary care is one way to address growing patient demand and improve care delivery. However, little is known about trends in NP presence in primary care practices, or about how state policies such as scope-of-practice laws and expansion of eligibility for Medicaid may encourage or inhibit the use of NPs. We found increasing NP presence in both rural and nonrural primary care practices in the period 2008-16. At the end of the period, NPs constituted 25.2xa0percent of providers in rural and 23.0xa0percent in nonrural practices, compared to 17.6xa0percent and 15.9xa0percent, respectively, in 2008. States with full scope-of-practice laws had the highest NP presence, but the fastest growth occurred in states with reduced and restricted scopes of practice. State Medicaid expansion status was not associated with greater NP presence. Overall, primary care practices are embracing interdisciplinary provider configurations, and including NPs as providers can strengthen health care delivery.

Spanish-Speaking Immigrants’ Access to Safety Net Providers and Translation Services Across Traditional and Emerging US Destinations

Policy Points: nLatino immigrants have recently spread beyond traditional US enclaves to “emerging destinations.” The arrival of limited English proficiency (LEP) Spanish-speakers to these areas can challenge the health care system, as translation services may not be readily available for LEP patients. nTrained auditors posed as family members of LEP patients seeking primary care in a safety net setting. We found substantially lower appointment availability for LEP adults in emerging destinations compared to traditional destinations. nGreater bilingual resources are needed within safety net clinics to accommodate LEP Spanish speakers as this population continues to grow and expand throughout the United States. n n n nContext nRecent demographic trends show Latino immigrants moving to “emerging destinations” outside traditional Latino enclaves. Immigrants in emerging destinations with limited English proficiency (LEP) may experience greater challenges finding health care services oriented to their linguistic needs than those in traditional enclaves, especially if the supply of language resources in these areas has not kept pace with new demand. n nMethods nThis study uses an experimental audit design to directly compare the ability of uninsured Spanish-speaking LEP adults to access interpreter services and to obtain new patient primary care appointments at federally qualified health centers (FQHCs) across traditional and emerging destinations. We additionally compare the appointment rates of English-proficient uninsured and English-proficient Medicaid patients across these destinations that contacted the same FQHCs. English-proficient patients serve as an access benchmark that is independent of differences in Spanish language services. n nFindings nResults indicate that LEP Spanish-speaking patients within emerging destinations are 40 percentage points less likely to receive an appointment than those in traditional destinations. English-proficient groups, by contrast, experience similar levels of access across destinations. Disparities in safety net provider access by destination status are consistent with differences in the availability of bilingual services. Ninety-two percent of FQHCs in traditional destinations offered appointments with either Spanish-speaking clinicians or translation services with non-clinical bilingual staff, while only 54% did so in emerging destinations. LEP patients denied care in emerging destinations must also travel greater distances than in traditional destinations to reach the next available safety net provider. n nConclusions nOur findings highlight that current language resources in emerging destinations may be inadequate for keeping up with the transforming needs of the patient population. As the Latino immigrant population continues to expand and diffuse, better accommodation within the health care safety net is likely to increase in importance.

Heterogeneity in the smoking response to health shocks by out-of-pocket spending risk

An existing literature demonstrates that adverse changes to health can lead to improvements in health behaviors. Although the exact explanations for these empirical findings are debated, some posit that individuals learn about their true health risks through health shocks. Updated health risk information can then induce changes in health behaviors. While we follow a learning framework, we argue that past work has neglected the role of health insurance and medically related financial risk within this decision making context. Using longitudinal data from 11 European countries, we investigate the impact of a new cardiovascular (CV) health shock on smoking decisions among older adults and examine whether personal exposure to medical spending risk influences the smoking response. We then explore two potential mechanisms for this link: larger updates to health risk beliefs and higher medical expenditures to incentivize behavior change. We find that CV shocks impact the propensity to smoke, with relatively more impact among individuals with high financial risk exposure to medical spending. We also see larger increases in out-of-pocket expenditures following a shock for this group--consistent with the latter mechanism for behavior change.

Physician Competition in the Era of Accountable Care Organizations

OBJECTIVEnTo calculate physician concentration levels for all U.S. markets using detailed data on integration and accountable care organization (ACO) participation.nnnDATA SOURCEn2015 SK&A office-based physician survey linked to all commercial and public payer ACOs.nnnSTUDY DESIGNnWe construct three separate Herfindahl-Hirschman Index (HHI) measures and plot their distributions. We then investigate how prevailing levels of concentration change when incorporating more detailed organizational features into the HHI measure.nnnPRINCIPAL FINDINGSnHorizontal and vertical integration strongly influences measures of physician concentration; however, ACOs have limited impact overall. ACOs are often present in competitive markets, and only in a minority of these markets do ACOs substantively increase physician concentration.nnnCONCLUSIONSnMonitoring ACO effects on physician competition will likely have to proceed on a case-by-case basis.

Market environment and Medicaid acceptance: What influences the access gap?

The U.S. health care system is undergoing significant changes. Two prominent shifts include millions added to Medicaid and greater integration and consolidation among firms. We empirically assess if these two industry trends may have implications for each other. Using experimentally derived (secret shopper) data on primary care physicians real-world behavior, we observe their willingness to accept new privately insured and Medicaid patients across 10 states. We combine this measure of patient acceptance with detailed information on physician and commercial insurer market structure and show that insurer and provider concentration are each positively associated with relative improvements in appointment availability for Medicaid patients. The former is consistent with a smaller price discrepancy between commercial and Medicaid patients and suggests a beneficial spillover from greater insurer market power. The findings for physician concentration do not align with a simple price bargaining explanation but do appear driven by physician firms that are not vertically integrated with a health system. These same firms also tend to rely more on nonphysician clinical staff.