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Study Shows a Patient's Insurance Still Determines Physician Access

By Rebecca Adams, CQ HealthBeat Associate Editor

August 6, 2012 -- About 69 percent of physicians nationwide accepted new Medicaid patients last year, compared to the 83 percent who took new Medicare patients or the nearly 82 percent who saw new privately insured patients, according to a study in the journal Health Affairs published last week.

The study is extrapolated from an annual Centers for Disease Control and Prevention (CDC) survey of 4,326 doctors.

The report included a state-by-state chart showing physician acceptance rates. New Jersey was the state where new Medicaid patients faced the biggest challenge in finding a physician; there, about 40.4 percent of doctors accepted new individuals. The state with the second-lowest acceptance rate was California, although its rate was similar to the national average.

Higher Medicaid rates played a role in persuading physicians to schedule new patients for appointments.

"Acceptance rates of new Medicaid patients were higher in states with higher Medicaid-to-Medicare fee-for-service fee ratios," wrote author Sandra Decker, an economist with the CDC's National Center for Health Statistics. Medicare generally pays physicians higher rates than Medicaid, although the difference varies because each state sets its own Medicaid physician payment rates.

Decker found that a 10 percentage-point rise in the Medicaid-to-Medicare payment ratio increased the acceptance of new Medicaid patients by an average of four percentage points.

The study said that primary care doctors were 11 percent less likely than other physicians to agree to see new Medicaid patients.

Physicians outside of cities and metropolitan statistical areas were 19 percent more likely to take new patients. Doctors in the Midwest were 12 percent more likely to accept new Medicaid patients than those in the Northeast.

It isn't clear how temporary payment changes in the 2010 health care law (PL 111-148, PL 111-152) will affect physicians' behavior. In 2013 and 2014, doctors will be paid the higher Medicare rates. But that federal payment boost will disappear the following year. However, states could choose to maintain the higher rates if officials believe that they can afford to do so.

The findings come as many states are considering whether to expand their Medicaid programs under the 2010 overhaul.

Another recent Health Affairs study released by George Washington University professor Sara Rosenbaum and former federal Medicaid director Tim Westmoreland examined the June 28 Supreme Court decision on Medicaid. The ruling removed a requirement that states who choose not to expand Medicaid under the law would have to forfeit all of the federal matching funds for their existing program. Instead, states would only lose the opportunity to gain federal matching rates for the population of people who would be newly eligible.

Rosenbaum and Westmoreland raised questions about whether the Department of Health and Human Services (HHS) has the flexibility to allow states to expand Medicaid by a portion of the group that the health care law would have covered. The pair explored three potential responses from HHS officials.

Under the first, HHS officials may take a hard line approach and decide that states must either expand their programs to all of the population that would have been covered under the law or none of them.

Rosenbaum and Westmoreland said that this perspective is backed by the plain text of the law.

The HHS secretary, they write, "lacks the authority to break the expansion group into pieces, to allow less than full coverage of the group, or to allow states to phase in coverage."

But they write that "although correct as a matter of law, this position increases attention and pressure on Congress at a critical time in the Affordable Care Act's implementation." Some supporters fear that "in a climate driven by political animosity" toward the law, Congress could end up getting rid of the Medicaid expansion altogether if lawmakers start revising it.

Under another scenario, which the authors describe as tricky, HHS officials could use flexibility, such as allowing states to expand the program in phases.

"However, if the secretary were to take this initial step, there would be no obvious stopping point to the calls for interpretation and flexibility," they wrote.

Under a third possible interpretation, HHS officials might use their demonstration authority under Section 1115 of the part of the Social Security Act governing Medicaid waivers. But that could be fraught with legal peril.

"Low-income people have challenged unwarranted uses of Section 1115 and won," warned the pair.

HHS officials have not yet released information on which approach they are inclined to pursue.

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