Just try to get an appointment with a Medicaid managed care provider

Department of Health and Human Services
Office of Inspector General
December 2014
Access to Care: Provider Availability in Medicaid Managed Care

Examining access to care takes on heightened importance as enrollment
grows in Medicaid managed care programs. Under the Patient Protection
and Affordable Care Act, States can opt to expand Medicaid eligibility,
and even States that have not expanded eligibility have seen increases
in enrollment. Most States provide some of their Medicaid services—if
not all of them—through managed care. The Office of Inspector General
received a congressional request to evaluate the adequacy of access to
care for enrollees in managed care.

We found that slightly more than half of providers could not offer
appointments to enrollees. Notably, 35 percent could not be found at the
location listed by the plan, and another 8 percent were at the location
but said that they were not participating in the plan. An additional 8
percent were not accepting new patients. Among the providers who offered
appointments, the median wait time was 2 weeks. However, over a quarter
had wait times of more than 1 month, and 10 percent had wait times
longer than 2 months. Finally, primary care providers were less likely
to offer an appointment than specialists; however, specialists tended to
have longer wait times.

Findings

* Half of providers could not offer appointments to enrollees

* Forty-three percent of providers were not participating in the plan
at the listed location

* Another 8 percent of providers were not accepting new patients

* Among the providers who offered appointments, the median wait time
was 2 weeks; however, over a quarter had wait times of more than 1 month

* A small number of providers required patients to submit medical
records prior to scheduling an appointment or would not accept patients
with certain medical conditions

* Primary care providers were less likely to offer an appointment than
specialists; however, specialists tended to have longer wait times

* The median wait time for specialists was twice as long as that for
primary care providers

Conclusion

Our findings demonstrate significant vulnerabilities in provider
availability, which is a key indicator for access to care. These
findings also raise serious questions about the abilities of plans,
States, and CMS to ensure that access-to-care standards are met. Without
adequate access, enrollees cannot receive the preventive care and
treatment necessary to achieve positive health outcomes and improved
quality of life.

Notably, 51 percent of providers were either not participating in the
plan at the location listed or not accepting new patients enrolled in
the plan. When providers listed as participating in a plan cannot offer
appointments, it creates a significant obstacle for an enrollee seeking
care. Moreover, it suggests that the actual size of provider networks
may be considerably smaller than what is presented by Medicaid managed
care plans.

Among the providers who offered appointments, the median wait time was 2
weeks. However, over a quarter had wait times of more than 1 month, and
10 percent had wait times longer than 2 months. Long wait times can have
a significant impact on patient care. It also raises questions about
whether these plans are complying with their States' standards for
access to care, as most States have access standards that require
appointments be provided within 1 month or less. That so many providers
could not offer appointments within a month raises concerns about
enrollees' ability to obtain timely access to care.

http://oig.hhs.gov/oei/reports/oei-02-13-00670.pdf

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Comment by Don McCanne

One of the major features of the Affordable Care Act was to expand
Medicaid to cover a greater number of low-income individuals. Although
many states opted out of the expansion, nevertheless Medicaid enrollment
increased in those states as well. Because of the expansion of state
budgets required to cover the burgeoning Medicaid population, most
states have moved most if not all of their Medicaid patients into
Medicaid managed care plans.

Although states claim that this benefits patients by placing them in
organizations that are designed to manage their health care, the real
reason is that the states wanted to save money. The managed care plans
agree to provide care at a cost lower than the costs of comparable care
provided by community hospitals and physicians. Because of the increased
enrollment, the total costs of Medicaid are increasing, but the payments
per individual are not.

Medicaid, being a welfare program, was already chronically underfunded.
Further limiting payments per patient can place a serious strain on
resources that would pay for all of the promised care. This OIG study
was done in the summer of 2013, before the surge in enrollment that
began later that year. If half of providers could not offer appointments
to patients at that time, what is happening now that the managed care
organizations must accommodate the added demand?

Although there are already many anecdotal reports that the managed care
organizations are not meeting their obligations under these state
contracts, we will have to wait longer before we have a comprehensive
objective evaluation of the extent of the deficiencies in health care
services.

Isolating low-income individuals and placing them into an underfunded
welfare program will certainly perpetuate disparities in care. Yet the
deficiencies in health care services are even worse in those states that
opted out of Medicaid expansion, and they are worse for the undocumented
residents who are prohibited from participating in Medicaid or in the
subsidized plans offered by the exchanges.

Under a single payer national health program - an improved Medicare for
all - everyone would have access to a system that met the highest
standards of care. The wealthy would still have their high standard of
care, but with their special amenities paid for separately, such as
private hospital suites, whereas low-income individuals could have the
same high standard of care, but without the amenities. Because of the
efficiencies of the single payer model, it would not cost the nation any
more than we are now spending on health care.