Health plans, providers and legislators need to increase the number of primary care practitioners participating in Medicaid as the wait for many to access care is inadequate and getting worse as enrollment mushrooms.
But a number of the actions needed are embroiled in financial, political and cultural battles arising from the Affordable Care Act, according to panel speakers at an Oct. 1 conference sponsored by America's Health Insurance Plans.
Higher payments for physicians, more residencies to meet the number of medical school graduates, additional support by federal and state legislators and faster adoption of pay for performance models top the list.
"The number one way to overcome barriers to access is to improve reimbursement so physicians are willing to see more Medicaid patients," said Thomas James III, MD, corporate medical director for clinical policy at AmeriHealth Caritas companies.
The ACA provided for Medicaid parity with Medicare in paying for primary care in both fee-for-service and managed care programs, with the federal government financing the difference for calendar years 2013 and 2014.
But Congress will need to extend the Medicaid provider payment bump or it will expire in January, cutting payments back to pre-ACA rates, he said.
Standards for access to care vary by state in terms of geography, specialty, availability, and enforcement – and only 50 percent of physicians accept Medicaid. With the expansion of Medicaid under the ACA, one quarter of all Americans will be covered by Medicaid for at least part of the year by 2016.
"We then have real disparities in care, which should make us all angry," James said. The need is not only to provide for adequate access but making sure that it is affordable.
In a survey he cited of physicians by the Ohio State Medical Association in the spring, 40 percent of doctors who didn't accept Medicaid in 2013 now do because of higher reimbursement; 40 percent of those who were already accepting Medicaid patients increased those numbers with a portfolio of payers; and 40 percent said they plan to cut back on their Medicaid patient volume if the program is not extended.
But primary care organizations don't have a handle yet on what the impact is on visits, cost and quality, James said.
Kip Piper, senior consultant for Sellers Dorsey, said a comprehensive strategy is needed for assuring services to low income populations. "Rates are important, but it is not sufficient for access and volume of visits," he said. "We have to have a more aggressive strategy about payment at the provider and plan levels and aligning that with outcomes, access being one of them."
Supplemental payment is one approach; some states have targeted money for hospitals. Similarly, states could improve reimbursement for primary care physicians and, as they expand the scope of practice, to other practitioners, such as nurse practitioners, physician assistants, dentists, and pharmacists, through Medicaid managed care programs to improve access and outcomes.
"It's kind of creative financing, and you're dealing with counties and other public institutions," he said. "But it's getting a lot of attention in a number of states."