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

Research Brief

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

'Secret Shopper' Study Points to Advantages of Private Option

Simon Basseyn, Brendan Saloner, Genevieve M. Kenney, Douglas Wissoker, Daniel Polsky, and Karin V. Rhodes, Medical Care, July 2016

Key Findings: In 2014, Arkansas and Iowa expanded their Medicaid programs and enrolled many of their adult beneficiaries in commercial Marketplace plans. This study suggests that this “private option” may make it easier for new Medicaid patients to get primary care appointments.

The Question

In 2014, Arkansas and Iowa received waivers from the federal government to expand their Medicaid programs by enrolling adult beneficiaries in commercial plans on the Marketplaces established by the Affordable Care Act, instead of in traditional Medicaid. The “medically frail” remained in traditional Medicaid. In the first year, Arkansas enrolled 182,000 of 225,000 eligible people in marketplace plans, while Iowa enrolled 25,000 of 61,000 eligible people.

In this “premium assistance” model (also known as the “private option”), the state pays the premiums and cost-sharing payments to commercial plans and Medicaid beneficiaries use the same provider networks as higher-income enrollees. As providers in private insurance plans are generally paid at a higher rate than Medicaid providers, one possible benefit to this model is an increased ability to schedule care with a wider range of providers. In this “secret shopper” study, trained staff posing as patients with either traditional Medicaid or Marketplace coverage called participating primary care practices in Arkansas and Iowa seeking new patient appointments. Would the rate of appointment availability, or the wait-time for an appointment, differ based on coverage?

The Findings

Callers with Marketplace plan coverage had higher appointment rates than Medicaid callers. In Arkansas, Marketplace appointment rates were 27.7 percentage points higher than traditional Medicaid appointment rates (83.2% vs. 55.5%); in Iowa, Marketplace appointment rates were 12 percentage points higher (86.3% vs. 74.3%). Once an appointment was offered, the median wait-time was seven days for both groups.

2014 new patient primary care appointment rates among in-network providers for traditional Medicaid plans and premium assistance carriers in Arkansas and Iowa. (Medical Care, July 2016)

The Implications

This study is the first to rigorously assess access to appointments in commercial plans offered on the Marketplaces established by the Affordable Care Act. Further, it is the first to assess appointment availability in the two states that experimented with putting most of their Medicaid population into Marketplace commercial plans.

Consistent with the idea that commercial enrollees would have greater access to primary care providers, the study found that participating providers in the marketplace plans offered appointments at greater rates than the Medicaid providers, although the differential was larger in Arkansas.  Marketplace appointment rates in Arkansas and Iowa were relatively similar, but traditional Medicaid appointment rates were significantly lower in Arkansas. Appointment wait times were similar, suggesting that there is sufficient primary care capacity in both traditional Medicaid and Marketplace plans, and that providers willing to schedule appointments were also providing timely care.

The study does not explain the disparity in access to appointments, but prior work has pointed to lower reimbursements, greater administrative burdens, payment delays, and perceptions of lower patient compliance and greater patient complexity in Medicaid compared with private insurance.

In evaluating the premium assistance programs, the availability of appointments is only one of many important outcomes. The costs and quality of care are critical as well, and are being studied. For example, a report by the Government Accountability Office concluded that Arkansas’ private option will exceed the costs of a traditional Medicaid expansion by $778 million, although other evidence suggests that the additional costs may not be this extreme.

The private option has fared better in Arkansas than in Iowa. Arkansas has maintained a fairly large and competitive Marketplace pool with moderate and stable premiums compared with neighboring states.  In Iowa, however, including the small Medicaid population in the marketplace did not appear to spur enough competition in the marketplace. In late 2014, one of the two insurers participating in premium assistance withdrew, and the remaining insurer withdrew in 2015. Marketplace premium increases in Iowa also exceeded national averages. Within 2 years, the premium assistance experiment in Iowa was over. Iowa has since been approved for a waiver amendment that requires all adults who are eligible for Medicaid to enroll in private capitated Medicaid managed care organizations, which has prompted new waves of public concern and reinforces the need for ongoing monitoring of access. The state began enrolling beneficiaries into managed care plans on Jan. 1, 2016.

The Study

The study used audit methodology, or “secret shoppers” to assess the availability of primary care appointments. Trained field staff posed as patients with either Medicaid or Marketplace coverage, and called participating primary care physicians in Iowa and Arkansas requesting a new patient appointment. Callers portrayed a patient seeking either a routine check-up or an evaluation for possible hypertension.  Prior to the call, a survey confirmed the insurance plans accepted by the practice, and calls were made only to participating practices. In Arkansas, the researchers conducted 248 calls in the Medicaid arm and 570 in the Marketplace arm, and in Iowa, 261 calls in the Medicaid arm and 564 in the Marketplace arm.

First Author: Simon Bassyn

Simon Basseyn is a MD/MBA candidate at the Perelman School of Medicine and Wharton School of Business at the University of Pennsylvania. He holds a BA in politics from New York University and took a year out from medical school to conduct health services research as a fellow at the University of Pennsylvania’s Center for Emergency Care Policy and Research and Leonard Davis Institute of Health Economics. His interests lie in the intersection of medicine, business, and politics. His previous work has focused on access to care, transitions of care, patient-centered medical homes, and barriers to unscheduled care. Simon has also worked in management consulting for McKinsey & Company and venture capital for SR One.

This study is part of a multi-year effort by investigators from Penn, Johns Hopkins, Urban Institute, and Northwell Health/Hofstra Medical School. Co-authors include Brendan Saloner, Genevieve M. Kenney, Douglas Wissoker, Daniel Polsky, and Karin V. Rhodes.


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