Health Policy$ense

Ongoing Challenges in Access to Care in Medicaid Managed Care

51% of Providers Could Not Offer Appointments to Callers

A recent report from the Office of Inspector General (OIG) found significant ongoing challenges in access to care for enrollees in Medicaid managed care (MMC). Through “mystery shopper” calls to 1,800 primary care and specialty care providers on state provider lists, OIG found that only 49% of providers offered an appointment across 32 states. Primary care providers offered appointments at a lower rate (44%) than specialty care providers (57%).

The 51% of providers who could not offer appointments to callers consisted of 35% who could not be found at the listed location, 8% who were at the listed location but did not participate in the plan, and 8% who were simply not accepting new MMC patients. The report notes that sometimes “the practice had never heard of the provider” and that “some providers had left months or even years before the time of the call.” Even when providers were at the listed location, some “had never participated in the MMC plan.”

Even though federal regulations require states to ensure that each managed care organization “maintains and monitors a network of appropriate providers…sufficient to provide adequate access to all services…,” a companion OIG report released earlier this year found that state standards for access to care and strategies to assess compliance vary widely. Most states did not identify any violations in access standards over the previous 5 years, but the few states that did identify significant numbers of violations were those that used “direct tests of compliance,” such as mystery shopper calls, highlighting the effectiveness of this assessment strategy.

The recent report highlights two critical but distinct challenges in access to care for MMC enrollees: inaccuracy of provider lists and limited appointment availability for Medicaid beneficiaries.

Inaccurate provider lists are neither new nor unique to Medicaid, plaguing both traditional commercial insurance as well as new exchange plans. Responding to the report, both the Centers for Medicare and Medicaid Services (CMS) and Medicaid Health Plans of America argued that the “cold-call” methodology employed by OIG does not reflect how real MMC enrollees find a doctor, instead relying on support services like managed care call centers, care coordinators, ombudsman offices, and community health centers. Nonetheless, state provider lists reflect the “official” source of participating physicians used by many enrollees and even patient navigators.

Even when calling participating providers, however, MMC enrollees may experience lower appointment availability compared to commercial insurance beneficiaries. A study published earlier this year in JAMA-IM by Rhodes, et al. conducted similar mystery-shopper calls across 10 states but only called primary care practices that were already confirmed to participate in a specific MMC plan through a non-deceptive survey conducted prior to the mystery-shopper calls. Even when only calling identified participating providers, Medicaid callers were offered appointments only 57.9% of the time compared to privately insured callers who were offered appointments 84.7% of the time. Even with perfect provider lists, therefore, MMC enrollees may experience lower access to providers than their commercially-insured counterparts.

These results likely reflect the lower willingness of some providers to see new Medicaid patients in order to maintain a desired payer-mix, even among providers who participate in MMC plans. Previous literature has identified many reasons for this, including lower reimbursements, increased administrative burden, delays in payments, and negative perceptions of Medicaid patients. The OIG report identified cases in which providers denied appointments to MMC callers citing concerns such as frequent no-shows, certain medical conditions like chronic pain, and even an excessive body-mass index.

Median wait-times for MMC enrollees who received an appointment were 10 days for primary care (7 days in the Rhodes 10-state study) and 20 days for specialty care. Overall, 51% of callers experienced wait-times fewer than 2 weeks while 10% experienced wait-times greater than 2 months. While results indicate that most Medicaid enrollees experience reasonable wait-times, long wait-times may have a negative impact on the health of patients with more acute needs.

Moving forward, OIG recommended that CMS work with states on 3 key issues:

  1.  Assessing the number of providers offering appointments and improving the accuracy of plan information
  2.  Ensuring that plans’ networks are adequate and meet the needs of MMC enrollees
  3.  Ensuring that plans comply with existing network adequacy standards and assessing whether additional standards are needed.


In its response to the report, CMS agreed with all 3 recommendations.

Rigorously measuring and monitoring MMC network adequacy and access to care for Medicaid beneficiaries will become even more critical as enrollment continues to increase by millions around the country, further increasing demand for both primary and specialty care among beneficiaries.