Mailbag: Medicaid’s Physician Participation

This week, a reader sent us comments on the reasons behind lower physician participation in Medicaid, as compared with private insurance or Medicare.

In the FactCheck Mailbag, we feature some of the email we receive. Readers can send comments to editor@factcheck.org. Letters may be edited for length.

Doctors Who Don’t Take Medicaid 

I am an assistant professor of health policy and management at Emory University’s Rollins School of Public Health. Much of my research concerns physicians’ participation (and non-participation) in Medicaid among other Medicaid policy issues. As such, I enjoyed reading your article today on physicians’ participation in Medicaid [“Medicaid’s Doctor Participation Rates,” March 29], and I think the main thrust of your response to Rep. Paul Ryan’s and Sec. Tom Price’s comments on the subject was appropriate.

I did want to offer one comment. I believe your article, like much of the literature on this subject, overplays the importance of Medicaid fee levels (relative to Medicare or private insurance) as a driver of levels of physician participation in Medicaid. The fee levels are surely important, and if they were higher, physicians’ participation in Medicaid would be higher as well. But what I have found is often missing or underplayed in reviews and papers on this issue is discussion of the non-financial factors that drive physician practices’ decisions about whether or not to accept Medicaid patients. Several papers have documented how these non-financial factors affect Medicaid participation, but because data on them are not widely available, they do not receive as much consideration as they merit. Among the factors I am speaking about are:

  • Differences in physician practice structures. Large, multispecialty physician groups are much more likely to accept Medicaid patients than small practices with only one or two physicians.
  • Delays in Medicaid programs’ systems for paying claims.
  • Administrative hassles and paperwork.
  • Some physicians’ distaste for restrictive policies and practices of the managed care plans through which three-quarters of Medicaid beneficiaries’ benefits are administered.
  • Relative difficulties of serving Medicaid beneficiaries. Relative to privately insured patients, Medicaid beneficiaries on average require more care management support, miss appointments more often, more often struggle to adhere to physician-recommended treatments, may have a greater general distrust of the health care system, etc.
  • Concerns that a Medicaid patient they see today will become an uninsured patient tomorrow. Medicaid beneficiaries eligible on the basis of low income often churn in and out of eligibility because of volatile incomes, inflexible work schedules that do not allow for visits to the social services offices where some states require documentation be submitted, etc.
  • Restrictive state regulations governing the practice of nurse practitioners and physician assistants. Many physicians would like to delegate the responsibilities of Medicaid patient visits to non-physician clinician staff, given that these lower-cost providers’ salaries more closely mirror expected reimbursement.

Moving forward, when policymakers note that fewer physicians treat Medicaid patients than treat patients insured through Medicare or private insurance, it is important to keep these factors in mind. Evidence suggests low Medicaid fees are by no means the only reason for this disparity, and thus raising Medicaid fees is not the only feasible solution.

Adam S. Wilk, Ph.D.
Rollins School of Public Health
Emory University

Atlanta, Georgia 

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