States get creative to meet Medicaid specialty care shortfall

Washington Programs in at least a half-dozen states are leveraging technology and primary care resources to improve specialty care access for Medicaid patients, according to a study by the Center for Studying Health System Change conducted on behalf of the Commonwealth Fund (link).

Compared with individuals who have private insurance, those on Medicaid find it more difficult to obtain timely care from specialty physicians, the study stated. Primary care referrals to specialists may not always result in appointments because of the challenges associated with finding doctors that will take on these new patients. Physicians who do accept the patients can have long waiting periods for appointments.

Low Medicaid payment rates may contribute to these access problems, but “administrative burdens, patients' nonmedical needs, and challenges keeping appointments and adhering to treatment plans play a role as well,” according to the findings.

The study examined models launched in Connecticut, Illinois, Minnesota, New Mexico, Oregon and Tennessee to improve specialty care efficiency and access for Medicaid patients. Some programs have expanded the role of nonspecialists, such as primary care physicians and nurse practitioners, to take on more specialty care issues.

One of the models studied, a partnership between Medicaid managed care plan CareOregon and several other health care organizations, uses physician assistants to provide pre-and postoperative care to surgical patients as well as to treat those who don't require surgery. These caregivers also provide screenings to patients with orthopedic conditions.

Other programs are trying to increase access to specialists through telehealth initiatives. UnitedHealthcare Community Plan, a partnership among the Tennessee Primary Care Assn. and several other medical organizations, communicates with specialists through the use of video conference appointments. Another model, Community Health Centers, which partners with Yale Medical Group and the University of Connecticut, “uses store-and-forward technology that collects images for later review by an ophthalmologist to screen for early signs of blindness in diabetic patients,” the study said.

Some models have incorporated the use of “access coordinators” and medical homes to help coordinate interactions among patients, specialists and primary care practitioners.

Pay a limiting factor

In the cases of the six states surveyed, some progress in boosting specialty access was seen despite the limitations imposed by the Medicaid rate structure.

“Although resources remain limited, participating organizations report better access to specialty care for Medicaid patients and early signs of improvements in quality and costs of care,” the study said. The authors noted that revisions to Medicaid payment methods may be needed to expand or replicate these access models elsewhere.

Larry Downs, CEO of the Medical Society of New Jersey, said network adequacy for specialists in Medicaid is a significant issue in his state. The underlying problem is that physicians in New Jersey are some of the most poorly paid participants in the Medicaid program, and it has gotten to the point where many specialists say they must reach into their own pockets to take care of these patients, he said. Some of the federally qualified health centers, which treat the state's most underserved patients, are reporting long wait times for specialists, he said. “It's a problem that we're trying to work on with the policymakers in Trenton.”

Other research has cited the barriers to care that Medicaid patients face. A study in the August 2012 Health Affairs by Sandra L. Decker, PhD, an economist at the National Center for Health Statistics, found that 96% of 4,300 licensed, office-based physicians had accepted new patients in 2011 but that doctors were least willing to take on new Medicaid patients. Sixty-six percent of primary care physicians and 72% in other specialties accepted new Medicaid patients in 2011, according to Decker's study (link).