1. Anna Sommers † Julia Paradise ‡ Carolyn Miller * † Center for Studying Health System Change ‡ Kaiser Commission on Medicaid and the Uninsured * Independent consultant Presentation at State Health Research & Policy Interest Group Meeting, Seattle June 11, 2011 Physician Willingness and Resources to See New Medicaid Patients: Perspectives of Primary Care Physicians

2. Center for Studying Health System Change – www.hschange.org ACA places new pressures on the Medicaid program Center for Studying Health System Change – www.hschange.org  Extends Medicaid eligibility to most people up to 133% of FPL  16 million people will gain Medicaid coverage  25% increase over current enrollment  Raises Medicaid payment rates for primary care services delivered by primary care physicians to Medicare payment levels.  Temporary (2013 and 2014)  Rates for specialty services remain unchanged. 2

3. Center for Studying Health System Change – www.hschange.org Study Objective  Describe willingness and resources of primary care physicians to accept new Medicaid patients.  For Medicaid policy, willingness to treat patients just as critical to understand as physician capacity.  First study to combine data on these two dimensions. 3

4. Center for Studying Health System Change – www.hschange.org Survey Data  2008 Center for Studying Health System Change (HSC) Health Tracking Physician Survey  Nationally representative sample of U.S. physicians  Self-administered mail survey  Provide direct patient care (20+ hrs per week)  62% response rate  More information:  Strouse et al. 2009, www.hschange.org 4

5. Center for Studying Health System Change – www.hschange.org Survey Data  Analytic sample  Primary care physicians (PCPs) based on self-report  internal medicine  family medicine  general practice  Excludes if practiced most hours on hospital staff or in ED  1,460 PCPs 5

6. Center for Studying Health System Change – www.hschange.org Methods  PCPs ranked by level of participation in Medicaid  High-share Medicaid  26% or more of practice revenue from Medicaid  Moderate-share Medicaid  6-25% of practice revenue from Medicaid  Accept new Medicaid patients  High-share Medicare (“Medicare”)  26% or more of practice revenue from Medicare  Accept new Medicare patients  Revenue from Medicaid 1% or more  Low and no-share Medicaid – none of the above 6

7. Center for Studying Health System Change – www.hschange.org In-depth Follow-up Interviews  15 PCPs were interviewed in Summer 2010, after the ACA became law:  (5) High-share Medicaid, (4) Moderate-share Medicaid, (6) High-share Medicare  Stratified by practice size, type, and region  Various markets represented (eg. low-income urban, small town, suburban middle-income). 7

8. Center for Studying Health System Change – www.hschange.org 8

9. Difference from high-share Medicaid PCPs is statistically significant at *p<.05 and **p<.01. Difference from moderate-share Medicaid is statistically significant at †p<.05 and ‡p<.01. Source: 2008 HSC Health Tracking Physician Survey Difference from high-share Medicaid PCPs is statistically significant at *p<.05 and **p<.01. Difference from moderate-share Medicaid is statistically significant at †p<.05 and ‡p<.01. Source: 2008 HSC Health Tracking Physician Survey 9

10. Center for Studying Health System Change – www.hschange.org  High-share Medicaid PCPs:  More in hospital-based offices and community health centers (38 vs 17 and 6%).  High- and moderate-share Medicaid PCPs:  More report hospital ownership interest (30 vs 19%).  Located in areas with lower household income.  Medicare PCPs (vs high/moderate Medicaid):  More in solo/2-physician practices (44 vs 26 and 32%). Practice Type and Location by Level of Medicaid Participation 10

11. Center for Studying Health System Change – www.hschange.org Difference from high-share Medicaid PCPs is statistically significant at *p<.05 and **p<.01. Difference from moderate-share Medicaid is statistically significant at †p<.05 and ‡p<.01. Source: 2008 HSC Health Tracking Physician Survey Difference from high-share Medicaid PCPs is statistically significant at *p<.05 and **p<.01. Difference from moderate-share Medicaid is statistically significant at †p<.05 and ‡p<.01. Source: 2008 HSC Health Tracking Physician Survey 11

12. Center for Studying Health System Change – www.hschange.org  PCPs currently limiting Medicaid panel expected to revisit participation level after Medicaid expansion.  Most cited at least one issue besides payment that would be considered.  Difficulty finding specialists, paperwork, time-burden of non-medical needs are all factors.  Some consider Medicare patients/program to be more of a burden than Medicaid.  Illness burden of new patients Findings of In-depth Interviews: Willingness 12

13. Center for Studying Health System Change – www.hschange.org  PCPs most willing to accept new Medicaid patients are already serving many of them.  Just as likely to use health IT, more likely to offer other key supports.  Practice in low-income areas.  Report more constraints on time and difficulty finding specialists.  Supporting new capacity here might improve access. Summary and Discussion 13

14. Center for Studying Health System Change – www.hschange.org  Moderate-share Medicaid PCPs hold some promise for adding capacity in Medicaid:  Practice in lower-income areas, use health IT, some have other supports in place.  Decision matrix and makers may be different because practice settings are different.  Addressing issues other than payment (payment delays, prior authorization) may increase participation levels. Summary and Discussion 14

15. Center for Studying Health System Change – www.hschange.org  High-share Medicare PCPs hold less promise for increasing capacity:  More are in solo/2-physician practices.  Fewer have key patient supports.  Location in higher-income areas may be a barrier.  Payment increases in Medicaid and trends in hospital acquisition of practices may impact both willingness and capacity. Summary and Discussion 15

16. Center for Studying Health System Change – www.hschange.org Kaiser Family Foundation http://www.kff.org/medicaid/8178.cfm Jointly released in Medicare & Medicaid Research Review (MMRR) Publication of the Centers for Medicare & Medicaid Services, Center for Strategic Planning https://www.cms.gov/MMRR/ Published study now available 16