Care in Medicaid managed care networks is highly concentrated among small number of physicians

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Medicaid managed care services are mainly concentrated across a handful of providers in a trend that's happening at a time when the managed care space is becoming more lucrative for health insurance providers, according to findings in a study Health Affairs published this week.

That's because states are increasingly deferring more to managed care private plans to deliver certain benefits to patients, the study found. At issue are network adequacy standards, which currently may not reflect actual access.

To ensure plans maintain access to care, many states set network adequacy standards that require plans to contract with a minimum number of physicians. About one-third of outpatient primary care and specialist physicians contracted with Medicaid managed care plans in the study's four-state sample saw fewer than 10 Medicaid beneficiaries in a year.

Care was highly concentrated: 25% of primary care physicians provided 86% of the care, and 25% of specialists, on average, provided 75% of specialty care.

WHAT'S THE IMPACT?

The findings highlighted the fact that almost a third of office-based physicians do not participate in Medicaid – far more participate in Medicare or the commercial insurance markets. And slightly more than 16% of physicians listed in Medicaid managed care plan provider network directors in a year qualified as "ghost" physicians – meaning they didn't see any Medicaid beneficiaries over the course of the year in an outpatient setting.

"The share of ghost physicians ranged from 13.4% to 24.9% across states," the study said.

Of all specialties, psychiatrists were most likely to be ghost physicians, with more than 35% not seeing any Medicaid patients. At 11%, primary care physicians were the least likely to be ghost physicians.

Many states, according to the study, rely on provider network directories to ensure network adequacy. But this "may be insufficient to ensure satisfactory access to physicians who are both valued by Medicaid managed care beneficiaries and willing to treat them," and network directors can overestimate how many physicians can actually provide care through Medicaid.

Authors suggested the federal government should be more explicit on how states can meet the requirement that they demonstrate managed care network adequacy standards. There's a large amount of variation among states when it comes to those standards, the study found.

It also recommended penalizing plans that have physicians in their networks who don't see Medicaid beneficiaries.

THE LARGER TREND

In February 2021, a study in Health Affairs said that in 2019, as in prior years, Medicaid physician fees remained well below Medicare and private insurance fees despite growth in Medicaid enrollment.

"Low Medicaid physician fees have important implications in terms of access to care for Medicaid enrollees …" the study in Health Affairs said.

Last year, AHIP president and CEO Matt Eyles called for strengthening and protecting Medicare Advantage as well as Medicaid Managed Care, calling the programs "efficient, effective and popular."

As Medicaid and CHIP programs provide coverage and a pathway to care for one out of every five Americans, Medicaid managed care plans serve two-thirds of them, according to Eyles – low-income families, women and children, older adults, people with disabilities and military veterans.

Such plans, he said, deliver savings through patient-centered care coordination programs, increased use of generic drugs, accessible provider networks and programs focused on routine and preventive care. Managed care plans also encourage vaccinations, help those with substance use disorders overcome their addiction and help with challenges in care access, such as housing, transportation and healthy food.

"States have selected Medicaid managed care plans as a strategic partner because managed care works," said Eyles. "With more than 77 million Americans – nearly half of which are children – states and plans work together to ensure that they meet very high metrics for quality, value and satisfaction. And as a result, 84% of enrollees say they have regular access to the care they need.

"Adults and children alike are many times more likely to have a doctor they see regularly, and to get preventive services to stay healthy. And Medicaid managed care offers Americans access to home and community-based services, giving them the freedom to receive care in their home."
 

Twitter: @JELagasse
Email the writer: jeff.lagasse@himssmedia.com