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Medicaid programs are facing "mismatch" with primary care
The states with the largest expected Medicaid enrollment growth are the very ones that have the fewest number of primary care physicians, according to a March 2011 report.1 Temporary increases in Medicaid reimbursement are unlikely to make much of a difference in states facing the biggest enrollment increases, says study author Peter Cunningham, PhD, a senior fellow and director of quantitative research at the Center for Studying Health System Change in Washington, DC.
This is because states that currently have the lowest primary care physician capacity tend to already have Medicaid reimbursement rates that are close to Medicare rates, or in some cases exceed Medicare rates, explains Dr. Cunningham.
"That was a bit of a surprise," he says. "That means they are not going to benefit as much by the two-year increase in rates that is part of health care reform."
While states with the smallest number of primary care physicians per capita overall will see the largest percentage increases in Medicaid enrollment, states with the largest number of primary care physicians per capita will see more modest increases in Medicaid enrollment, the researchers found. "It doesn't mean that they don't have to increase their reimbursement," says Dr. Cunningham. "It's just that the impact won't be as great."
Reasons for shortage
The overall shortage of primary care physicians is a larger problem than the Medicaid reimbursement rates, adds Dr. Cunningham. "There is only so much that states can do," he says.
Increasing the role of nurse practitioners is one possible approach to addressing the primary care shortage in the short term, says Dr. Cunningham. "Obviously, it becomes a big political issue. The medical groups are generally opposed to that," he adds.
States that tend to have low primary care physician supply tend to have more stringent rules for what nurse practitioners can do without the supervision of a physician, says Dr. Cunningham. "But for the short term, a lot of people believe it is crucial to more fully utilize nurse practitioners and other non-MDs, in order to address the primary care shortages," he says.
Dr. Cunningham notes that some states are building new medical schools. "That could potentially increase the supply of physicians in those states, to the extent that they can keep them," he says. "The other thing that people need to keep in mind is why there is a shortage of physicians in these states to begin with."
States with large numbers of uninsured individuals aren't viewed by physicians as an attractive place to practice, explains Dr. Cunningham.
While some people may view the study's findings as an indication that health care reform is fundamentally flawed, says Dr. Cunningham, there is another way to look at it. "To address the geographical distribution of providers, you really need to address the coverage issues," he says. "The only way to attract more physicians in the long term is to reduce the number of uninsured."
Rates aren't silver bullet
There is no question, says Dr. Cunningham, that reimbursement in some states is so low that it just is not worthwhile for many physicians to take on Medicaid patients. The Medicaid population is more likely to have complex health problems, he adds, and some physicians perceive they are not good with following up on treatment and prescriptions.
Regarding efforts to reduce administrative burdens for providers, Dr. Cunningham says there is a "delicate balance" to maintain. "Paperwork issues can't be completely eliminated without increasing the potential for fraud, which is a big issue in Medicaid," he explains.
As of 2008, about 41% of all primary care physicians were accepting all or most new Medicaid patients, notes Dr. Cunningham. If the whole nation went to 100% Medicare rates for Medicaid patients, he says, that percentage would probably increase to about half of primary care physicians.
"So reimbursement does have an impact, but it is not necessarily the silver bullet," says Dr. Cunningham. "Physicians complain about Medicare rates, which are lower than private pay rates. For a lot of physicians, 100% of Medicare for just two years may not be enough of an inducement."
Contact Dr. Cunningham at (202) 484-4242 or PCunningham@hschange.org.
1. Cunningham, PJ. State variation in primary care physician supply: Implications for health reform Medicaid expansions. Research Brief No. 19. Center for Studying Health System Change, Washington, D.C. (March 2011).