Assessment of the Patient Protection and Affordable Care Act’s Increase in Fees for Primary Care and Access to Care for Dual-Eligible Beneficiaries

Vicki Fung,Benjamin Lê Cook,Peter Hull,John Hsu,Joseph P Newhouse,Mary Price

doi:10.1001/jamanetworkopen.2020.33424

Abstract

The Patient Protection and Affordable Care Act (ACA) temporarily increased primary care practitioners' (PCP) Medicaid fees to that of Medicare for 2013 to 2014 (fee bump) to help accommodate potential increases in demand for care with ACA coverage expansion. This also increased fees for PCPs treating dual-eligible Medicare and Medicaid beneficiaries in many states and eliminated payment differentials for dual-eligible vs non-dual-eligible Medicare beneficiaries that could limit access to care. To examine the association between the ACA fee bump and primary care visits for dual-eligible Medicare and Medicaid beneficiaries. This cohort study used a difference-in-difference design and Medicare claims data from 2012 to 2016 to compare changes in visit rates for full-subsidy dual-eligible Medicare and Medicaid beneficiaries vs non-dual-eligible Medicare beneficiaries with low income whose fees did not change. Changes were examined overall and separately in states with temporary, extended, or minimal fee increases for dual-eligible vs non-dual-eligible beneficiaries in 2013 to 2014 (mandatory bump) and 2015 to 2016 (postbump or bump extension) vs 2012 (prebump). The study used linear regression models with beneficiary fixed effects, adjusting for time-changing area and beneficiary characteristics. Statistical analysis was performed from February 2018 to November 2019. ACA-mandated Medicaid fee bump. Primary care visits per 100 beneficiaries overall and visits billed by physicians vs nurse practitioners and physician assistants. The study included 3 052 044 dual-eligible and non-dual-eligible beneficiaries in 2012; 1 516 534 (49.7%) were aged 65 years or younger, 1 797 556 (58.9%) were women, and 1 754 626 (57.5%) had non-Hispanic White race/ethnicity. Overall primary care visit rates for dual-eligible beneficiaries were unchanged or decreased slightly relative to non-dual-eligible beneficiaries during the fee bump (2013-2014) and the postbump or bump extension period (2015-2016) vs baseline. Compared with non-dual-eligible beneficiaries, visit rates with primary care physicians declined more uniformly for dual-eligible beneficiaries across state groups and time periods (difference-in-difference: -0.37 [95% CI, -0.43 to -0.32] visits per 100 beneficiaries in 2013-2014 vs 2012; P < .001; and difference-in-difference: -0.62 [95% CI, -0.68 to -0.56] visits per 100 beneficiaries in 2015-2016 vs 2012; P < .001), whereas visits with nurse practitioners and physician assistants increased over time (difference-in-difference: 0.11 [95% CI, 0.08 to 0.14] visits per 100 beneficiaries in 2013-2014 vs 2012; P < .001; and difference-in-difference: 0.46 [95% CI, 0.43 to 0.50] visits per 100 beneficiaries in 2015-2016 vs 2012; P < .001). These changes, however, were not associated with the timing of the payment changes. The ACA fee bump was not associated with increases in primary care visits for dual-eligible Medicare and Medicaid beneficiaries. Visits for dual-eligible beneficiaries with primary care physicians decreased after the ACA, a decrease that was partially offset by increases in visits with nonphysician clinicians.

Highlights

Compared with non–dual-eligible beneficiaries, visit rates with primary care physicians declined more uniformly for dual-eligible beneficiaries across state groups and time periods, whereas visits with nurse practitioners and physician assistants increased over time
The Affordable Care Act (ACA) fee bump was not associated with increases in primary care visits for dual-eligible Medicare and Medicaid beneficiaries
Visits for dual-eligible beneficiaries with primary care physicians decreased after the ACA, a decrease that was partially offset by increases in visits with nonphysician clinicians

Summary

Introduction

Medicare is the primary payer for primary care services for individuals with dual eligibility, and Medicaid provides wraparound coverage that pays the Medicare cost-sharing for qualified beneficiaries. Many states cap Medicaid reimbursement for Medicare cost-sharing at the Medicaid rate (known as lesser-of policies), such that health care practitioners frequently receive partial or no reimbursement for the standard 20% coinsurance for dual-eligible patients.[6,8] A recent analysis found that the number of states capping dual reimbursement increased from 36 to 42 between 2004 and 2018.9 Federal law prohibits health care practitioners from directly billing dualeligible beneficiaries for the uncovered coinsurance amount, some improper billing occurs, which can further impede access to care for these patients.[10]

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Results

Discussion

Conclusion