Medicaid Fee Research Articles

The Impact of Changes in Medicaid Provider Fees on Provider Participation and Enrollees' Care: a Systematic Literature Review.

Changing Medicaid fees is a common approach for states to address budget fluctuations, and many currently set Medicaid physician fees at levels lower than Medicare and private insurers. The Affordable Care Act included a temporary Medicaid fee bump for primary care providers (PCPs) in 2013-2014 that recently led to both an increase and then subsequent decrease in PCP fees in many states. To conduct a systematic literature review on the effects of changing Medicaid fees on provider participation and enrollees' access to care and service use. We searched PubMed/Medline and JSTOR and identified 18 studies that assessed the longitudinal impact of provider fee changes in Medicaid on the outcomes of interest. We summarized information on study design, methods, and findings. Seven studies examined the impact of fee changes on provider participation in Medicaid. Of these, three studies found that fee increases were associated with positive effects on providers' likelihood of accepting Medicaid patients or on their Medicaid caseloads. Five studies that examined the impact of fee changes on Medicaid enrollees' access to care found a positive association withone or more access measure, such as having a usual source of care or appointment availability. Lastly, eight of 14 studies that examined service use found positive associations between fee changes and at least one measure of use, such as changes in the probability of enrollees having any visit, the number of visits, and shifts in the site of care toward office-based care; others largely did not find significant associations. There is mixed evidence on the impact of changing Medicaid fees on provider participation and enrollees' service use; however, increasing fees appears to have more consistent positive effects on access to care. Whether these improvements in access translate into better health outcomes or downstream cost savings are critical questions.

Impact of insurance plan design on bariatric surgery utilization

BackgroundBariatric surgery is underused in the United States. ObjectivesThis study examined whether utilization of bariatric surgery is associated with payor and insurance plan type, after removing potential sociodemographic confounders. SettingThe study used Pennsylvania Health Care Cost Containment Council’s data in 5 counties of Pennsylvania from 2014 to 2016. MethodsBariatric surgery patients and eligible patients who did not undergo surgery were identified and 1:1 matched by age, sex, race, and zip code (n = 5114). A logistic regression was performed to investigate the association of payor type and insurance plan within payor type with odds of undergoing bariatric surgery. ResultsThe odds of undergoing bariatric surgery were not statistically different based on payor type. Medicare preferred provider organization plan was associated with greater odds of undergoing surgery (odds ratio [OR] = 2.49, 95% confidence interval [CI] 1.23–5.04, P = .01) compared with Medicare health maintenance organization (HMO). Medicaid fee for service plan was associated with smaller odds of undergoing surgery (OR = .04, 95% CI .005–.27, P = .001) compared with Medicaid HMO. Individuals with Blue Cross preferred provider organization (OR = 2.43, 95% CI 1.83–3.24, P < .001), Blue Cross fee for service (OR = 1.79, 95% CI 1.32–2.43, P < .001), and Blue Cross HMO (OR = 1.85, 95% CI 1.39–2.46, P < .001) had greater odds of undergoing surgery compared with those with other commercial HMO plans. ConclusionsSpecific aspects of insurance plan design, rather than more general payor type, is more strongly associated with the utilization of bariatric surgery. Further investigations could identify which components of insurance plan design have the greatest influence on the utilization of bariatric surgery.

Breast and Cervical Cancer Screening Among Medicaid Beneficiaries: The Role of Physician Payment and Managed Care.

Medicaid-insured women have low rates of cancer screening. There are multiple policy levers that may influence access to preventive services such as screening, including physician payment and managed care. We examine the relationship between each of these factors and breast and cervical cancer screening among nonelderly nondisabled adult Medicaid enrollees. We combine individual-level data on Medicaid enrollment, demographics, and use of screening services from the Medicaid Analytic eXtract files with data on states' Medicaid-to-Medicare fee ratios and estimate their impact on screening services. Higher physician fees are associated with greater screening for comprehensive managed care enrollees; for enrollees in fee-for-service Medicaid, the findings are mixed. Patient participation in primary care case management is a significant moderator of the relationship between physician fees and the rate of screening, as interactions between enrollee primary care case management status and the Medicaid fee ratio are consistently positive across models of screening.

A Cost Analysis of Universal versus Targeted Cholesterol Screening in Pediatrics

To compare the number of children needed to screen to identify a case of childhood dyslipidemia and estimate costs under universal vs targeted screening approaches. We constructed a decision-analytic model comparing the health system costs of universal vs targeted screening for hyperlipidemia in US children aged 10 years over a 1-year time horizon. Targeted screening was defined by family history: dyslipidemia in a parent and/or early cardiovascular disease in a first-degree relative. Prevalence of any hyperlipidemia (low-density lipoprotein [LDL] ≥130 mg/dL) and severe hyperlipidemia (LDL ≥190 mg/dL or LDL ≥160 mg/dL with family history) were obtained from published estimates. Costs were estimated from the 2016 Maryland Medicaid fee schedule. We performed sensitivity analyses to evaluate the influence of key variables on the incremental cost per case detected. For universal screening, the number needed to screen to identify 1 case was 12 for any hyperlipidemia and 111 for severe hyperlipidemia. For targeted screening, the number needed to screen was 7 for any hyperlipidemia and 49 for severe hyperlipidemia. The incremental cost per case detected for universal compared with targeted screening was $1980 for any hyperlipidemia and $32 170 for severe hyperlipidemia. Our model suggests that universal cholesterol screening detects hyperlipidemia at a low cost per case, but may not be the most cost-efficient way to identify children with severe hyperlipidemia who are most likely to benefit from treatment.

Expanding Medicaid Access without Expanding Medicaid: Why Did Some Nonexpansion States Continue the Primary Care Fee Bump?

Six states that have rejected the Patient Protection and Affordable Care Act's (ACA) Medicaid expansion nonetheless extended the primary care "fee bump," by which the federal government increased Medicaid fees for primary care services up to 100 percent of Medicare fees during 2013-14. We conducted semistructured interviews with leaders in five of these states, as well as in three comparison states, to examine why they would continue a provision of the ACA that moderately expands access at significant state expense while rejecting the expansion and its large federal match, focusing on relevant economic, political, and procedural factors. We found that fee bump extension proposals were more successful where they were dissociated from major national policy debates, actionable with the input of relatively few stakeholder entities, and well aligned with preexisting policy-making structures and decision trends. Republican proposals to cap or reduce federal funding for Medicaid, if enacted, would compel states to contain program costs. In this context, states' established decision-making processes for updating Medicaid fee schedules, which we elucidate in this study, may shape the future of the Medicaid program.

Insurance Type and Access to Health Care Providers and Appointments Under the Affordable Care Act.

Millions of adults have gained insurance through the Affordable Care Act (ACA). However, disparities in access to care persist. This study examined differences in access to primary and specialty care among patients insured by private individual market insurance plans (both on-exchange and off-exchange) and Medicaid compared with those with employer-sponsored insurance. Using data from the 2014 and 2015 California Health Interview Survey, logistic regression analyses were used to calculate the odds of being unable to access primary care providers, access specialty care providers and receive a needed doctor's appointment in a timely manner, with insurance type serving as the independent variable. Interaction terms examined if the expiration of the ACA's optional Medicaid primary care fee increase in 2014 modified any of these associations. Findings showed poorer access to providers among those insured through Medicaid and the individual market (whether purchased through the state's health insurance exchange or off-exchange) relative to employer-based insurance. Poor access to primary care providers was seen among private coverage purchased via exchanges, relative to private coverage purchased on the individual market. In addition, findings showed that reduction of Medicaid fees coincided with reduced ability to see primary care providers. However, a similar trend was seen among those with employer-based coverage, which suggests that this change may not be attributable to reductions in Medicaid fees. Despite ACA-related gains in insurance coverage, those with on-exchange and off-exchange individual private insurance plans and Medicaid encounter more barriers to care than those with employer-based insurance.

The impact of Medicaid expansion, diversity and the ACA primary care fee bump on the performance of Medicaid managed care

In response to the policy changes to Medicaid, this research examines the impact of Medicaid expansion, diversity, and the Medicaid fee bump on Medicaid managed care. It aims to provide insights to health insurers, consumers, regulators and policymakers regarding profitability, better services, reducing expenses and improving efficiency. The results indicate that Medicaid expansion increases the profit efficiency of Medicaid managed care, but it has no significant impact on medical service efficiency or composite efficiency. The diversity of business lines, product types or payment methods does not create economies of scope for Medicaid profitability, medical service efficiency or composite efficiency. However, the diversity of product types is associated with more ambulatory encounters, while the diversity of payment methods reduces medical and administrative expenses. The Medicaid fee bump does not increase medical expenses or the utilization of medical services, and it has no significant impact on profitability or composite efficiency. "Medicaid lower reimbursement" should not be a big concern for Medicaid managed care in terms of profitability, medical services, expenses or overall efficiency. Another finding was that offering more preferred provider organization (PPO) plans improves the performance in profits, services and expenses; and managed care organizations (MCOs) also serving Medicare beneficiaries perform better in Medicaid managed care. In addition, capitation and contractual fee payments both enhance composite efficiency. The value-based payments do not have a significant impact on expenses or efficiency, but they are associated with more ambulatory encounters.

Declining Medicaid Fees and Primary Care Appointment Availability for New Medicaid Patients

Declining Medicaid Fees and Primary Care Appointment Availability for New Medicaid Patients

State Medicaid fees and access to primary care physicians.

Medicaid and uninsured patients are disadvantaged in access to care and are disproportionately Black and Hispanic. Using a national audit of primary care physicians, we examine the relationship between state Medicaid fees for primary care services and access for Medicaid, Medicare, uninsured, and privately insured patients who differ by race/ethnicity and sex. We found that states with higher Medicaid fees had higher probabilities of appointment offers and shorter wait times for Medicaid patients, and lower probabilities of appointment offers and longer wait times for uninsured patients. Appointment offers and wait times for Medicare and privately insured patients were unaffected by Medicaid fees. At mean state Medicaid fees, our analysis predicts a 27-percentage-point disadvantage for Medicaid versus Medicare in appointment offers. This decreases to 6 percentage points when Medicaid and Medicare fees are equal, suggesting that permanent fee parity with Medicare could eliminate most of the disparity in appointment offers for Medicaid patients. The predicted decrease in the disparity is smaller for Black and Hispanic patients than for White patients. Our research highlights the importance of considering the effects of policy on nontarget patient groups, and the consequences of seemingly race-neutral policies on racial/ethnic and sex-based disparities.

AGING WITH A PHYSICAL DISABILITY IN MEDICAID MANAGED CARE

This study examines health services appraisal (HSA) and unmet health-care needs for adults (age 50 and over) with physical disabilities in Medicaid managed care (MMC) versus Medicaid fee for service (FFS). Surveys from 309 individuals in MMC and 349 in FFS 2 years after MMC implementation included demographics, MMC processes, HSA, and unmet health-care needs. Regression analyses with HSA and unmet health-care needs as outcomes included demographics and group status (MMC or FFS) for the entire sample, and demographics and MMC processes (continuity of care, experience with care coordinators and primary care physicians) as independent variables for only MMC enrollees. Group status was not associated with HSA or unmet needs. Among MMC enrollees, better health and more positive MMC processes related to higher HSA and lower unmet needs. It is important to consider the perspectives of people aging with disabilities in MMC to better serve their needs.

The Effect of Medicaid Physician Fee Increases on Health Care Access, Utilization, and Expenditures.

To evaluate the effect of Medicaid fee changes on health care access, utilization, and spending for Medicaid beneficiaries. We use the 2008 and 2012 waves of the Medical Expenditure PanelSurvey linked to state-level Medicaid-to-Medicare primary care reimbursement ratios obtained through surveys conducted by the Urban Institute. We also incorporate data from the Current Population Survey and the Area Resource Files. Using a control group made up of the low-income privately insured, we conduct a difference-in-differences analysis to assess the relationship between Medicaid fee changes and access to care, utilization of health care services, and out-of-pocket medical expenditures for Medicaid enrollees. We find that an increase in the Medicaid-to-Medicare payment ratio for primary care services results in an increase in outpatient physician visits, emergency department utilization, and prescription fills, but only minor improvements in access to care. In addition, we report an increase in total annual out-of-pocket expenditures and spending on prescription medications. Compared to the low-income privately insured, increased primary care reimbursement for Medicaid beneficiaries leads to higher utilization and out-of-pocket spending for Medicaid enrollees.

Impact of fee increases on dental utilization rates for children living in Connecticut and enrolled in Medicaid

BackgroundIn 2008, Connecticut’s Medicaid program administration increased children’s dental fees to match approximately the 70th percentile of what the market fees were for dental care in 2005. These Medicaid program changes occurred at the same time as a national economic recession, which took place from 2007 through 2009. MethodsThe authors obtained Medicaid eligibility, claims, and provider data before and after the fee increase, in 2006 and 2009 through 2012, respectively. Their analysis examined changes in utilization rates, service mix, expenditures, and dentists’ participation. The authors qualitatively assessed the general impact of the recession on utilization rate changes. ResultsThe Medicaid fee increase, program improvements, and the recession resulted in a dramatic increase in utilization rates. For children continuously enrolled in Medicaid, utilization rates increased from 45.9% in 2006 to 71.6% in 2012. Rates increased across sex, race, ethnicity, and geographic areas. These increased utilization rates eliminated the disparities in access to dental services between children with private insurance and children receiving Medicaid benefits. Children enrolled in Medicaid now have utilization rates that are similar to or higher than privately insured children. Expenditures increased $62 million; this represents less than 1% of 2012 State Medicaid expenditures. Dentist participation increased by 72%. These results suggest that dentists will participate in the Medicaid program if adequately compensated, and low-income families will seek dental services. ConclusionThe Medicaid fee increase, program improvements, and the recession had a dramatic impact on reducing disparities in children’s access to dental care in Connecticut. Practical ImplicationsOne solution to the substantial disparities in access to dental care is to increase Medicaid fees to competitive levels.

To Extend or Not to Extend the Primary Care “Fee Bump” In Medicaid?

Policy makers and researchers are eager to learn the effects of the Patient Protection and Affordable Care Act of 2010 (ACA) and its many provisions, but to date, they have been frustrated by the dearth of robust evidence on the ACA's true impacts on important health care and patient outcomes (e.g., access to primary care services). The present limitations of evidence, often a consequence of delays and inconsistencies in the law's implementation, have begun to affect policy making in the ACA's wake. In this article, we consider the debates among state and federal policy makers about whether to extend the ACA's so-called fee bump provision, whereby Medicaid fees for primary care services were increased to 100 percent of Medicare levels during 2013 and 2014. We describe the difficulties state Medicaid programs have experienced in implementing the fee bump, as well as how the resulting evidence gap and the broader political context have shaped the deliberations. To conclude, we identify policy alternatives and other factors policy makers should consider when deciding whether to extend or reinstitute the fee bump in the coming years.

Do the Medicaid and Medicare programs compete for access to health care services? A longitudinal analysis of physician fees, 1998–2004

As the demand for publicly funded health care continues to rise in the U.S., there is increasing pressure on state governments to ensure patient access through adjustments in provider compensation policies. This paper longitudinally examines the fees that states paid physicians for services covered by the Medicaid program over the period 1998-2004. Controlling for an extensive set of economic and health care industry characteristics, the elasticity of states' Medicaid fees, with respect to Medicare fees, is estimated to be in the range of 0.2-0.7 depending on the type of physician service examined. The findings indicate a significant degree of price competition between the Medicaid and Medicare programs for physician services that is more pronounced for cardiology and critical care, but not hospital care. The results also suggest several policy levers that work to either increase patient access or reduce total program costs through changes in fees.

Differential responses among primary care physicians to varying Medicaid fees.

The Affordable Care Act (ACA) provided for significant increases in Medicaid fees for primary care services-up to 100 percent of Medicare fees for 2013 and 2014-to encourage increased Medicaid participation among primary care physicians (PCPs). In this study, I use non-linear multivariate regression techniques and data from nationally representative physician surveys and periodic Medicaid fee surveys to investigate heterogeneity in the effects of such increases. I find that the PCPs more responsive to Medicaid fee changes are those who see fewer Medicaid patients typically. I also estimate effects associated with Medicaid fee increases comparable with the ACA's fee changes.

Funding Medicaid codes for screening and brief intervention services: lessons learned

There is a growing body of evidence that screening, brief intervention, and referral to treatment (SBIRT) is effective in reducing drinking and substance use problems. Based on the outcomes from MOSBIRT, Missouri’s Substance Abuse and Mental Health Services Administration (SAMHSA)-funded SBIRT program, individuals receiving brief interventions show reductions in risky use, along with improvements in employment, housing, legal involvement and physical and mental health. As numerous studies indicate a cost savings of $3.81 to $5.60 for each dollar invested in screening for risky use, the most promising approach to sustaining SBIRT services in Missouri after SAMHSA support expires is to fund the state Medicaid codes already on the state’s fee schedule, thereby allowing for reimbursement of SBI services. To that end, an analysis of the Medicaid fee schedules of the 50 states and DC was conducted to determine which states currently have SBI Medicaid codes H0049 and H0050, as well as the American Medical Association’s Common Procedural Terminology (CPT) codes 99408 and 99409, on their schedules. The analysis indicated that 22 states have either the Medicaid or CPT codes with associated billing amounts on their Medicaid fee schedules. The average billing rate for screening is about $25 per unit, with rates of around $40 per unit for brief interventions. This information was presented to the Missouri governor’s budget office and resulted in rate setting and coverage of SBI services at federally qualified health centers and community mental health centers across the state. A rationale for supporting SBI services nationally is provided, along with recommendations for petitioning state budget offices to fund the Medicaid codes based on lessons learned from the MOSBIRT project.

The effect of Medicaid physician fees on take-up of public health insurance among children in poverty

I investigate how changes in fees paid to Medicaid physicians affect take-up among children in low-income families. The existing literature suggests that the low level of Medicaid fee payments to physicians reduces their willingness to see Medicaid patients, thus creating an access-to-care problem for these patients. For the identical service, current Medicaid reimbursement rates are only about 65 percent of those covered by Medicare. Increasing the relative payments of Medicaid would increase its perceived value, as it would provide better access to health care for Medicaid beneficiaries. Using variation in the timing of the changes in Medicaid payment across states, I find that increasing Medicaid generosity is associated with both an increase in take-up and a reduction in uninsured rate. These results provide a partial answer to the puzzling question of why many low-income children who are eligible for Medicaid remain uninsured.

Costs and benefits of targeted screening for causes of sudden cardiac death in children and adolescents.

Sudden cardiac death in children is a rare but devastating event. Experts have debated the merits of community-based screening programs using an ECG and targeting 2 potential high-risk groups: school-aged children initiating stimulant medications to treat attention-deficit/hyperactivity disorder and adolescents participating in sports. Simulation models incorporating detailed prevalence, sensitivity and specificity, and treatment algorithms were built to determine the cost-effectiveness of targeted sudden cardiac death screening. Clinical care algorithms were constructed for asymptomatic children initiating stimulants for attention-deficit/hyperactivity disorder (8 years of age) or participating in sports (14 years of age) and presenting with a positive ECG finding suggestive of 1 of the 3 most common pediatric disorders causing sudden cardiac death and identifiable by ECG. Information to develop simulation model assumptions was drawn from the existing literature, Medicaid fees, and expert judgment. Sensitivity analyses examined parameter ranges to identify influential sources of uncertainty. Outcomes included costs and lost life-years caused by condition-related mortality. Our models estimate that screening for all 3 conditions simultaneously would reduce sudden death risk by 3.6 to 7.5 × 10(-5) with projected life expectancy increases of 0.8 to 1.6 days per screened individual. The incremental cost-effectiveness of screening is $91,000 to $204,000 per life-year. Sensitivity analysis showed that assumed disease prevalence, baseline mortality, and the relative risk of mortality resulting from stimulant medication use and sports participation had the greatest impact on estimated cost-effectiveness. Results based on assumptions favoring sudden cardiac death screening indicated that its cost is high relative to its health benefits.

The Effect of Medicaid Physician Fees on Take-Up of Public Health Insurance Among Children in Poverty

I investigate how changes in fees paid to Medicaid physicians affect take-up among children in low-income families. The existing literature suggests that the low level of Medicaid fee payments to physicians reduces their willingness to see Medicaid patients, thus creating an access-to-care problem for these patients. For the identical service, current Medicaid reimbursement rates are only about 65 percent of those covered by Medicare. Increasing the relative payments of Medicaid would increase its perceived value, as it would provide better access to health care for Medicaid beneficiaries. Using variation in the timing of the changes in Medicaid payment across states, I find that increasing Medicaid generosity is associated with both an increase in take-up and a reduction in uninsured rate. These results provide a partial answer to the puzzling question of why many low-income children who are eligible for Medicaid remain uninsured.

Measuring Clinical Productivity in Community‐Based Dental Education Programs

Community-based dental education programs (CBDEPs) are an important part of the curriculum in many dental schools. This article describes the redesign of the CBDEP at the University of Kentucky College of Dentistry. As part of the formative evaluation of this CBDEP, information on clinical productivity was collected in order to educate intramural faculty members about the scope and extent of services provided in extramural sites; develop an understanding of the productivity expected; complement the intramural education by placing dental students in particular settings where they could enhance certain clinical disciplines; and serve as a decision making tool in the selection of sites that provide the richest clinical experiences. A total of 158 students participated in the CBDEP during the three years of our study (2006-08). Productivity per site was calculated based on total, mean, and median number of services provided, billing (utilizing Kentucky's Medicaid fees for 2006), and Relative Value Units (RVUs). A total of 26,202 services, $972,109 in billing, and 43,053 RVUs was generated by the students, with an average of 175 services, $6,481, and 287 RVUs per student. Four categories (restorative, oral surgery, preventive, and diagnostic) accounted for 88 percent of total RVUs for all sites and all years. Productivity measured with RVU was the highest at private practices. Students spent most of their time providing restorative and oral surgery services. Measuring clinical productivity can be an effective tool to establish benchmarks, improve the site selection process, and educate those skeptical about the benefits of extramural education. Such an evaluation will enable faculty and program administrators involved in CBDEP to make continuous improvements.