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July 24, 2018

The ACA boosted Medicaid payments for two years. But doctors were no more likely to take Medicaid patients, studies find.

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    The Affordable Care Act's (ACA) temporary increase in Medicaid payments for primary care physicians (PCPS) did not result in more PCPs participating in Medicaid, according to two recent studies.

    August 14 webconference: How to succeed under Medicaid risk

    Medicaid reimbursements vary by state and generally are lower than Medicare reimbursements and private insurer payments. To encourage PCPs to treat more Medicaid beneficiaries, the ACA raised Medicaid reimbursements for 2013 and 2014 to the same rate as Medicare reimbursements. The pay increase came as more U.S. residents enrolled in Medicaid in states that expanded the program under the ACA.

    Some states have opted to continue the higher Medicaid payments, while others have not.

    Researchers find net decrease in PCPs seeing Medicaid beneficiaries

    For one study, published last week in JAMA Internal Medicine, researchers from RAND and HHS examined both Medicaid participation rates and Medicaid service volume among PCPs. The researchers analyzed medical claims and encounter data from IMS Health on 20,723 qualifying PCPs in all states except Alaska and Hawaii, with observations each month from Jan. 1, 2012, to Dec. 31., 2015.

    The researchers found no change in the share of PCPs who saw any Medicaid beneficiaries or more than five Medicaid beneficiaries from 2012 to 2015. According to the study, the share of PCPs seeing more than five Medicaid beneficiaries per month increased by 0.7% from 2012 to 2013, but then declined slightly through the end of 2015, resulting in a net decrease of 0.2% from 2012 to 2015.

    At the same time, the researchers found that the share of U.S. patients enrolled in Medicaid increased by about 25% from 2012 to 2015, rising from 15.5% to 20%. According to the researchers, the share of U.S. patients enrolled in Medicaid increased the most after 2014, when the ACA's Medicaid expansion took effect.

    Overall, the researchers concluded that the ACA's temporary Medicaid "payment increase had limited association with [PCPs'] Medicaid participation or Medicaid service volume based on the metrics defined for this study." The researchers said their findings align with qualitative reports from state Medicaid officials, who have said few physicians who enrolled and qualified to receive higher payments under the ACA in 2013 and 2014 were new to Medicaid.

    According to the researchers, their findings do not mean that a "differently formulated payment policy could not have achieved more robust outcomes or that states spending some of their own funds to maintain higher payment rates are erring." They wrote, "The short duration of the ACA payment increase, its delayed implementation, and its complicated attestation process may have contributed to [the] results."

    However, Allan Goroll of Harvard Medical School in a commentary accompanying the study questioned whether increasing fee-for-services (FFS) Medicaid payments is the proper way to incentivize PCPs to participate in the program. He wrote, "This is not to deny that an astronomical increase in evaluation and management valuations might have some result, but certainly not the aforementioned raising of FFS pay from an impossibly low Medicaid level to an undervalued Medicare level."

    Study finds no association between higher payments and PCP's Medicaid participation

    For the second study, published this month in Health Affairs, Sandra Decker—a researcher from the Agency for Healthcare Research and Quality's Division of Research and Modeling—examined Medicaid participation among PCPs by analyzing National Electronic Health Records Survey data from 2011 to 2015 on 7,758 PCPs.

    Decker found about 65% of PCPs in 2012 and 2013 reported accepting new Medicaid beneficiaries, while about 67% of PCPs in 2014 reported accepting new Medicaid beneficiaries. Decker said the difference in PCPs accepting new Medicaid beneficiaries from 2012 to 2014 was not significant.

    Decker concluded that the ACA's temporary Medicaid payment rate increase "was not significantly associated with the overall acceptance rate or the percentages of [PCPs'] patients on Medicaid." Decker wrote, "The lack of a sizable change in measures of physician participation in Medicaid may have been due to the temporary nature of the [payment] bump" (Baker, "Vitals," Axios, 7/17; Ingram, MedPage Today, 7/16; Haefner, Becker's Hospital CFO Report, 7/20; Mulcahy et al., JAMA Internal Medicine, 7/16; Decker, Health Affairs, July 2018).

    How to succeed under Medicaid risk—and meet the needs of your Medicaid patients

    The Medicaid population presents a challenge for many health care providers. Low reimbursement rates coupled with high patient complexity are responsible for margin pressure.

    Join our virtual expert panel discussion on Tuesday, August 14 to learn about key considerations for taking on Medicaid risk and setting up the right infrastructure to manage the population.

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