The provider that accepts a large number of Medicaid patients and makes it work for his or her practice is much like the fabled unicorn: there are rumors that they exist, but no one has actually seen them.
But with more states expanding Medicaid through the Affordable Care Act (ACA), the number of patients covered by the program is growing, and not all these new patients will find it easy to get to a provider.
Medicaid is a well-known irritant of physicians, and many providers won’t even accept it as a payer. A 2014 study by Merritt Hawkins looked at Medicaid acceptance by physicians in 15 major metropolitan areas called 1,400 offices across five specialties: family medicine, cardiology, dermatology, obstetrics and gynecology and orthopedic surgery.
They found that the average overall rate of Medicaid acceptance by physicians was 45.7% in 2014, down from 55.4% in 2009. Cardiologists averaged the highest rate of acceptance at 63%; primary care providers averaged 50%. The lowest acceptance rate was among dermatologists at 27%.
The trend of Medicaid non-acceptance by physicians may only worsen given the expiration of the Medicaid pay boost tied to the ACA at the end of 2014. A study by the Urban Institute estimates that primary care physicians could see their Medicaid reimbursements cut by an average of 43%.
At groups such as Salud Family Health Centers, a system of community health clinics in northeastern Colorado, Medicaid expansion was welcome. The federally qualified health centers saw a jump from 30% percent of its patient population with Medicaid coverage prior to expansion to 57% post-expansion.
Jennifer Morse, development director for Salud, admits there can be challenges to accepting Medicaid, including access issues and greater complexity among patients. But for them, moving 27% of patients from self-pay to insured represented a significant improvement.
Healthcare is a business. If the money is there to make taking a patient worthwhile, doctors will take them, Morse said. If the reimbursement doesn’t warrant the administrative burdens, they won’t be as motivated. Much of the issue of Medicaid is perspective, she said.
“It is a good payer for us, so we don’t experience a lot of challenges,” she said. “We have a really unique perspective–we would rather a patient have Medicaid than no insurance at all.”
An increasing number of patients will be enrolling in Medicaid and will be seeking care as states continue to expand the program. Accepting such patients may pose challenges, but making Medicaid a larger part of a practice–or just accepting any Medicaid patients–may be a viable option with some tweaks to a practice.
Addressing the issues
The most frequently cited reason for not accepting Medicaid? Low reimbursements. Payments vary from state to state, but, on average, Medicaid pays about 66% of what Medicare reimburses, according to the Kaiser Family Foundation.
But that clearly isn’t the only challenge. Medicaid acceptance is down across the country even as provisions in the ACA increased reimbursements (primary care fees were increased to Medicare rates in 2013 and 2014).
“Reimbursement is the number one factor (physicians provide for not taking Medicaid), but we have seen in states that have increased rates, it doesn’t cause physicians to take more patients,” said Catherine Sreckovich, M.S., managing director in Navigant’s Healthcare practice. “It motivates physicians that are already taking it to take more patients, but not make others add it.”
Sreckovich said it can be a challenge for physicians because patients often don’t have child care, so their whole family comes to the waiting room. Physicians tell her that their Medicaid claims are rejected more than other payers. It is more challenging to verify eligibility and deal with prior authorization than with other insurers.
Referring to specialists can also be difficult because “there aren’t an overabundance of specialists taking Medicaid, particularly in pediatric subspecialties,” she says. Physicians also cite high turnover rates and long wait times for reimbursements as challenges to accepting Medicaid patients.
A study published in Health Affairs found that Medicaid reimbursement times vary considerably from state to state. The shortest wait time was in Kansas, at 36.9 days (compared with 29 days for commercial insurers) and the longest was 114.6 days in Pennsylvania (compared with 26.8 percent for commercial payers).
Not surprisingly, physicians in states with faster reimbursements were more likely to accept Medicaid patients.