Medicaid provider figures don’t reflect reality of patient care

December 12, 2014

The number of Americans eligible for Medicaid is growing, but so is the problem of finding a doctor who will treat them

More than half of the physicians across the country who supposedly treat Medicaid patients don’t actually do so, a new government report finds.

Approximately 49 million Americans obtain healthcare services under the Medicaid program, and most of those services are provided through Medicaid managed care organizations (MCOs). 

But according to a report prepared by the Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services, 43% of providers listed by MCOs as accepting Medicaid patients either were not practicing at the location where they were listed or were not participating in the MCO, and another 8% were not accepting new patients enrolled in the plan.

Read: Medicaid expansion: An answer to uncompensated care?

“When providers listed as participating in a plan cannot offer appointments, it may create a significant obstacle for an enrollee seeking care,” the report notes. “Moreover, it suggests that the actual size of provider networks may be considerably smaller than what is presented by Medicaid managed care plans. It also raises questions about whether these plans are complying with their states’ standards for access to care.”

Under the Affordable Care Act, states have the option of expanding Medicaid eligibility to include families earning up to 138% of the federal poverty level, with the additional costs covered entirely by the federal government for the first four years and at 90% thereafter.

To-date 27 states and the District of Columbia have expanded Medicaid eligibility, and the Congressional Budget Office estimates that the number of people covered by Medicaid will increase to 87 million by 2018. The OIG report thus may raise doubts as to Medicaid’s ability to deliver healthcare services to new enrollees in a meaningful way.

NEXT PAGE: The report's recommendations

 

 

Other findings from the report:

  • among the 49% of providers who did offer appointments, the median wait time was two weeks, but more than 25% had wait times of more than one month,

  • specialists were more likely to provide appointments than primary care providers (57% versus 44%),

  • the median wait time for a specialist appointment was 20 days, versus 10 days for a primary care provider

 

The report recommends that the Centers for Medicare and Medicaid Services work with states to:

  • assess the number of network providers and improve the accuracy of plan information,

  • ensure that MCO networks meet the needs of their enrollees, and

  • ensure that plans are complying with existing state standards and assess whether additional standards are needed.

Results of the study were based on telephone calls to a random sample of primary care providers and specialists from July through October, 2013.