With Expansion Looming, Less Than Half of Physicians Accept Medicaid
Physician Assistants & Nurse Practitioners Not Poised to Fill the Gap
Not all doctors accept Medicaid and the quantity of doctors rejecting Medicaid insurance presents a potential challenge to the Affordable Care Act’s expansion of the program. HealthPocket’s examination of over one million healthcare providers, from physicians and therapists to counselors and other specialists, found that only 43% were documented as accepting Medicaid.1
Historically Medicaid payments to doctors have been lower than payments from both private insurance and Medicare despite being for the same services.2 For example, Medicaid reimbursement fees average only 66% the amount of Medicare fees for the same service.3 The result of this lower reimbursement rate is a smaller pool of doctors who are willing to accept Medicaid.
Physician Assistants & Nurse Practitioner to the Rescue?
It has been suggested that some additional healthcare capacity may be found for new Medicaid enrollees through greater use of physician assistants and nurse practitioners. Physician assistants and nurse practitioners are medical professionals with advanced training who can prescribe treatments and deliver other services beyond that allowed for registered nurses.
This idea has its merits, particularly with respect to the compatibility of Medicaid reimbursement rates with the lower costs of these healthcare providers as compared to doctors. However, when examining Medicaid acceptance for physician assistants and nurse practitioners HealthPocket found that nationally only 20% currently accept Medicaid, less than half the rate seen for the other categories of healthcare providers examined in this study.
There were a few states that had Medicaid acceptance rates for physician assistants and nurse practitioners that were at least as high as the average rate for doctors. New Hampshire, for example, had the highest Medicaid acceptance rate for their physician assistants and nurse practitioners at 53%. However, many other states had decidedly poorer statistics. New York, for example, and 14 other states had Medicaid acceptance rates that were below the 20% national average.
It is possible that Medicaid acceptance by physician assistants and nurse practitioners is under reported to some degree. A portion of these healthcare providers may work under a Medicaid-accepting doctor even if the physician assistants and nurse practitioners don’t document themselves as accepting Medicaid. While Medicaid in every state reimburses physician assistant services, only 36 states allow advanced nurses to directly bill Medicaid as oppose to a supervising doctor.4 The other issue here, however, is that depending on the state and the services rendered Medicaid may pay a physician assistant or nurse practitioner a lower reimbursement than the already low Medicaid reimbursement given to a doctor.5 This lower reimbursement rate may discourage these healthcare providers from seeing Medicaid patients. Taking both the supervising doctor issue and the reimbursement issue into consideration, even generous scenarios of under reporting would still result in the majority of the physician assistants and nurse practitioners not accepting Medicaid currently.
Average Income & Medicaid Acceptance
Given the national rate of Medicaid acceptance, HealthPocket reviewed Medicaid acceptance rates in cities of contrasting economic status to determine if an area’s average household income had a bearing on Medicaid acceptance. HealthPocket limited its analysis to the five richest cities and five poorest cities based on average household income within the United State’s 25 most populous cities.6
A comparison of Medicaid acceptance between these two groups of cities revealed very little difference in Medicaid acceptance despite the difference in average household incomes. In the five richest cities, the average Medicaid acceptance rate is 41%, slightly lower than the national average. Healthcare providers in the poorest cities accepted Medicaid at an average rate of 44%, slightly higher than the national average.
However, both the rich city and poor city averages conceal the actual range of Medicaid acceptance seen within the data. San Jose had the highest acceptance rate among rich cities at 51% while Washington D.C., on the other hand, had the lowest Medicaid acceptance among rich cities at 31%. The gap between the highest and lowest Medicaid acceptance rates among the poorest cities was almost identical to the range noted for the richest cities. Detroit had the lowest Medicaid acceptance rate among poor cities at 31% while Memphis had the highest at 54%.
|5 Richest Cities||% of Healthcare Providers Accepting Medicaid|
|San Francisco, CA||36%|
|San Diego, CA||42%|
|San Jose, CA||51%|
|5 Poorest Cities||% of Healthcare Providers Accepting Medicaid|
Medicaid Expansion Plans No Indication of Medicaid Acceptance Rate
Do Medicaid expansion plans have any bearing on current Medicaid acceptance rates? For the cities HealthPocket reviewed, the answer is “no.” For example, both Philadelphia and San Diego have a Medicaid acceptance rate of 42% yet California is expanding Medicaid eligibility while Pennsylvania is not. Washington D.C. and Detroit, on the other hand, both had the lowest Medicaid acceptance rate among their income categories at 31% and both of these cities are in regions that will expand Medicaid eligibility. On the other end of the spectrum, Memphis and San Jose had the highest Medicaid acceptance rate among their respective income categories yet Tennessee is undecided whether it will expand Medicaid while California, as previously noted, will expand the program.7
California & The Question of Consistency
On the surface, the disparity in Medicaid acceptance for major cities within the same state was a counter intuitive finding. California is below the national average with respect to Medicaid reimbursement and pays its Medicaid doctors reimbursements that average 51% of Medicare’s reimbursement rate for the same services.8 Despite operating in the same Medicaid environment, San Francisco healthcare providers accepted Medicaid at a rate of 36% while San Jose accepted Medicaid at a rate of 51%. One of the issues that may be driving this Medicaid acceptance gap between the cities is their respective pools of Medicaid and non-Medicaid patients.
HealthPocket’s analysis of Medicaid acceptance in the richest and poorest cities illuminates one of the challenges facing the expansion of state Medicaid programs. Nationally less than half of physicians, therapists, and other healthcare providers examined accept Medicaid. The same is true on average for the richest and poorest cities. To further complicate matters, a portion of healthcare providers who currently treat Medicaid patients may not accept new Medicaid patients. A 2011 study found that 31% of physicians analyzed would not accept new patients with Medicaid insurance coverage.9 This shortage of doctors accepting Medicaid will become more pronounced as Medicaid eligibility expands and enrollment increases. Additionally, the Medicaid doctor shortage will likely exacerbate existing delays for Medicaid patients with respect to obtaining doctor appointments.10
The need for more healthcare providers accepting Medicaid is obvious but the path to address this need is unclear. The federal government is implementing a temporary two-year increase for Medicaid reimbursement rates. However, healthcare providers may stay on the sideline rather than accept new Medicaid patients given the prospect that they may need to discontinue care for these patients once Medicaid rates are lowered due to an expiration of the increased reimbursement rate. Some states, on the other hand, are exploring the Medicaid adoption of existing health plans with established physician networks.
Given the importance of Medicaid acceptance, HealthPocket enables doctors to update their Medicaid acceptance status as well as other practice information by using the doctor search tool on HealthPocket.com and then clicking the “Edit Info” link on their record. This same tool allows consumers to find physicians within a given region that accept Medicaid, Medicare, or a specific insurer.
Statistics regarding healthcare provider acceptance of Medicaid patients is based on data from the NPI Registry. HIPAA-covered healthcare providers are required to obtain a National Provider Identifier (NPI) and self-report information regarding their current acceptance of patients covered by Medicaid. NPI data was obtained on April 23, 2013 from data supplied from the Centers for Medicare & Medicaid Services and scoped for 55,742 individual physicians, therapists, counselors, and other selected healthcare providers located within 334 zip codes spread across 10 cities. Hospitals and other facilities were not included within the analysis. National statistics were based on 1,214,337 individual physicians, therapists, counselors, and other selected healthcare providers.
All analysis assumes the accuracy of the underlying government data. While every effort was made towards to enhance data accuracy, HealthPocket makes no representation that every healthcare provider in the selected geographies were included in this study.
Percentages are rounded according to standard industry practices. The list of the five richest cities and five poorest cities is based on a 2012 study on average household income within the 25 most populous U.S. cities.11
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This survey analysis was completed by Kev Coleman, Head of Research & Data at HealthPocket.com. Correspondence regarding this study can be directed to Mr. Coleman at firstname.lastname@example.org.
Feedback and questions are welcome but, given the volume of email, personal responses may not be feasible.
1 Statistics regarding healthcare provider acceptance of Medicaid patients is based on data from the NPI Registry.
2 A temporary two-year increase in reimbursement to doctors for services to Medicaid patients is being implemented to encourage more doctors to accept Medicaid. While the implementation of this program is behind schedule, it is planned to be retroactive to January 1, 2013. Japsen, Bruce. "Obamacare's 73% Medicaid Pay Raise For Doctors Is Delayed" Forbes (March 15, 2013). http://www.forbes.com/sites/brucejapsen/2013/03/15/obamacares-73-medicaid-pay-raise-for-doctors-is-delayed/
3 Stephen Zuckerman and Dana Goin, "How Much Will Medicaid Physician Fees for Primary Care Rise in 2013? Evidence from a 2012 Survey of Medicaid Physician Fees," Urban Institute and Kaiser Commission on Medicaid and the Uninsured (December 2012). available at http://www.kff.org/medicaid/upload/8398.pdf
4 Paradise, Julia et al. “Improving Access to Adult Primary Care in Medicaid: Exploring the Potential Role of Nurse Practitioners and Physician Assistants” Kaiser Family Foundation (March 2011) p.6.
6 Classification of cities as richest and poorest based on average household income assembled by the Census Bureau. Mantell, Ruth. "Richest and poorest US cities by income" MarketWatch. http://money.msn.com/personal-finance/richest-and-poorest-us-cities-by-income.
7 State status regarding Medicaid expansion reviewed as of April 23, 2013. http://www.advisory.com/Daily-Briefing/2012/11/09/MedicaidMap
8 Zuckerman, p.14.
9 Decker, Sandra. "In 2011 Nearly One-Third Of Physicians Said They Would Not Accept New Medicaid Patients, But Rising Fees May Help" HealthAffairs (August 2012) vol. 31 no. 8.
10 Norton, Amy. "Getting a doctor's appointment tougher on Medicaid" Reuters Health (March 27, 2012).
11 Mantell, Ruth. "Richest and poorest US cities by income."