Providing Insights that Contribute to Better Health Policy The Effects of Medicaid Reimbursement on Access to Care of Medicaid Enrollees: A Community Perspective Peter Cunningham Len Nichols Center for Studying Health System Change

LOW FEES STILL A CONCERN Fewer physicians accept Medicaid patients relative to other insured patients Variation in fee levels across states Mixed results concerning effects of fees on physician access Fee levels influence physician participation No direct effect of fees on enrollee access

TWO-PART MODEL OF ACCESS Medicaid acceptance by physicians Fee levels in the state Physician, practice, community factors Interaction effects Access for Medicaid enrollees Medicaid acceptance rates (predicted) Other enrollee and community factors

COMMUNITY TRACKING STUDY Surveys of physicians and households Nationally representative estimates Estimates for 60 randomly selected communities 12 MSAs selected for case studies

MEDICAID ACCEPTANCE Physician survey – 12,000 patient care physicians DV – Acceptance of Medicaid patients State-level measure of Medicaid fees (2000 Lewin survey) Volume-weighted average of fees across 31 CPT codes Computed as a percentage of Medicare- allowed charges

OTHER INDEPENDENT VARIABLES Medicaid managed care Practice type (institutional vs. office-based) Other physician and practice characteristics Health system and community characteristics

VARIATION IN ACCEPTANCE RATES Percent accepting new Medicaid patients

VARIATION IN MEDICAID FEES Medicaid fees as a percent of Medicare fees

SUMMARY OF REGRESSION RESULTS Higher Medicaid fees associated with greater Medicaid acceptance Effects of fees vary depending on practice type and Medicaid MC Fees have less impact on institutional-based docs Fees have less impact in high Medicaid MC areas Physician and practice characteristics important More insured people in area increases acceptance

MARGINAL EFFECTS OF FEE LEVELS Effects of 20 percentage point increase in fees

EFFECTS ON ENROLLEE ACCESS Household survey – 3,000 nonelderly Medicaid enrollees Key IV is Medicaid acceptance rates for each community (predicted from part 1) 5 widely used measures of access to care Includes other person-level and community characteristics

SUMMARY OF RESULTS Higher acceptance rates associated with greater access on 3 of 5 measures Direct effects of Medicaid fees either not significant or contrary to expectations

MARGINAL EFFECTS ON ACCESS USCUnmet Need ER Visit Mean PP increase in acceptance rates PP increase in supply = 20 PP increase in fees