Robert Lowes - Dec 10, 2014 - Medicaid managed-care plans are obliged to offer enrollees an adequate network of clinicians, but half of those listed in provider directories were unavailable for an office appointment in a federal investigation unveiled yesterday.
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Actual size of provider networks may be considerably smaller than what is presented by Medicare managed care plans]
It is not that these physicians, nurse practitioners, and other clinicians were simply turning away Medicaid patients — most of the unavailable clinicians were not participating in the Medicaid managed care plan at the listed location or at any location, said a report from the Office of Inspector General (OIG) in the Department of Health and Human Services. Some of them had withdrawn from the program, left the practice listed in the directory, or retired. And some drew complete blanks ("I never heard of [him]") from the receptionist picking up the telephone.
The findings suggest that "the actual size of provider networks may be considerably smaller than what is presented by Medicare managed care plans," the report states.
The OIG stressed that evaluating access to care in Medicaid is more important than ever, given how Medicaid expansion under the Affordable Care Act will add 18 million more people to the rolls by 2018. It recommended that the Centers for Medicare and Medicaid Services (CMS) ride herd on state Medicaid programs so they would hold their managed care plans more accountable.
The government report drew praise from Dee Mahan, the Medicaid program director at the consumer healthcare group [www.]Families USA[.org]. "We are happy to see the OIG pointing out that [provider network] information needs to be improved and kept up to date," Mahan told Medscape Medical News.
Jeff Myers, the president and chief executive officer of Medicaid Health Plans of America, said he agrees with the OIG that provider directories need to be more accurate. However, Medicaid beneficiaries also connect with providers through health plan call centers, care coordinators, and ombudsmen. All in all, satisfaction with provider access among Medicaid beneficiaries closely resembles what is found in Americans with commercial health plans, Meyers told Medscape Medical News [saying that the report] suggests that "because they found some deficiencies in directories, that Medicaid patient access and care could be compromised, and that's just not accurate" ... Myers claimed that Medicaid managed-care networks are generally more ample than those for bronze plans available on the Affordable Care Act state exchanges.
Inaccurate Directories Plague Commercial Insurance, Too
Almost 75% of Medicaid beneficiaries receive their care under managed-care plans, which resemble Medicare Advantage plans in that CMS pays a private company to reimburse providers and coordinate what they do. Medicaid managed-care plans usually assume full risk, receiving a fixed monthly fee per member in exchange for supplying everything from primary care to hospitalization. Providers are paid according to a fee schedule.
The OIG focused exclusively on full-risk managed-care plans in its study of provider availability. It identified 221 such plans in 32 states that were operating throughout 2012 and the first 8 months of 2013. From that pool, the OIG selected a sample of 1800 providers listed in provider directories as of January 1, 2012, and called them in the summer and fall of 2013 to schedule an appointment. Various exclusions whittled down the number to 1092 providers.
Attempts to make an appointment with 50.6% of providers in directories were a complete bust. For one reason or another, 35.4% were not at the listed location; 7.6% were at the location, but no longer or had never participated in the Medicaid health plan, and another 7.5% were not accepting new patients.
[Myers asked] how the accuracy of provider directories in his field compares with that in commercial and Medicare Advantage plans. "It's hard to know whether we are dramatically worse, the same, or slightly better," he said.
Claire McAndrew, the private insurance program director at Families USA, has an answer for Myers: about the same, and not too good. "This is the exact same problem we see in commercial health insurance," said McAndrew[, noting that] insurers in the commercial market also run Medicaid managed care plans — hence the commonality.
McAndrew cited a study of 525 psychiatrists listed in network provider directories of commercial health plans in New Jersey. Contact information turned out to be inaccurate for one third of them. Sixteen percent said they were not taking new patients, and 8% were not psychiatrists to begin with.
Providers often fail to notify health plans when they leave the network or move down the street, McAndrew said. However, health plans still have the responsibility to publish accurate information.
Body Mass Index of 40 kg/m2 or More? No Appointment
With successful appointment attempts in the OIG study, the median wait time was 2 weeks, and was twice as long for specialists (20 days) than for primary care practitioners (10 days). For 28.4% of the appointments, however, the wait time exceeded a month. Most state Medicaid programs require appointments within a month of the request, according to the OIG.
Myers said that Medicaid wait times "in the real world" are lower than those in the OIG study, which he characterized as artificial. "It's predicated on a hypothetical patient calling a doctor they don't know [about] an unspecified disease," said Myers. "It should not be surprising that those doctors don't place them at the front of the line."
The OIG report noted that a few clinicians offered Medicaid appointments in less than a free-handed way: Some turned away patients with certain medical conditions, such as a body mass index topping 40 kg/m2, and others required patients to submit their medical records before a visit. Such practices may limit access to care, the agency said.
The OIG report is available on the agency's website.
Report pdf, 31 pages: "ACCESS TO CARE: PROVIDER AVAILABILITY IN MEDICAID MANAGED CARE, Department of Health and Human Services, Office of Inspector General https://oig.hhs.gov/oei/reports/oei-02-13-00670.pdf