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Session Recap: Medicaid Policy, Scope of Practice Regulations, and Access to Care

November 12, 2014 09:00 AM

By Sana Ahmad, Rutgers University

With the ACA increasing coverage of low-income people through Medicaid expansions, there has been much research on the effect of such an expansion on healthcare and health. The group of researchers presenting in this panel look at the impacts of Medicaid on various aspects of healthcare.

How do Providers Respond to Public Health Insurance Expansion: Evidence form Adult Medicaid Dental Benefits

Under Medicaid, dental services are mostly not covered, but some states have periodically passed legislation requiring such covering. The authors use repeated cross-section data from the Survey of Dental Practices from 1999-2011 to gauge provider response to Medicaid dental services expansion. They present a reduced form model including various relevant controls and a dummy variable for state coverage of full dental services benefits.

Results show that when adult dental benefits are turned on, dentists are more likely to report having some public payer patients. The authors report a reduction in self-pay and also say that they observed no crowd-out of private insurance. In order to rule out the possibility that the same patients are being seen with a difference insurance status and to confirm that the number of visits is indeed higher, the authors look at the types of visits. There was increase in the overall number of visits with much of the extra volume coming from increase in visits with dental hygienists. Medicaid expansion to cover dental services leads to a 2percent significant increase in the time that dentists work, and they also hire more dental hygienists.        

One concern highlighted by authors is that the state decision to add or drop benefits is not random, and thus it might be possible that the results are not Medicaid specific but picking up macro state policy elements. The authors deal with this concern through a placebo test by assessing effect of policy on geographic and economic neighbor states that did not have dental coverage through Medicaid; there was no effect. By showing that the results are not picking up economic shocks, the original conclusion is strengthened.

Some spillover effects were also reported. When dental services are covered, the wait-time for appointments increases by one day and there is also a small statistically significant increase in the wait-time at the office.

2) Provider Mix, Regulatory Hurdles, and New Patient Primary Care Visit Availability

Michael Richards’ presentation revolves around assessment of how clinic provider mix might influence healthcare access for different types of patients including privately and publically insured. The authors’ main hypothesis is that providers of different skill types, including nurse practitioners and physician assistants, can lower a practice’s production costs, allowing a greater supply of services to low-payment market. The authors point out, however, that in order to such a thing to happen, the policy conditions regarding scope of practice regulations must not be an impediment.

With Medicaid providing less generous reimbursement, providers are often less willing to provide services, and there is much literature showing that access for Medicaid recipients is affected by payment rates. With nearly half of the states expanding Medicaid, there is concern that the provider supply will not be sufficient to meet the increased demand.

The authors’ conceptual framework is built on the assertion that physician practices are selling services to public and private patients with different payment rates. Practices can organize themselves with a mix of providers and patients, and regulations impose policy constraints that matter most for the low-paying patients.

The authors use data from field experiments across 10 states collecting through a simulated patient methodology in which trained field staff members, assigned to simulate patients with private or public insurance, try to get appointments with non-elderly adult primary care practices which are randomly selected. The variables of interest include acceptance of Medicaid by the practice as well as the wait-time for appointment. The regulatory environment governing scope of practice laws is defined as liberal if the scopes of practice regulations allow Nurse Practitioners or Physician Assistants to administer care. Estimating linear models for 3 outcomes: comparing Medicaid to private insurance, within-clinic analysis using non-physician clinical categorical variables, and out-of-pocket costs at time of visit.

The results should that in liberal scope of practice states, there is more willingness to take on a Medicaid Patient; this pattern is not observed in other states. Additionally, more diverse provide mix appears to increase access to care, and such clinics have increased willingness to supply more new-patient visits to the Medicaid market and lower cost visits for self-pay patients. One limitation is identified as the limited geographical coverage with only 10 states being covered and only 3 among those states having liberal scope of practice regulations.

3) Do the Poor Benefit from More Generous Medicaid Physician Payments?

Alice Chen, assistant professor at University of Southern Californis, presents her work on Medicaid by first outlining the objectives of determining effects of changes in Medicaid payment and eligibility on types of patients seen and on rates of insurance enrollment. Using data from physician survey, Dr. Chen shows that when Medicaid payments go up there is an increase in physician willingness to treat Medicaid patients, a decrease in charity care, and no reported changes in private insurance. Despite the increase in physician willingness to treat Medicaid patients, less total care is available for the poor, for the sum of hours of care for Medicaid and Charity Care patient falls. However, not all uninsured are worse of due to supplier-induced-demand, with physicians encouraging patients to enroll in Medicare.

In terms of policy implications, changing provider payments is a method often used as a tool to influence patient’s potential access to base. Dr. Chen’s research is noteworthy in showing that in order to ensure sufficient access to care, increases in provider payments should be complemented in Medicaid eligibility expansions


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