Physicians with many Medicaid patients are likely to treat more in 2014

Increasing patient capacity for primary care physicians already seeing a large number of Medicaid patients might be the best way to prepare for the millions of people who will become eligible for the program in 2014 under the health system reform law.

That's because these physicians are much more willing and able to handle new Medicaid patients than doctors who see relatively few people on Medicaid, according to "Physician Willingness and Resources to Serve More Medicaid Patients," an analysis released April 27 by the Kaiser Commission on Medicaid and the Uninsured and the Center for Studying Health System Change.

For example, 84% of physicians with Medicaid patient caseloads of at least 26% are willing to see all or most new Medicaid enrollees, according to the analysis. But only 8% of physicians with Medicaid patient loads of less than 6% were willing to see all or most new people covered by the program.

The report does not attempt to predict if enough primary care physicians exist to care for the 16 million people expected to gain Medicaid eligibility through the health reform law's Medicaid expansion, which begins in 2014. Rather, it assesses the possible response of physicians to this expansion based on their Medicaid participation, said Julia Paradise, associate director at the Kaiser commission and a report co-author. The report is based on a 2008 survey of doctors, the most recent data available.

Primary care physicians' willingness to see new Medicaid patients will depend in large part on their practice conditions, said Roland Goertz, MD, president of the American Academy of Family Physicians. Pay rates and administrative burdens vary widely from state to state. The academy supports increasing Medicaid pay to track Medicare rates more closely. The national health reform law temporarily will increase Medicaid primary care pay to match Medicare rates in 2013 and 2014.

Medicaid rates are an important factor in physicians' decisions to expand or limit their Medicaid patient mix. Nearly 90% of physicians who are willing to see only some Medicaid patients or who were unwilling to see any cited inadequate pay as a reason. But about three-quarters of these doctors said payment delays and Medicaid billing requirements were important or moderately important reasons for limiting their Medicaid patient loads. Ninety-one percent cited more than one reason.

The survey also found that a quarter of physicians who limited their Medicaid caseloads also capped their acceptance of new privately insured patients. "They're less engaged in public insurance for sure, and private insurance, too," Paradise said.

These low-share Medicaid doctors might offer fewer opportunities for expanding access to program enrollees in part because they are more likely to practice in the highest-income ZIP codes, the survey found. These physicians are somewhat less likely to offer patient education for people with chronic conditions and to use full electronic medical records at their main practices.

In contrast, physicians with higher Medicaid patient mixes were more likely to work in lower-income areas. Nearly 40% work at community health centers or in hospital-based or hospital-affiliated practices, settings that may have more resources to handle Medicaid patients' needs, such as translators. These practices may have the ability to expand their Medicaid capacities, the survey suggested.

However, recent cuts to community health center funding will hurt the facilities' ability to prepare for the patients gaining coverage through the health reform law, said Dan Hawkins, senior vice president for public policy and research for the National Assn. of Community Health Centers. The fiscal 2011 budget deal reached by President Obama and Congress on April 8 reduced funding for health centers by $600 million and trimmed the National Health Service Corps budget by $125 million, he said.

Hawkins criticized the part of the budget deal that cut the health centers' funding. "Talk about cutting off your nose to spite your face," he said.

In addition, 28% of high-share Medicaid physicians report that a lack of qualified specialists in their area is a major obstacle to providing high-quality care. "It's been a perennial problem," Hawkins said.

Some groups of community health centers are trying to improve access to specialists by developing formal associations with hospitals and health networks, Hawkins said. For example, all health centers in Utah have a relationship with Intermountain Healthcare, a health system with 23 hospitals based in Salt Lake City.

"That's just one example, and it's happening everywhere around the country," he said.

The report is based on a sample of 1,460 primary care physicians. The authors also conducted 15 in-depth interviews with a range of physicians between July and September 2010.