Is money motivation enough to get more doctors to open their doors to Medicaid patients?

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    Medicaid doesn’t pay enough. For years that’s been the complaint from some doctors.

    Two years ago, as part of the Affordable Care Act, the federal government boosted certain payments to doctors in the program, and now there’s early evidence that the temporary pay raise made it easier for people to book an appointment with a doctor.

    “Secret shoppers” posing as Medicaid patients called up 3,000 physician offices beginning in 2012, then again in 2014 after Medicaid reimbursement fees had increased.

    “What they did is essentially say: ‘Ah, I just moved into town, and I’m looking to get a primary care doctor. Can I get an appointment?” said University of Pennsylvania health economist Daniel Polsky.

    He’s lead author on the survey of physicians’ offices in 10 states, including Pennsylvania and New Jersey. The study appears online in the New England Journal of Medicine.

    Back in 2012, the callers posing as Medicaid patients booked an appointment about 58.7 percent of the time. After the pay raise, the appointment availability was 66.4 percent. Polsky says that 8 percent increase—in just a year and a half–made his jaw drop.

    “What I make of that number is that doctors responded. They said: ‘Gee, you know, I should see more patients in my panel that have Medicaid, it seems worth it to me now,'” Polsky said.

    Traditionally Medicaid has been the federal health plan for very poor people—and the disabled. Under the Affordable Care Act, some states expanded the program to give health coverage to millions more people. From the start, there were big worries that doctors would not be willing to take on those newly insured Medicaid people as patients.

    The Medicaid pay bump was an experiment to help ease that concern.

    “The federal government said, ‘Listen if you do this: I’ll pay 100 percent.’ They would pay 100 percent of the increase from whatever the state was paying before to make it even with Medicare,” Polsky said.

    The pay increase was steep in some places, less dramatic in others because the base rates paid to health providers varies state to state. As an example, Polsky says in New Jersey the Medicaid fee paid for a typical 30-minute primary-care doctor visit jumped to Medicare’s $115 rate, up from about $62.

    In Pennsylvania, the Medicaid fee increased to about $106, up from $54.

    The boost was designed to nudge primary care physicians to take on more Medicaid patients, but family doctor Lucy Hornstein said she was not enticed.

    “The real problem with all of these things is the idea that I’m only about money,” said Hornstein, who has a solo practice in Phoenixville, Chester County, Northwest of Philadelphia. “The whole idea that you can incentivize or disincentive us based on money, it’s not true. For doctors, professionals in general, what we respond to is autonomy. We do the right thing because that’s what we do.”

    Hornstein opted out of the Medicaid program years ago. The paperwork requirements were a headache she says.

    “It just became way too many hoops to jump through for way too little payment,” she said.

    When a long-time patient, who formerly had private insurance, switches to the Medicaid program, Hornstein says she continues to see him but typically ends up writing off the cost of medical services as charity care.

    In the commonwealth, Medicaid patients typically join a managed care plan, and Hornstein said that’s another reason she doesn’t participate in the Medicaid system.

    Hornstein said she considers managed care a “scheme” to shift the financial risk of caring for the patients from the insurance company to the doctor. “The idea is: ‘We’ll pay you a certain amount of money per person per month’—capitation–or paying by the head,” Hornstein said.

    During the run-up to the fee bump, the Pennsylvania Academy of Family Physicians, reminded its 5,500 doctors that the pay increase would be temporary.

    “We didn’t look at it as something that would be sustained in the future, we didn’t look at that as a money maker, that’s not the decision driving a family physician every day,” said academy president Douglas Spotts.

    “It was not about a dollar grab,” he said.

    Spotts’ medical practice is in Lewisburg, Pennsylvania. The office kept its population of Medicaid patients about the same during the temporary pay increase, he said.

    Family physicians in Pennsylvania are advocating for fixes–beyond dollars—Spotts said that would improve the system by making the care delivered to patients less disjointed.

    The study from the researchers at the University of Pennsylvania and the Urban Institute is just one lens to figure out if money is motivation enough to get more doctors to open their door to more Medicaid patients.

    At the beginning of 2015, after two years, the Medicaid rates dropped again. Researcher Dan Polsky says now it’s up to policy makers to decide if fees should be boosted permanently.

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