Blocked at the Front Desk

Health services scholars describe “access” as having 5 dimensions: availability, accessibility, affordability, acceptability, and accommodation. That means that even if patients can get insurance to pay for an appointment, make the appointment, get to the clinic, and see the appropriate provider, there is still a key component left: the provider still has to be willing to take their method of payment. This can be a challenge for patients with Medicaid: up to 1/3^rd of office-based primary care physicians (PCPs) don’t accept new Medicaid patients. A new study in Medical Care Research and Review asks whether this phenomenon of non-Medicaid acceptance contributes to racial health disparities, and if it is greater in areas with higher African American and Hispanic populations.

The study looks at insurance acceptance from the patient’s perspective — measuring the share PCPs who are within 30 minutes’ drive from a block group – a residential area – who were accepting new Medicaid patients. It found that, on average, 57.4% of geographically accessible PCPs were accepting new Medicaid patients; Medicaid acceptance was lower around urban areas such as Washington, DC. In urban and suburban areas, those rates were also lower around areas with more predominantly African American or Hispanic populations. In rural areas, by contrast, there was no association between racial composition of a community and Medicaid acceptance for new patients in nearby PCP offices. 

The study’s strengths are in its format. By using drive times from a given area, rather than simply calculating the number of Medicaid-accepting physicians in that area, it accounts for the “border crossing” phenomenon that invalidates many studies. It fails to account, though, for those other dimensions of access: do these clinics actually have appointments? Accessible transportation?

Overall, the implication for policy makers and administrators is clear: Medicaid acceptance is key in order to improve access and health disparities. For Medicaid policymakers the message is obvious: without increases in payment rates for primary care access will be meaningless for patients blocked at the front desk.

Abstract

Physician acceptance is an important dimension of access to care, especially for Medicaid patients. We constructed two new measures to quantify primary care physician (PCP) acceptance of Medicaid patients using geocoded Virginia physician addresses and population data and geospatial methods. For each Census block group, we measured the shares of “accessible PCPs” accepting any Medicaid patients or new Medicaid patients. Accessible PCPs were defined as those located within 30-minute travel from patient locations and patient locations were proxied by Census block group geographic centroids. We found that the shares of accessible PCPs accepting Medicaid varied within Virginia, and were significantly lower in urban communities where larger fractions of the population were Hispanic, even controlling for unobserved market-level traits associated with Medicaid acceptance. Policy makers and Medicaid program officials should continue to improve nonfinancial access to primary care, especially by addressing access barriers in communities with high shares of minority residents. 

PMID: 29708053

Daly, MR and Mellor, JM. Med Care Res Rev. 2018 Apr 1. (ePub)