Nineteen states have continued a temporary Medicaid pay increase for primary care physicians, and some data indicate that approach can improve access.

July 24—The share of office-based primary care physicians accepting new patients has decreased in recent years, according to survey data from the Centers for Disease Control and Prevention (CDC).

Recent CDC data found 11.1 percent of primary care physicians reported that they accepted no new patients in 2015. The share was 8.4 percent in 2013, according to an earlier CDC report.

New Medicaid patients were the least likely to be accepted by primary care physicians that took new patients: 71.6 percent of that group accepted new Medicaid patients, compared with 77.4 percent that accepted new Medicare patients and 94.2 percent that accepted new patients with private insurance.

It was unclear how those percentages changed from prior years because CDC previously did not compare the acceptance rates based on a subset of primary care physicians that accepted any new patients.

“Currently, there is no apples-to-apples version of the new data that matches up with previous CDC reports that looked at physicians accepting patients with various payers as a share of all such physicians,” a CDC spokesman said in an email.  

The results are similar to a large 2016 survey by the Physicians Foundation, which found that 39 percent of primary care physicians either did not see Medicare patients (22.2 percent) or limited the number they saw (16.8 percent). That was a decrease from 2012, when 32.9 percent of primary care physicians reported that they were no longer accepting or were limiting their number of Medicare patients. Likewise, the 2016 survey found that Medicaid patients were the least accepted group of patients, with more than 41 percent of primary care physicians saying they did not see them (16.3 percent) or limited the number they saw (24.8 percent).

The reduced primary care acceptance rates come as the ranks of both Medicare and Medicaid enrollees are growing rapidly due to population aging and the expansion of Medicaid eligibility through the Affordable Care Act (ACA).

The Medicare Payment and Access Commission (MedPAC) found in a March report to Congress that 35 percent of Medicare beneficiaries reported problems in getting access to a new primary care physician. However, a similar share of people ages 50 to 64 with private insurance reported the same problem. MedPAC also noted that in 2015, the ratio of physicians in primary care specialties to the number of beneficiaries was 3.6 per 1,000, which was the same as in 2014.

Experience Differs

But the experience of some runs counter to MedPAC’s finding of stability.

“In spite of what you have been reading from MedPAC and others, it is getting increasingly difficult to get a primary care physician if you’re in an upper-middle-class community,” said Stuart Altman, PhD, an economist and chairman of the Massachusetts Health Policy Commission.

Altman, who is a Medicare beneficiary, said he lost three primary care physicians over the last five years.

“I’ve given up,” said Altman, who has moved to receiving care from a concierge practice.

“I predict that if government at the federal level continues down the road it is going down, where what it does is keep impacting on the price because it can’t impact on the utilization very much, and it doesn’t do anything else, then increasingly Medicare is going to look like Medicaid,” Altman said.

Sheila P. Burke, a strategic adviser for the Baker Donelson law firm and formerly a senior Republican congressional staffer, said the declining number of primary care physicians who accept Medicare patients is as much about workforce and training issues as it is about Medicare payment.

“We’ve had that problem for years in Medicaid, where we have a relatively small number of physicians who are willing to take Medicaid patients,” Burke said.

A recent development that highlighted the strain of declining Medicaid payments on providers, Burke said, was the decision of Ohio’s largest Medicaid managed care plan to terminate its contract with the Cleveland Clinic.

Pay Rate Impacts

Some have warned that Medicare and Medicaid acceptance rates by primary care and other physicians are set to worsen as payment rates tighten for those two programs. For example, under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), Medicare will provide physicians in a qualifying advanced alternative payment model with several bonuses through 2024 but then limit annual payment increases to 0.75 percent. Similarly, Medicare physicians in the Merit-based Incentive Payment System will receive a cumulative 2.5 percent increase over several years, followed by revenue-neutral increases or decreases before annual increases are limited to 0.25 percent starting in 2026.

“So every physician in the country who doesn’t agree to go into essentially an [accountable care organization] … their fees will forever grow at no more than 0.25 percent annually,” said Jim Capretta, a fellow at the American Enterprise Institute. “That’s a massive cut if you do it in present-value terms.”

Such caps are intended to force other decision making to bring costs under control, Capretta said.

“There is a problem with a strategy that builds in as low an increase as what we have seen in MACRA,” said Gail Wilensky, former administrator of the precursor agency to the Centers for Medicare & Medicaid Services. “You do have a problem when you don’t have sustainable spending that is anywhere near where a cost is likely to be when it comes to the physician portion.”

A 2017 analysis by the Urban Institute noted that Medicaid programs in 2016 paid primary care physician fees at 66 percent of Medicare fees.

That report found 19 states have continued a temporary ACA-authorized Medicaid fee increase for primary care physicians, which was aimed at increasing beneficiary access.

The research noted that the initial evidence is mixed on whether the payment increase improved access to primary care for Medicaid enrollees. One study found an increase of 7.7 percentage points in the availability of appointments for Medicaid enrollees between 2012 and 2014 in 10 states.

“The increase in availability was greater for states with larger increases in reimbursement rates, suggesting that the fee bump likely contributed to the greater availability of physicians,” the authors noted.

Rich Daly is a senior writer/editor in HFMA’s Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare

Publication Date: Monday, July 24, 2017