Contracted Medicaid Managed Care Providers Treated Few Beneficiaries

[MM Curator Summary]: The PAR rate is even worse than we thought.


The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.


Treatment from contracted Medicaid managed care providers was highly concentrated, with a quarter of physicians and specialists accounting for the majority of claims.


Source: Getty Images


By Victoria Bailey

May 04, 2022 – Around one-third of primary care and specialty physicians that contracted with Medicaid managed care plans saw fewer than ten Medicaid beneficiaries over a year, suggesting that network adequacy standards may not accurately reflect beneficiary access to physicians, a Health Affairs study found.

Over 70 percent of Medicaid beneficiaries are enrolled in managed care plans, which are responsible for constructing physician networks from which beneficiaries can seek care. Physician networks in Medicaid managed care plans are typically similar to those in private plans offered through the state health insurance market.

However, network directories may be out of date or list physicians that are not willing to treat Medicaid beneficiaries, indicating that the networks may not reflect the actual availability of physicians. In addition, beneficiaries may prefer providers not included in the network.

To understand how accurate Medicaid managed care plan networks are in determining the availability of physicians for Medicaid beneficiaries, researchers gathered administrative medical claims, Medicaid eligibility and enrollment files, and provider network directories for managed care plans in Kansas, Louisiana, Michigan, and Tennessee between 2015 and 2017.

There were around 22,000 physicians in adult primary care, pediatric primary care, cardiology, and psychiatry in Medicaid managed care networks across the four states, the study found.

About 16 percent of the physicians saw zero Medicaid beneficiaries over one year—defined as ghost physicians. Psychiatrists were the most likely to be ghost physicians, with 35.5 percent treating no Medicaid beneficiaries. Pediatric primary care physicians were least likely to be ghost physicians (11 percent).

Similarly, 17 percent of physicians treated between one and ten Medicaid beneficiaries and were classified as peripheral physicians. Nearly 43 percent of providers saw between 11 and 150 beneficiaries (standard physicians), while 23.7 percent of providers treated more than 150 beneficiaries within a year (core physicians).

The majority of physicians (87.8 percent) who provided care to Medicaid beneficiaries were contracted with Medicaid managed care plans, but 2,500 out-of-network physicians treated at least one Medicaid beneficiary. This suggests that there is a small level of care available to beneficiaries outside the physicians listed in network directories.

Treatment from physicians included in Medicaid managed care plan networks was highly concentrated among small percentages of physicians.

For example, among pediatric and adult primary care physicians that treated at least one Medicaid beneficiary, 25 percent of physicians were responsible for 86.2 percent of claims. Additionally, a quarter of cardiologists accounted for 69.2 percent of claims and 25 percent of psychiatrists were responsible for 86.5 percent of claims.

Among physicians who treated more than 150 Medicaid beneficiaries, 29 percent of primary care physicians accounted for 88 percent of care, 22 percent of cardiologists provided 632 percent of the care, and 15 percent of psychiatrists were responsible for 70.6 percent of care.

Care concentration was slightly higher in urban areas compared to rural areas, the study noted.

Network adequacy requirements vary across the 20 states that have them. Some require plans to contract with at least one primary care provider for every 100 beneficiaries, while others require one provider for every 2,500 beneficiaries.

Based on these network adequacy standards, 94.2 percent of the counties in the four states included in the study had sufficient access to primary care physicians, with an average of one primary care physician for every 440 beneficiaries.

Across the four states, 12.4 percent of counties met the standard for cardiologists, while 10.4 percent met the standard for psychiatrists. After excluding ghost and peripheral physicians, these figures decreased for each provider group.

“Our findings suggest that provider network directories may overstate the availability of physicians in the Medicaid program; many states’ reliance on directories to ensure network adequacy may be insufficient to ensure satisfactory access to physicians who are both valued by Medicaid managed care beneficiaries and willing to treat them,” the researchers wrote.

Medicaid managed care plans are required to demonstrate the adequacy of their networks, but federal leaders have not provided much oversight on how to do this, the study noted. In addition, state network adequacy standards and enforcement vary widely.

Researchers suggested two policy solutions to improve the oversight of Medicaid provider networks. First, states should direct resources to regularly evaluate managed care networks through a combination of audit studies and administrative claims data.

Additionally, states should enact strict penalties for managed care plans that do not comply with network adequacy standards.


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