MM Curator summary
[MM Curator Summary]: Nearly 60% of all providers listed in directories were not actually providing services to Medicaid members.
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.
- Researchers found significant discrepancies between provider directories and the actual availability of providers in a large study examining access to mental health services among Medicaid recipients in Oregon. Directories full of “phantom” providers may prevent patients from obtaining necessary mental health care in a timely manner, the study authors said.
- The inaccurate listings may be especially harmful for Medicaid enrollees, who already face high rates of serious mental illness, according to the researchers at Oregon Health and Science University and Johns Hopkins University.
- “Constraining or disguising supply is an insidious barrier to realizing access to mental health treatment,” Howard Goldman, of the University of Maryland in Baltimore, wrote in an opinion piece accompanying the research findings in the July issue of Health Affairs.
Medicaid patients are disproportionately likely to have severe, persistent mental health disorders, in addition to complex social and medical needs, according to the non-partisan Medicaid and CHIP Payment and Access Commission.
Medicaid is the single largest payer for mental health care in the U.S. Yet with high demand for those services, there is low provider participation and facility shortages in rural areas, the researchers at Oregon Health noted.
Research from Yale and Cornell universities, published earlier this year in Health Affairs, showed that managed care provider directories may overstate the availability of doctors to see Medicaid patients and suggested that private insurers may be padding networks with physicians unwilling to treat program beneficiaries.
U.S. lawmakers held a hearing earlier this year focused on a U.S. mental health crisis that was exacerbated by the COVID-19 pandemic, shining a spotlight on rising rates of depression, anxiety and suicidal ideation, as well as widespread inequities in insurance benefits.
The Oregon Health study, though limited to one state, shows federal and state efforts to enforce network adequacy standards may be falling short, the authors concluded.
The study compared listings of providers in network directories against provider networks constructed from administrative claims among members under the age of 64 who were enrolled in Oregon’s Medicaid managed care organizations in 2018. Provider directory files included 7,899 unique primary care providers, 722 mental health prescribers and 6,824 mental health non-prescribers in Medicaid managed care networks.
Overall, 58% of network directory listings were “phantom” providers who did not see Medicaid patients, including 67% of mental health prescribers, 59% of mental health non-prescribers, and 54% of primary care providers.
The influence of provider networks is potentially greater in the Medicaid program than in commercial insurance, the study found, because out-of-pocket payment is often unaffordable, and enrollees are generally limited to contracted providers and do not have cost-sharing options for going out of network for non-emergency care.