Physician Access Improves After Medicaid Expansion in MI

The findings in a "secret shopper" survey of about 300 primary care providers across the state before and after the implementation of the Healthy Michigan Plan were counterintuitive.

Access to primary care physicians in Michigan increased after the Medicaid expansion, even with the rapid addition of about 350,000 newly insured adults, a new study shows.

Renuka Tipirneni, MD, the lead author of the study and a clinical lecturer at the University of Michigan Medical School, says the findings in the "secret shopper" survey of about 300 primary care providers across the state before and after the implementation of the Healthy Michigan Plan were counterintuitive.

"We had an expectation that practices would get full due to the multiple insurance coverage expansions, both through Medicaid and private insurance on the exchanges under the [Patient Protection and] Affordable Care Act," says Tipirneni, who is also a practicing internist. "We thought we would see decreased availability of appointments and longer wait times. What is interesting is we saw the opposite happen."

In a study published in Health Affairs, U-M researchers in 2014 called primary care physicians posing as relatively healthy patients looking for a routine checkup with a new healthcare provider. For those who said they had Medicaid, 49% of clinics offered an appointment before the expansion and 55% offered an appointment after expansion.

For those who posed as patients with private insurance, 88% of clinics said they could take them before expansion and 86% said they could after expansion, the study said.

Overall, wait times for the first available appointment for all patients stayed the same as before the Medicaid expansion took effect, at about a week.

"There was more flexibility in the capacity of primary care providers to accommodate new patients than we initially anticipated," Tipirneni says "As a practicing primary care physician, I can see there are multiple impacts on my schedule and how easy it is to accommodate new patients and new patient appointments on the schedule. It's not just related to the number of providers. It is also related to the types of providers, whether they are physicians or non-physicians. It is related to how many appointments we can make available both on a daily basis and on a long-term basis."

One Huge Caveat

Before the PPACA, Medicaid reimbursements in Michigan were about 50% of Medicare. During the survey period, Medicaid rates were temporarily raised to 100% of Medicare, specifically to entice primary care physicians to accept Medicaid recipients. That rate has now dropped to about 75% of Medicare.

Tipirneni says it's not clear if new Medicaid patients would have a more difficult time finding a primary care physician now that the rates have decreased to 75% of Medicare.

"That is a good question and one of the reasons why we continue to track these patterns of appointment availability and wait times," she says. "We continue to track this into 2015 to see how these availability of appointments may or may not change once the rates have gone down."

Tipirneni says there were concerns among clinicians and health policy experts in Michigan that the rapid expansion of Medicaid would make it difficult for new enrollees to see a primary care physicians within three months of gaining coverage – a key provision of the Medicaid waiver that created Healthy Michigan Plan.  

Tipirneni says the easy access to primary care may reflect increased efficiencies from primary care practices.

"Primary care practices are redesigning how they practice and a lot of that is related to improved efficiency," she says. "A lot of it is to improve patient-centered care. This is not related to coverage expansion but happening at the same time. There is a strong movement for patient-centered care and particularly having patients in medical homes and primary care clinics. There are many incentives that weren't always the ones intended that have made primary care practices potentially more efficient."

There were exceptions. "Clinics that had long wait times for new patient appointments had long waits for everyone," says Tipirneni.

About half the clinics had only one or two primary care providers; 6% had 10 or more providers. Nine percent of the clinics were safety-net clinics, in line with the state's overall distribution of clinics that accept all patients regardless of insurance status. While there was a small drop in the percentage of clinics that were taking new privately insured patients after expansion, this did not result in an overall increase in wait times.

Tipirneni says it's not clear if the results of the Michigan survey would apply in other states.

"There is the old adage that if you have seen one Medicaid program you've seen one Medicaid program," she says. "There are important distinctions and differences between settings and states and different programs and for that reason it is really going to be important to study this across many states."