eTable 1. Description of State Specialty Access Standards for Medicaid Managed Care
eMethods 1. Description of Control State Selection Criteria
eMethods 2. Description of Weights
eTable 2. Change in Perceived Access to Specialty Care Among Medicaid Enrollees and Commercial Beneficiaries in Case States Before and After Implementation of Access Standards
eTable 3. Change in Perceived Access of Specialty Care (States with Wait Time Only Standards)
eTable 4. Change in Perceived Access of Specialty Care (States with Two Year Post Data Subgroup)
eTable 5. Change in Perceived Access of Specialty Care (States with One Year Post Data Subgroup—MA & NE)
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Ndumele CD, Cohen MS, Cleary PD. Association of State Access Standards With Accessibility to Specialists for Medicaid Managed Care Enrollees. JAMA Intern Med. 2017;177(10):1445–1451. doi:10.1001/jamainternmed.2017.3766
What is the effect of state Medicaid managed care (MMC) specialty access standards on enrollees’ timely accessibility to specialist physicians?
Using a difference-in-differences study design, state standards were not associated with significant improvement in timely access to specialty services for MMC enrollees relative to enrollees in matched control states, nor any improvement in insurance-based disparities relative to commercial beneficiaries.
The adoption of specialty access standards by state Medicaid agencies will likely not lead to meaningful improvements in access to specialty care for Medicaid recipients, suggesting other policy interventions may be needed to address access problems.
Medicaid recipients have consistently reported less timely access to specialists than patients with other types of coverage. By 2018, state Medicaid agencies will be required by the Center for Medicare and Medicaid Services (CMS) to enact time and distance standards for managed care organizations to ensure an adequate supply of specialist physicians for enrollees; however, there have been no published studies of whether these policies have significant effects on access to specialty care.
To compare ratings of access to specialists for adult Medicaid and commercial enrollees before and after the implementation of specialty access standards.
Design, Setting, and Participants
We used Consumer Assessment of Healthcare Providers and Systems survey data to conduct a quasiexperimental difference-in-differences (DID) analysis of 20 163 nonelderly adult Medicaid managed care (MMC) enrollees and 54 465 commercially insured enrollees in 5 states adopting access standards, and 37 290 MMC enrollees in 5 matched states that previously adopted access standards.
Main Outcomes and Measures
Reported access to specialty care in the previous 6 months.
Seven thousand six hundred ninety-eight (69%) Medicaid enrollees and 28 423 (75%) commercial enrollees reported that it was always or usually easy to get an appointment with a specialist before the policy implementation (or at baseline) compared with 11 889 (67%) of Medicaid enrollees in states that had previously implemented access standards. Overall, there was no significant improvement in timely access to specialty services for MMC enrollees in the period following implementation of standard(s) (adjusted difference-in-differences, −1.2 percentage points; 95% CI, −2.7 to 0.1), nor was there any impact of access standards on insurance-based disparities in access (0.6 percentage points; 95% CI, −4.3 to 5.4). There was heterogeneity across states, with 1 state that implemented both time and distance standards demonstrating significant improvements in access and reductions in disparities.
Conclusions and Relevance
Specialty access standards did not lead to widespread improvements in access to specialist physicians. Meaningful improvements in access to specialty care for Medicaid recipients may require additional interventions.
Medicaid recipients have consistently reported less timely access to physicians than counterparts with other forms of coverage.1-3 Although a number of recent federal policy efforts have attempted to close this gap for primary care services, facilitating access to specialty care has largely been left to states and local communities.4,5 Decades of research indicates that low-income populations face many challenges accessing specialists when they need advanced care.6-9 Reports have generally found that Medicaid enrollees have better access to specialists than the uninsured, but poorer access than commercially insured individuals.6,8,9
Several communities have had success improving access to specialty care for Medicaid enrollees, but these efforts have been limited in scope, often require significant organizational restructuring, and may be difficult to sustain.10,11 Advocates argue that the proliferation of managed care plans with distinct physician networks, along with the growing number of Medicaid enrollees with complex health conditions, necessitate a national policy to ensure access to specialty services.12-14 However, some policy observers fear that limited oversight and enforcement of network access standards may not lead to meaningful changes in access to care for enrollees.15,16
New federal Medicaid managed care rules (MMC), expected to be implemented by 2018, require all states to set time and distance standards for specialty care services, to ensure adequate networks and timely access to care.17 Wait time standards require that appointments be scheduled within a certain timeframe and distance standards dictate the maximum amount of time or distance an enrollee must travel (in miles) to receive specialty care. The standards represent the most robust policy effort to improve access to specialty services to date, but some policy observers have noted that there is no evidence of the effectiveness of such standards. Typically, access standards have been aspirational and are not linked to reimbursement, placing into question their ability to improve access. Over the past decade, several states have implemented similar standards regarding time to get an appointment and/or distance to specialty care in an attempt to improve Medicaid enrollees’ access to specialty care. However, to our knowledge, there have been few local, and no national evaluations of the effects of these policies on access to services.
In this study, we evaluate the effects of specialty care access standards in 5 states that previously implemented policies for Medicaid recipients. Using data from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey, we assess whether state-initiated specialty access standards have improved ratings of access to specialty care for Medicaid managed care recipients and have been successful in reducing existing gaps in access between Medicaid and commercially insured individuals.
We used CAHPS survey data corresponding to our study period (2005-2011) to assess enrollee access to specialty medical care. The CAHPS surveys are widely used to ask patients about their health care expereinces.18 For these analyses, we used data from Medicaid and commercial Health Plan CAHPS surveys that had been contributed to the CAHPS Database, for which submissions are used to benchmark health plan performance. This study was deemed exempt from review by the institutional review board at Yale University. Additional details regarding survey design, administration, and response rates are available elsewhere.19 To account for differences in health care environments, we used previously published data from the Kaiser Family Foundation and the US Census Bureau for information on yearly state-level total population sizes, number of Medicaid enrollees, and Medicaid managed care penetration rates.20,21
We acquired information on access standards for Medicaid managed care plans from the US Department of Health and Human Services (HHS). The HHS maintains data on state use of access standards and the year of implementation for new standards. Current information on state access standards can be accessed elsewhere.22 We identified 5 states that implemented time- or distance-based standards for specialty care during our study period: California, Colorado, Massachusetts, Nebraska, and New Mexico (hereafter referred to as case states). We also identified potential control states that had implemented specialty standard(s) at least 2 years prior to the start of the study period. Using this preliminary list of possible control states, we matched each case state to 1 or more control states. Controls were required to have a Medicaid managed care penetration rate and the percentage of a state’s population enrolled in Medicaid that was within 5% of a given case state in the year prior to adoption of the access standard because previous research has demonstrated that MMC penetration is a significant predictor of physician acceptance of Medicaid enrollees.23 For 2 states without controls using our initial criteria, we relaxed the 5% criterion and identified the next closest state matches that had not already been selected as a match for other case states. We tested whether trends in the prepolicy period were significantly different between implementation states and matched control states by estimating the coefficient on the interaction between a linear time trend and a case-state indicator variable and found the interaction to be nonsignificant, offering support for our matching criteria. Details of each case state’s access standard(s), and further information on the selection of control states are available in the appendix (eTable 1, eMethods 1 in the Supplement).
Medicaid managed care CAHPS respondents were eligible for the study if they reported that they tried to use specialty care services in the 6 months prior to survey administration and were not dual-eligibles; commercially insured respondents were eligible if they reported trying to use specialty care in the 12 months prior to survey administration. Recent work has found no difference in respondents’ ratings of getting timely care, appointments, or information using a 6-month vs 12-month look back period.24 In total, our sample included 20 163 adult MMC enrollees in 5 case states and 37 290 MMC enrollees in 5 control states. In addition, we compared Medicaid enrollees’ specialty care access with 54 465 commercially insured enrollees residing in the 5 case states.
Our primary outcome was access to specialty care reported by enrollees in MMC health plans. We used the CAHPS question: “in the last six months, how often was it easy to get appointments with specialists?” We collapsed the 4-level Likert responses (always, usually, sometimes, never) into a dichotomous variable that operationalized adequate access as individuals who responded that they always or usually had ease in getting access to specialists.
Our primary independent variable was whether a state initiated specialty access standards during our study period. To ensure the comparability of groups and to account for effects in important subgroups, respondent characteristics asked about on the survey were used in our regression analyses. These characteristics were sex, age (18-34, 35-44, or 45-64 years) education (high school or less, some college or more), race (white, black, Asian, other), Hispanic ethnicity, self-rated health (excellent, very good, good, fair, poor), and whether a proxy helped fill out the survey. We also included health plan identification numbers to account for possible cluster effects.
To estimate the effect of implementing time- or distance-based standards on access to specialty care, we employed a difference-in-differences model. This quasiexperimental approach compares changes in each outcome over time, in case states (adopters of access standards) vs control states (prior adopters). Because we did not know the exact date of survey administration, we did not include individual responses that occurred in the year of adoption. Pooled regression models included 4 years of data prior to the adoption of the standards and up to 2 years of data after their implementation.
We used 2 different control groups to answer the research questions. To answer whether access standards were associated with changes in timely access to specialty care, we used the responses of Medicaid enrollees in the matched control states. To examine whether these standards have been successful in reducing gaps in access between Medicaid enrollees and the commercially insured, we used survey responses from commercially insured individuals living in case states as the control group.
We estimated regression models that included indicators for the postpolicy period, being a case state, and the interaction of these 2 terms, as well as the individual-level covariates described above. Models also included state and period fixed effects, as well as interactions between the period and each case-control state pairing to adjust for distinct time trends for each pair. We constructed separate models independently for each state pair, to examine the heterogeneous effect of access standards on perceived access across states. For analyses that pooled multiple case and control states, we estimated robust standard errors clustered at the state level to adjust for correlated outcomes within states and serial correlation; for models that included only a single state pairing, or that explored gaps in access between the Medicaid and commercially insured populations, standard errors were clustered at the health plan level.
The number of survey responses submitted by a state to the CAHPS database is not necessarily representative of the size of the state’s total Medicaid or commercially insured population. Thus, we weighted the data in adjusted pooled regressions to make estimates reflect the actual number of Medicaid enrollees and commercial beneficiaries over time in each of the 10 states included in our sample. For Medicaid respondents, we created weights to reflect each state’s Medicaid enrollee population size for each period included in our study timeframe. For commercial respondents, weights reflect the state’s total population, net of Medicaid enrollees, in a given period (eMethods 2 in the Supplement). In a separate sensitivity analyses, we stratified results by states that implemented time-based standards, distance-based standards, or both (eTable 3 and eTable 4 in the Supplement). Finally, we constructed separate regression models for 2 states for which we had only 1 year of data following the implementation of access standards to assess if the effect was distinct from the overall finding. (eTable 5 in the Supplement). This study was approved by the Institutional Review Board at Yale University. All analyses were conducted using Stata statistical software (version 14, StataCorp).
The characteristics of the case and control state respondents to the Medicaid CAHPS survey were largely comparable. The proportion of individuals self-identifying as Hispanic was considerably higher in case states relative to their matched control states. Medicaid beneficiaries in control states, however, were more likely to be enrolled in a health maintenance organization. There were larger differences in the demographic characteristics between the commercial and Medicaid recipients in the states that implemented specialty access standards. Relative to MMC recipients, commercial enrollees in the same state were, on average, older, less likely to be racial/ethnic minorities, more likely to have completed at least some college, and less likely to have used a proxy to complete their survey (Table 1).
There was not a statistically significant effect of implementing specialty access standards on enrollee reports of access to services in 4 of the 5 states included in our study (Table 2). In our pooled analysis, MMC enrollees in control states, where specialty access standards had previously been enacted, were 2.4 percentage points less likely than enrollees in case states to report that it was always or usually easy to get an appointment for specialty care at baseline. In regression models examining the implementation of specialty access standards, the proportion of enrollees reporting good access decreased from 69.3% to 66.9% in case states, compared with a 2.9% increase in control states (66.9% to 69.8%), resulting in a difference-in-differences estimate of −5.3 percentage points (95% CI, −9.4% to −1.3%) (Figure 1). After adjustment for demographic and plan-level characteristics, there was a nonsignificant effect of −1.2 percentage points. (95% CI, −2.7% to −0.1%) (Table 2). To examine the consistency of our pooled estimate across state case-control pairs, we conducted stratified analyses for each state pair. There was a significant and positive effect of specialty access standards in 1 of the 5 state pairs in our study, with enrollees in the case state reporting an adjusted 6.4% improvement in access relative to enrollees in a matched control state (95% CI, 0.8%-11.8%) (Figure 2).
We also found little evidence that access standards significantly reduced disparities in access to specialists among nonelderly MMC enrollees and commercial counterparts in the same state (Figure 3). In pooled analyses, commercial enrollees were more likely to report good access to services at baseline (75% to 69%), and this gap persisted in the period following the implementation of specialty access standards (adjusted difference-in-differences, 0.6 percentage points; 95% CI, −4.3% to 5.4%). There was, however, a 10.9% reduction in insurance-based disparities among MMC enrollees relative to commercial enrollees in 1 of the 5 case states in our study (95% CI, 5.9%-16.0%) (eTable 2 in the Supplement). This reduction occurred in the same state in which we previously observed a significant and positive gain in access to specialty care for MMC enrollees (Figure 2), indicating that our results were consistent across the 2 types of control groups used in this study.
Over the past decade, state Medicaid programs have increasingly implemented specialty access standards for managed care plans. Despite widespread adoption, and a federal mandate for an expansion of this policy, to our knowledge, this study is the first multistate evaluation of whether these standards have improved specialty access for Medicaid enrollees and ameliorated long-standing insurance-based disparities in access to specialists.
We find little evidence that access standards improved access to specialists for Medicaid enrollees. While we observed some baseline differences in the case and control states, they were largely persistent over time, reducing the likelihood that shifts in the composition of the sample were a major contributor to our results. Moreover, we adjusted for individual-level demographic differences in regression models. Our analysis showed no significant change in 4 of 5 states that implemented standards during our study period. Moreover, we find little evidence that policies reduced disparities between nonelderly Medicaid and commercial enrollees. We do, however, find that access standards did significantly improve access and reduce insurance-based disparities in 1 state that implemented both time- and distance-based standards.
The inconsistent effects associated with the introduction of specialty access standards may reflect, in part, the broader challenges associated with the enforcement of initiatives to promote network adequacy.25 Previous audit studies of physician offices have shown significant gaps in the availability of appointments to specialists for Medicaid and commercial patients.9,10 Moreover, when specialist physicians are available to Medicaid recipients, such patients often have to wait longer for an appointment than commercially insured patients, even when presenting with the same conditions.9 States and the federal government have traditionally lacked effective resources to ensure good access for Medicaid recipients or levers to spur corrective actions in the face of inadequate access.15 In the light of these limitations, our study suggests that standards alone may not consistently lead to meaningful improvements in access to specialty care.
The lack of effect of access standards underscores the need to strengthen and/or combine alternative policy and organizational strategies to improve enrollee access to specialists. For example, current access standards have no financial or regulatory consequences for Medicaid providers. Emerging delivery models, such as accountable care organizations, may incentivize providers and payers to prioritize the coordination of care and timely access for enrollees with more complex clinical needs.26,27 Locally, health plans have also embraced less costly mechanisms to deliver specialty care, including the use of e-consults and nonphysician personnel.12 Payment models that account for the increased use of nontraditional access may be useful in supporting these approaches and augmenting traditional models of care.
Disparities in the access to specialty care between commercial and Medicaid enrollees are particularly troubling given the changing characteristics of the Medicaid population. Studies following the implementation of the Affordable Care Act have found that as many as half of adults who have recently acquired Medicaid through state expansions have at least 1 chronic condition, with many of these individuals requiring care from specialists.12,13 To the extent that the demand for specialty care has increased following the expansion, our results further underscore the need for states to facilitate increased specialist participation in the Medicaid program. In contrast to the widely publicized “fee-bump” physicians who accept Medicaid received for primary care services via provisions in the Affordable Care Act, data indicate that physicians receive three-fourths of the Medicare payment rate for nonprimary care services provided for Medicaid recipients.4,28 It is unclear whether access standards have the potential to facilitate timely use of services for Medicaid recipients in the absence of changes in the supply of physicians willing to accept Medicaid reimbursement rates.
The challenges in accessing specialty care for Medicaid enrollees is in stark contrast to gains in access to primary care services observed in recent years, which have been the result of several targeted initatives.29-31 Nonetheless, there may be cause for optimism about the long-term prospects of specialty access standards in MMC. Some policy observers have noted that the widespread adoption of managed care and their associated networks of physicians in Medicaid has itself led to increases in access to all physicians, representing an improvement from a fee-for-service model where Medicaid beneficiaries were tasked with identifying doctors who would accept their coverage.23 In addition, we are encouraged to find significant improvements in access and reductions in disparities in Nebraska, where legislators simultaneously enacted time and distance standards. It is unclear whether this effect is related to the state-specific implementation of standards or if the introduction of multiple standards induces substantial changes in provider availability, however, this is a finding that warrants additional study.
Our study has several potential limitations. First, the CAHPS survey data came from a cross-section of individuals within health plans, rather than a longitudinal survey. Thus, we are estimating population-level changes in the reported access to specialty services, as opposed to within person ratings of how their access has changed over time. Nonetheless, differences in the distribution of samples were generally consistent over time and we used statistical adjustment to account, in part, for composition changes. Second, the plans providing data were not a random sample of health plans. While some states require health plans to submit data, many plans submit on a voluntary basis. To the extent that high-performing plans are more likely to submit than low-performing plans, the CAHPS sample may reflect an overestimate of the effect of specialty access policies. Third, respondents’ perceptions of access to care may not accurately reflect the true availability of services in their communities; however, perceived access remains an important predictor of whether individuals seek health services in a timely fashion.32 Fourth, the compositions of the plans and associated physician networks may have been different for beneficiaries receiving care in Medicaid and commercial populations, contributing to differences observed in our study. Fifth, the time and distance standards varied considerably from state to state. It is possible that the effectiveness of state standards is not accounted for in this study. Nonetheless, our study provides much needed evidence regarding a policy that has been widely adopted by state Medicaid agencies. Finally, it is unclear whether our results generalize to enrollees seeking specialty services in the period following the federal Medicaid expansion.
The federal government will require all states to create specialty access standards for MMC plans operating in their states by 2018. Our analysis shows that this policy alone is unlikely to lead to widespread improvements in access to health care services for Medicaid enrollees or to reduce gaps in specialty care access between Medicaid and commercial enrollees.
Corresponding Author: Chima D. Ndumele, PhD, Department of Health Policy and Management, Yale School of Public Health, 60 College St, New Haven, CT 06520 (firstname.lastname@example.org).
Accepted for Publication: June 7, 2017.
Published Online: August 14, 2017. doi:10.1001/jamainternmed.2017.3766
Author Contributions: Dr Ndumele had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Ndumele, Cohen.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Ndumele, Cohen.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Cohen.
Obtained funding: Cleary.
Supervision: Ndumele, Cleary.
Conflict of Interest Disclosures: None reported.
Funding/Support: The conduct of the research was supported by funding from the Agency for Healthcare Research and Quality (U18HS016978-08). Mr Cohen acknowledges support from a National Research Service Award training grant (T32 HS017589) from the Agency for Healthcare Research and Quality.
Role of the Funder/Sponsor: The sponsor or funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Additional Contributions: We thank Stephanie Dowling, MPH, Yale Public School of Health, for research assistance during the conduct of the study. She was compensated as a paid team member.