213
Medicaid Today, Uninsured Tomorrow? Effects of Relaxed Eligibility Redetermination Protocols on Medicaid Participation among Primary Care Physicians
The low level of physician participation in Medicaid is often attributed to disparities in fees paid for physician services—on average Medicaid pays considerably less than Medicare and private insurers for the same services. Primary care physicians (PCPs) willingness to see Medicaid patients may also be affected if stringent eligibility redetermination protocols increase the probability these patients will soon become uninsured and more unattractive financially (or privately insured and more attractive financially if found to have access to private insurance). While states have relaxed these policies to alleviate beneficiaries’ re-enrollment burdens and increase their access to Medicaid coverage, there may be unintended benefits of increased Medicaid participation among PCPs as well. We tested the impact of eligibility redetermination protocols on PCP participation in Medicaid, a relationship previously unexamined in the literature, in difference-in-differences models using plausibly exogenous changes over time in states’ policies to identify effects.
Methods:
We examined whether PCPs for adults (general practice, family practice, and internal medicine specialists) and pediatricians accept new Medicaid patients or new privately insured patients and their fractions of practice revenue by payer—our principal outcomes of interest—using longitudinal Community Tracking Survey Physician Survey data, 2000-2004. Our key predictors were state-year-level indicators for whether the state (1) required Medicaid recertification annually (“relaxed” requirement, versus more frequently) and (2) terminated face-to-face interviews for recertification (“relaxed” requirement, versus not). We constructed separate difference-in-differences models for PCPs for adults and pediatricians. To explore effect heterogeneity, we constructed triple-difference models, introducing interaction terms with dummies for practice size and non-zero Medicaid revenues in 2000. We controlled for several potential confounding factors, including salary incentives, practice type, practice capacity constraints, Medicaid fee generosity for primary care services, and Medicaid managed care penetration. We also included state and year fixed effects and clustered standard errors at the state level.
Results:
For our samples of 1,589 PCPs for adults and 482 pediatricians, we identified no significant associations between relaxed eligibility redetermination requirements and accepting new Medicaid patients or the probability that at least 2%, 5%, or 10% of the practice’s revenues came from Medicaid. However, in our triple-difference models for PCPs for adults, we found positive effects on these outcomes among larger practices (e.g., 26.6% versus mean 51% with at least 10% Medicaid revenues, p=0.021) and practices with non-zero Medicaid revenues in 2000 (e.g., 18.7% versus mean 69% accepting new Medicaid patients, p=0.070). Relaxed requirements also reduced the probability of accepting new privately insured patients among PCPs for adults (-2.6% versus mean 93%, p=0.037). Results for pediatricians were muted.
Conclusions:
While states’ decisions to relax Medicaid eligibility redetermination protocols may lessen administrative burdens and increase Medicaid coverage among low-income groups, our results suggest that the associated decreases in risks of beneficiaries “churning” off Medicaid rolls do not significantly affect PCP practices’ decisions about whether or not to accept Medicaid patients overall. However, these relaxed eligibility redetermination policies may have adverse financial consequences—rising Medicaid revenues and declining private insurance revenues—for larger practices more regularly treating Medicaid-enrolled adults.