Medicaid managed care services were primarily concentrated across few providers, prompting questions about network adequacy standards needing to be beefed up, a new study claims.
The study, published Tuesday in the journal Health Affairs, comes as states are deferring more and more to managed care private plans to deliver certain benefits to eligible participants. The managed care space has also become a lucrative market for the insurance industry.
“Our findings suggest that current network adequacy standards might not reflect actual access; new methods are needed that account for beneficiaries’ preferences and physicians’ willingness to serve Medicaid patients,” the study said.
Researchers looked at data from four states from 2015 to 2017 to examine how many physicians in provider network directories of managed care plans participated in Medicaid.
“We found that about one-third of outpatient primary care and specialist physicians contracted with Medicaid managed care plans in our sample saw fewer than ten Medicaid beneficiaries in a year,” the study said.
It showed that 25% of primary care doctors delivered 86% of the care, while 25% of specialists on average provided 75% of medical care.
The results come amid lingering issues with physician participation in Medicaid, which offers lower reimbursement rates than commercial plans, and concerns surrounding high rates of claim denials and long times to get payments, the study said.
“Studies show that almost a third of office-based physicians do not participate in Medicaid—far fewer than participate in Medicare or commercial insurance markets,” the study said.
The study’s sample comprised 22,056 physicians in adult and pediatric primary care, cardiology and psychiatry included in Medicaid managed care networks.
“Overall, 16.3% of physicians listed in Medicaid managed care plan provider network directors in a year qualified as ghost physicians, meaning they saw zero Medicaid beneficiaries over the course of the year in an outpatient setting,” the study said. “The share of ghost physicians ranged from 13.4% to 24.9% across states.”
The specialty most likely to be a ghost physician was psychiatry with 35.5% of the population not seeing any Medicaid patients, while pediatric primary care physicians were least likely with only 11%.
Overall, the study showed provider network directors may overstate how many physicians can actually offer care to Medicaid.
“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 study said.
States are required by the federal government to demonstrate managed care network adequacy standards, but the government has been less explicit on how exactly states must do this.
“States vary widely in the requirements of their network adequacy standards, oversight of those standards and penalties for overstating the breadth of networks,” the study said.
Researchers recommended that states do more to evaluate managed care networks including via audits and claims-based assessments. Another recommendation was to explore penalizing plans that have physicians in their networks but don’t see Medicaid beneficiaries.