Essays on Impacts of Medicaid Primary Care Fee Bump in 2013-14 on Primary Care Access and Utilization Open Access
Zhuo Yang (Spring 2018)
Abstract
Medicaid programs historically paid primary care physicians (PCPs) less than other
insurance types. Lower PCP payment is believed to hamper Medicaid beneficiaries’ access to
and utilization of primary care. In 2013 and 2014, Medicaid PCP payments were increased to
be on parity with Medicare using 100% federal funding, a provision so called the ‘Medicaid
primary care fee bump’. After 2014, some states extended the fee bump with state funding,
while others did not. This dissertation comprises three articles investigating the effect of the
fee bump and its extension on Medicaid beneficiaries’ care access and utilization and PCP
treatment pattern.
The first article examines changes in self-reported access to primary care and, as the
fee bump size varied by states, whether the changes correlated with the bump size. Based on
the Behavioral Risk Factor Surveillance System (BRFSS) data 2011-2014 from nine states, I
found no significant improvement in Medicaid beneficiaries’ likelihoods of having a personal
doctor or having routine checkup visits; flu vaccination exhibited seasonal fluctuation but no
consistent post-fee-bump improvement.
The second article assesses the fee bump’s effects on per-patient and within-visit
intensity of primary care services received by Medicaid beneficiaries. Based on the National
Ambulatory Medical Care Survey (NAMCS) 2010-2014 data, I found that PCPs did not
increase annual number of visits, minutes spent per visit, and type of services provided for
Medicaid beneficiaries following the fee bump, even for PCPs with practice ownership, who
are supposedly more incentivized than salaried counterparts.
The third article capitalizes the reverse experiment of state extending versus
terminating the fee bump in 2015 and 2016, estimating the effect of a state’s extension
decision on primary care access and utilization. By using the National Health Interview
Survey (NHIS) 2013-2016, I find that the extension decision was associated with increased
likelihoods of having a usual source of care and chronic condition checkups, decreased
likelihoods of rejection by a doctor’s office and using emergency departments for non-urgent
reasons, and more frequent office visits. Overall, the results suggest that the fee bump
extension in 2015-16 yielded positive impacts on access and utilization of primary care.
In sum, my dissertation suggests that the 2013-14 fee bump did not yield significant
impacts on Medicaid beneficiaries’ access and utilization of primary care, nor did it
incentivize PCPs to provide more intensive care. Nonetheless, the positive results found in
the extension states may suggest that a sustained, better implemented physician payment
incentive could potentially generate positive impacts on care access and utilization.
Table of Contents
CHAPTER 1 ....................................................................................................................................... 1
MAIN THEME ...................................................................................................................... 1
POLICY BACKGROUND ................................................................................................. 2
CONCEPTUAL FRAMEWORK ....................................................................................... 5
REFERENCES ...................................................................................................................... 8
CHAPTER 2 ..................................................................................................................................... 13
ABSTRACT........................................................................................................................... 13
INTRODUCTION .............................................................................................................. 14
METHODS ........................................................................................................................... 15
Data Source and Study Sample ............................................................................. 15
Outcome Measures ................................................................................................. 16
Analysis ..................................................................................................................... 17
RESULTS .............................................................................................................................. 19
Trends of Primary Care Access ............................................................................ 19
Adjusted Post-Fee-Bump Change in Primary Care Access .............................. 19
Effect of Bump Size on Primary Care Access .................................................... 21
DISCUSSION ....................................................................................................................... 21
REFERENCES .................................................................................................................... 25
CHAPTER 3 ..................................................................................................................................... 33
ABSTRACT........................................................................................................................... 33
INTRODUCTION .............................................................................................................. 34
BACKGROUND ................................................................................................................. 36
Rules and Design of Medicaid Fee Bump ........................................................... 36
Medicaid Financial Incentive, Facility Ownership, and Physician Behavior .. 37
METHODS ........................................................................................................................... 39
Data and Study Sample .......................................................................................... 39
Study Variables ........................................................................................................ 40
Empirical Approach ............................................................................................... 42
Validation of Study Design: Test Parallel Pre-Trend ......................................... 44
RESULTS .............................................................................................................................. 46
DISCUSSION ....................................................................................................................... 48
CONCLUSION ................................................................................................................... 52
REFERENCES .................................................................................................................... 53
CHAPTER 4 ..................................................................................................................................... 69
ABSTRACT........................................................................................................................... 69
INTRODUCTION .............................................................................................................. 70
DATA..................................................................................................................................... 71
Medicaid Fee Bump Extension and Eligibility Expansion ............................... 71
National Health Interview Survey ........................................................................ 74
EMPIRICAL STRATEGY ................................................................................................. 76
RESULTS .............................................................................................................................. 79
DISCUSSION ....................................................................................................................... 82
REFERENCES .................................................................................................................... 85
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