Essays on Impacts of Medicaid Primary Care Fee Bump in 2013-14 on Primary Care Access and Utilization Open Access

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

 

About this Dissertation

Rights statement

• Permission granted by the author to include this thesis or dissertation in this repository. All rights reserved by the author. Please contact the author for information regarding the reproduction and use of this thesis or dissertation.

School	Laney Graduate School
Department	Health Services and Research Health Policy
Degree	Ph.D.
Submission	Dissertation
Language	English
Research Field	Health Sciences, Health Care Management
Keyword	Acountable Care Act Physician Payment Primary Care Medicaid Financial Incentive
Committee Chair / Thesis Advisor	David H. Howard, Emory University
Committee Members	Adam Wilk, Emory University E. Kathleen Adams, Emory University

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