Abstract
We examine whether fees paid by Medicaid for primary care affects the use of health care services among adults with Medicaid coverage who have a high school or less than high school degree. The analysis spans the large changes in Medicaid fees that occurred before and after the ACA-mandated fee increase for primary care services in 2013–2014. We use data from the Behavioral Risk Factors Surveillance System and a difference-in-differences approach to estimate the association between Medicaid fees and whether a person has a personal doctor; a routine check-up or flu shot in the past year; whether a woman had a pap test or a mammogram in the past year; whether a person has ever been diagnosed with asthma, diabetes, cardiovascular diseases, cancer, COPD, arthritis, depression, or kidney diseases; and, whether a person reports good-to-excellent health. Estimates indicate that Medicaid fee increases were associated with small increases in the likelihood of having a personal doctor, or receiving a flu shot, although only having a personal doctor remained significant when accounting for multiple hypothesis testing. We conclude that Medicaid fees did not have a major impact on the use of primary care or on the consequences of that care.
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Notes
As we show below, 77% of Medicaid enrollees reported receiving a routine checkup before the mandated fee increase went into effect. Moreover, in 2016, established patient office visits (99213 and 99214) accounted for 65% of Medicaid expenditures for primary care services affected by the mandate (Zuckerman et al., 2017, Table 4). By comparison, new patient office visits accounted for just 9% of Medicaid expenditures among the affected primary care service codes.
Between 2010 and 2012, three states decreased the Medicaid-to-Medicare fee ratio by 12 percentage points, ten states decreased the fee ratio between 5 to 9 percentage points, twenty-eight states decreased the fee ratio between 1 to 4 percentage points, three states did not change the fee ratio, five states increased the fee ratio between 1 and 6 percentage points, and one state increased the fee ratio by 31 percentage points.
These data are available for each state in years 2011 to 2016 except 2012. The 2012 Medicaid Managed care Enrollment Report does not identify the unduplicated number of Medicaid enrollees with managed care plans by state. We averaged state-shares in 2011 and 2013 to calculate the 2012 share.
Figure 5 in the Appendix shows the state Medicaid FFS enrollment share by Medicaid-to-Medicare fee ratio. There is no clear relationship between the FFS share and the fee ratio and conditional on fee ratio, there is substantial variation in the FFS share.
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Partial support for this research was provided through Grant R01 AG043513 from the National Institute of Aging of the National Institutes of Health.
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Appendix
Appendix
See Tables 4, 5, 6, 7, 8 and Figs. 3, 4, 5.
a Raw changes in outcomes in the pre-period by the size of fee increase in 2014. Notes: Each data point represents a state average.The change in outcomes from 2011 to 2012 are plotted against the change in fees in 2014. Pap smear and mammogram were dropped because they were not available in 2011. Overall, the change in outcomes in the pre-trend are not systematically associated with the size of the fee increase in 2014. b Unadjusted trends in outcomes in the pre-period by fee ratio in 2011. Notes: this figure show the raw trends in outcomes by the quartiles of Mediaid-to-Medicare fee raio in 2011. Pap smear and mammogram were dropped because they were not available in 2011
a Raw changes in sample characteristics in the pre-period by the size of fee increase in 2014. Notes: Each data point represents a state average.The change in sample characterstics from 2011 to 2012 are plotted against the change in fees in 2014. Overall, the change in sample characteristics in the pre-trend are not systematically associated with the size of the fee increase in 2014. b Unadjusted Trends in Sample Characteristics in the Pre-period by Fee ratio in 2011. Notes: this figure show the raw trends in sample characteristics by the level of Mediaid-to-Medicare fee raio in 2011
State Medicaid fee-for-service enrollment share by Medicaid-to-Medicare fee ratio. Notes: Fee-for-service enrollment share is the share of Medicaid enrollees not enrolled in any form of Medicaid managed care. Data for these figures are from the Medicaid managed care enrollment report published annually by the Centers for Medicare and Medicaid services. Fee-for-service share equals to one minus the share of beneficiaries enrolled in any form of managed care
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Gangopadhyaya, A., Kaestner, R. & Schiman, C. Medicaid physician fees and the use of primary care services: evidence from before and after the ACA fee bump. Int J Health Econ Manag. 23, 609–642 (2023). https://doi.org/10.1007/s10754-023-09358-9
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DOI: https://doi.org/10.1007/s10754-023-09358-9