January 2008

Grant Results

National Program

Changes in Health Care Financing and Organization

SUMMARY

In this 2001 to 2005 project, Phillip R. Kletke, Ph.D., from Health Research & Educational Trust and other researchers studied the factors that determine physician participation in Medicaid, including the extent to which physicians have discretion over their acceptance of new Medicaid patients and the effect that this discretion has on their Medicaid participation.

This project was part of the Robert Wood Johnson Foundation (RWJF) national program Changes in Health Care Financing and Organization (HCFO) (for more information see Grant Results).

Key Findings
The researchers reported the following findings in the Findings Brief:

  • When determining whether to accept Medicaid patients:
    • 28 percent of physicians have individual discretion.
    • 56 percent make their decisions collectively with other physicians.
    • 14 percent follow the decision made by a board or another administrative body.
    • 2 percent make the decision in another, unspecified way.
  • Physicians with an ownership interest in their practices were more likely to have individual discretion over their Medicaid participation than were those who were employees.
  • Discretion over Medicaid participation varied significantly by specialty.

Funding
RWJF provided a $212,604 grant for the project from 2001 to 2005.

 See Grant Detail & Contact Information
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THE PROJECT

Medicaid's ability to make high-quality medical care accessible to low-income Americans depends, in part, on physician willingness to participate in the program. To examine the extent to which physicians have discretion over their acceptance of new Medicaid patients and the effect this discretion has on their Medicaid participation, Kletke and a team of researchers analyzed data from the American Medical Association's Socioeconomic Monitoring System, an annual telephone survey of approximately 4,000 physicians.

Researchers analyzed survey data from 1996 to 1998 on 2,328 physicians who worked in group practices. They excluded physicians practicing in hospitals or other institutions, physicians in hospital-based specialties and physicians in practices with a single physician owner.

The research team was composed of:

  • Janet D. Perloff, Ph.D., State University of New York at Albany.
  • James W. Fossett, Ph.D., Rockefeller Institute of Government, Albany, N.Y.
  • Jon Gabel, Center for Studying Health System Change, Washington.
  • David W. Emmons, Ph.D., American Medical Association, Chicago.
  • Gregory D. Wozniak, Ph.D., Blue Cross Blue Shield Association in Chicago.

As part of the project, the researchers also used data from the Socioeconomic Monitoring System to conduct three other analyses related to changes in physicians' decisions to treat Medicaid patients and the uninsured; for more information, see Other Analyses.

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FINDINGS

Findings About Physicians' Discretion Over Their Acceptance of New Medicaid Patients

Researchers reported the following findings in a Findings Brief (November 2006):

  • When determining whether to accept Medicaid patients:
    • 28 percent of physicians have individual discretion.
    • 56 percent make their decisions collectively with other physicians.
    • 14 percent follow the decision made by a board or another administrative body.
    • 2 percent make the decision in another, unspecified way.
  • Physicians with an ownership interest in their practices were more likely to have individual discretion over their Medicaid participation than were those who were employees. Employee physicians were significantly more likely than owner physicians to have their Medicaid participation determined administratively.
  • The likelihood of Medicaid participation decisions being made collectively decreased with the number of physicians in the practice. In large practices, these decisions were more likely to be made administratively or by physicians individually.
  • Discretion over Medicaid participation varied significantly by specialty. Physicians in psychiatry, general internal medicine and family/general practice were especially likely to have individual discretion over the acceptance of Medicaid patients.
  • Although discretion over Medicaid participation decisions varies systematically among physicians in group practices, it does not appear to have a strong effect on the extent to which physicians participate. The locus of decision-making changed, but the actual decisions did not.

Other Analyses

As of November 2007, the researchers had not published findings from the three other analyses because of the death of a member of the project team, job changes and other factors. They planned to conduct additional analyses and publish the findings.

Changes in the Determinants of Physician Participation in Medicaid
The researchers studied physician participation in Medicaid from 1984 through 1998. They found that:

  • Physician participation in Medicaid increased from 76 percent to 83 percent.
  • The proportion of physicians participating in Medicaid was highest among pediatric subspecialists (95 percent) and general surgeons (97 percent) and lowest among psychiatrists (66 percent).
  • More experienced physicians were less likely than younger physicians to participate in Medicaid.
  • Physicians in group practices were most likely to participate in Medicaid.
  • The generosity of Medicaid payments had a significantly positive effect on physician Medicaid participation.
  • Physicians in areas with higher HMO penetration were more likely than those in areas with lower HMO penetration to provide services to Medicaid patients.

Obstetrician/Gynecologists' Participation in Medicaid
This analysis examined how obstetrician/gynecologists' Medicaid participation changed in response to increased Medicaid eligibility for pregnant women and children under new federal laws passed during the 1980s and early 1990s. The researchers found that:

  • The proportion of obstetrician/gynecologists who accepted Medicaid patients increased from 68 percent in the mid-1980s to 82 percent in the late 1990s.
  • The proportion of obstetrician/gynecologists' patients covered by Medicaid doubled from 10 percent to 20 percent during the same period.

The Concentration of Medicaid Patients Into the Practices of a Few Physicians
This analysis examined if the concentration of Medicaid patients in the practices of a few physicians has changed over time and how it varies among different types of communities. The researchers found that:

  • Medicaid patients remained concentrated into a relatively small number of physician practices.
  • This uneven distribution is more pronounced in large, highly segregated communities. Uninsured patients are more evenly distributed than Medicaid patients across physician practices.

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CONCLUSIONS

The researchers presented the following conclusion about the project in a report to RWJF:

  • Taken together, the four analyses indicated that policy changes and secular trends, as well as changing demographics, affect physicians' participation in Medicaid. Some trends increase participation; others decrease it. Thus, it is critical that policy-makers think carefully about the intended and unintended consequences of future changes in Medicaid policy.

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GRANT DETAILS & CONTACT INFORMATION

Project

Changes in Physicians' Decisions to Treat Medicaid Patients and the Uninsured

Grantee

Health Research & Educational Trust (Chicago,  IL)

  • Amount: $ 212,604
    Dates: December 2001 to June 2005
    ID#:  044126

Contact

Phillip R. Kletke, Ph.D.
(708) 235-7660
p-kletke@govst.edu

Web Site

http://www.hcfo.net

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Report prepared by: Barbara Matacera Barr
Reviewed by: Lori De Milto
Reviewed by: Molly McKaughan
Program Officer: Nancy Barrand

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