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State access standards did not improve accessibility to specialists

The implementation of specialty access standards by state Medicaid agencies did not result in widespread, meaningful improvements in access to specialist physicians for Medicaid enrollees, and researchers suggest that additional interventions may be needed to expand access, according to a study published in JAMA Internal Medicine.

“Medicaid recipients have consistently reported less timely access to physicians than patients with other forms of coverage,” Chima D. Ndumele, PhD, from the department of health policy and management at Yale School of Public Health, and colleagues wrote. “By 2018, state Medicaid agencies will be required by the [CMS] to enact time and distance standards for managed care organizations to ensure an adequate supply of specialist physicians for enrollees; however, there have been no published studies of whether these policies have significant effects on access to specialty care.”

Ndumele and colleagues performed a quasiexperimental difference-in-differences analysis using data from the Consumer Assessment of Healthcare Providers and Systems survey to determine how the implementation of state access standards affects timely accessibility to specialist physicians for adult Medicaid and commercial enrollees. The analysis included 20,163 nonelderly adult Medicaid managed care enrollees from five states that were adopting access standards (case states) and 37,290 Medicaid managed care enrollees from five matched states that adopted access standards previously (control states). In addition, the researchers compared Medicaid enrollees’ specialty care access in the previous 6 months with 54,465 commercially insured enrollees from the five case states.

Data showed that getting an appointment with a specialist before the policy implementation was always or usually easy for 69% of Medicaid enrollees and 75% of commercial enrollees, compared with 67% of Medicaid enrollees in control states. After the implementation of standards, timely access to specialty services did not significantly improve for Medicaid managed care enrollees (adjusted difference-in-differences = –1.2 percentage points; 95% CI, –2.7 to 0.1). Furthermore, insurance-based disparities in access was not affected by the implementation of access standards (adjusted difference-in-differences = 0.6 percentage points; 95% CI, –4.3 to 5.4). Heterogeneity was achieved across states. Significant improvements in access and reductions in disparities was observed in one state that implemented time and distance standards.

A sole policy that requires states to create specialty access standards for Medicaid managed care plans “is unlikely to lead to widespread improvements in access to health care services for Medicaid enrollees or to reduce gaps in specialty care access between Medicaid and commercial enrollees,” Ndumele and colleagues concluded.

“The lack of effect of access standards underscores the need to strengthen and/or combine alternative policy and organizational strategies to improve enrollee access to specialists,” they added.

In an accompanying editorial, Mitchell H. Katz, MD, from the Los Angeles County Department of Health Services, wrote that states did not rigorously enforce the specialty access standards, which may explain the findings by Ndumele and colleagues. However, more robust measures, such as regular audits of plans and financial penalties when the standards have not been met, have the potential to eliminate this barrier.

“Access standards, which [the researchers] show us may not be effective, cannot substitute for good clinical judgement or wise use of scarce resources,” he wrote. – by Alaina Tedesco

Disclosure: All authors report no relevant financial disclosures.