Assessment of the Patient Protection and Affordable Care Act’s Increase in Fees for Primary Care and Access to Care for Dual-Eligible Beneficiaries

Abstract

IMPORTANCE The Patient Protection and Affordable Care Act (ACA) temporarily increased primary care practitioners' (PCP) Medicaid fees to that of Medicare for 2013 to 2014 (fee bump) to help accommodate potential increases in demand for care with ACA coverage expansion. This also increased fees for PCPs treating dual-eligible Medicare and Medicaid beneficiaries in many states and eliminated payment differentials for dual-eligible vs non-dual-eligible Medicare beneficiaries that could limit access to care. OBJECTIVE To examine the association between the ACA fee bump and primary care visits for dualeligible Medicare and Medicaid beneficiaries. DESIGN, SETTING, AND PARTICIPANTS This cohort study used a difference-indifference design and Medicare claims data from 2012 to 2016 to compare changes in visit rates for full-subsidy dualeligible Medicare and Medicaid beneficiaries vs non-dual-eligible Medicare beneficiaries with low income whose fees did not change. Changes were examined overall and separately in states with temporary, extended, or minimal fee increases for dual-eligible vs non-dual-eligible beneficiaries in 2013 to 2014 (mandatory bump) and 2015 to 2016 (postbump or bump extension) vs 2012 (prebump). The study used linear regression models with beneficiary fixed effects, adjusting for time-changing area and beneficiary characteristics. Statistical analysis was performed from February 2018 to November 2019. EXPOSURE ACA-mandated Medicaid fee bump. MAIN OUTCOMES AND MEASURES Primary care visits per 100 beneficiaries overall and visits billed by physicians vs nurse practitioners and physician assistants. RESULTS The study included 3 052 044 dual-eligible and non-dual-eligible beneficiaries in 2012; 1 516 534 (49.7%) were aged 65 years or younger, 1 797 556 (58.9%) were women, and 1 754 626 (57.5%) had non-Hispanic White race/ethnicity. Overall primary care visit rates for dual-eligible beneficiaries were unchanged or decreased slightly relative to non-dual-eligible beneficiaries during the fee bump (2013-2014) and the postbump or bump extension period (2015-2016) vs baseline. Compared with non-dual-eligible beneficiaries, visit rates with primary care physicians declined more uniformly for dual-eligible beneficiaries across state groups and time periods

Does Medicaid coverage of Medicare cost sharing affect physician care for dual‐eligible Medicare beneficiaries?

“…8,22,23 However, our findings are consistent with a recent study by Fung and colleagues, which did not find any increase in office visits among duals due to the fee bump, either overall or in states with larger or more sustained payment increases. 13 Our findings also resonate with Chen and Lakdawalla, 25 who found that separate Medicare payment changes led to smaller changes in physician visits among low-income beneficiaries than those with higher incomes. Chen and Lakdawalla hypothesize that this more muted response reflects physicians' recognition that higher prices will result in higher out-of-pocket costs for individuals without supplemental insurance, and that these outof-pocket costs may be more burdensome to low-income patients.…”

“…Our results differ from several prior studies which found positive supply elasticities ranging from 0.5 to 2 in response to Medicare price changes in the full Medicare population 8,22,23 . However, our findings are consistent with a recent study by Fung and colleagues, which did not find any increase in office visits among duals due to the fee bump, either overall or in states with larger or more sustained payment increases 13 . Our findings also resonate with Chen and Lakdawalla, 25 who found that separate Medicare payment changes led to smaller changes in physician visits among low‐income beneficiaries than those with higher incomes.…”

“…First, we add to a growing body of research on the effects of the Affordable Care Act's Medicaid fee bump-one of the largest payment changes in the history of the Medicaid program. 6 To our knowledge, only one other study by Fung et al 13 examined the effects of this fee bump among duals, while other studies examined the policy's effects in populations for which Medicaid was the primary (rather than the supplemental) insurer. [14][15][16][17] Second, we add to a limited literature on payment policy for duals.…”

The mental health of Medicare beneficiaries with disabilities during the COVID-19 pandemic.

“…Before the pandemic, Medicare beneficiaries with disabilities’, especially those who were dual eligible, access to care and the quality of care they receive were negatively impacted by the fragmented system through which they receive services (Cubanski & Neuman, 2010; Feng, 2018; Figueroa et al, 2018; Warshaw & DeGolia, 2015); this may contribute to why Medicare beneficiaries with disabilities did not get the counseling/therapy services they needed during the pandemic. In fact, some health care providers will not serve Medicare beneficiaries because of poor reimbursement rates (Cubanski & Neuman, 2010; Fung et al, 2021; Warshaw & DeGolia, 2015). Given lower income Medicare beneficiaries with disabilities in our study were more likely to not get the counseling/therapy they needed, we believe cost may have also been a factor in these disparities.…”

Food insecurity of people with disabilities who were Medicare beneficiaries during the COVID-19 pandemic

“…While food insecurity negatively harms the physical and mental health of everyone, 1 , 2 , 3 , 4 , 5 , 6 , 7 it may be particularly harmful for PWD who were Medicare beneficiaries who are already vulnerable, underserved, and have multiple chronic conditions. 26 , 27 , 33 , 34 , 35 , 36 , 37 A multipronged approach to food insecurity that addresses public health and other systems and structures, ranging from disability services to discrimination, is critical. 2 , 38 …”