Primary Care Access to New Patient Appointments for California Medicaid Enrollees: A Simulated Patient Study

Abstract

PURPOSE We undertook a study to evaluate variation in the availability of primary care new patient appointments for MediCal (California Medicaid) enrollees in Northern California, and its relationship to emergency department (ED) use after Medicaid expansion. METHODS We placed simulated calls by purported MediCal enrollees to 581 primary care clinicians (PCCs) listed as accepting new patients in online directories of MediCal managed care plans. Data from the California Health Interview Survey, MediCal enrollment reports, and California hospital discharge records were used in analyses. We developed multilevel, mixed-effect models to evaluate variation in appointment access. Multiple linear regression was used to examine the relationship between primary care access and ED use by county. RESULTS Availability of PCC new patient appointments to MediCal enrollees lacking a PCC varied significantly across counties in the multilevel model, ranging from 77 enrollees (95% CI, 70-81) to 472 enrollees (95% CI, 378-628) per each available new patient appointment. Just 19% of PCCs had available appointments within the state-mandated 10 business days. Clinicians at Federally Qualified Health Centers had higher availability of new patient appointments (rate ratio = 1.56; 95% CI, 1.24-1.97). Counties with poorer PCC access had higher ED use by MediCal enrollees. CONCLUSIONS In contrast to findings from other states, access to primary care in Northern California was limited for new patient MediCal enrollees and varied across counties, despite standard statewide reimbursement rates. Counties with more limited access to primary care new patient appointments had higher ED use by MediCal enrollees.

Potemkin Protections: Assessing Provider Directory Accuracy and Timely Access for Four Specialties in California

“…Surveys may be supplemented by "extraction," that is, using the providers' scheduling system to access appointment data (although this method may only be used if carriers can first establish whether providers are ineligible for the survey). Given the repeated multi-medium approach in reaching out to providers (email, fax, and phone), the surveys we utilize in our analyses below can essentially be viewed as advanced "secret shopper" surveys, which have been frequently used to assess provider networks by scholars, regulators, and advocacy organizations, or something closely analogous (Tipirneni et al 2016;Melnikow et al 2020;Cama et al 2017;Haeder, Weimer, and Mukamel 2016).…”

“…Yet the focus on coverage expansion in the wake of the ACA's implementation has obscured the importance of other challenges to health access beyond lack of insurance. In particular, while provider networks specifically have not been a priority for policymakers (Haeder, Weimer, and Mukamel 2019b), they have emerged as a focal point for scholars concerned about access to care, with studies repeatedly unearthing inaccuracies in the provider directories provided to consumers by carriers, as well as challenges in accessing timely care (Cama et al 2017;Haeder, Weimer, and Mukamel 2016;Melnikow et al 2020;Tipirneni et al 2016).…”

“…These challenges have only worsened as provider networks have grown narrower over time Mukamel 2015b, 2015a;Corlette, Giovannelli, and Lucia 2015;Polsky and Weiner 2015), essentially amplifying the effect of any potential inaccuracies on consumer access. And yet, despite the critical role provider directories play, studies have repeatedly found that provider directories are inaccurate and that plans struggle to provide prompt access to providers (Haeder, Weimer, and Mukamel 2016; U.S. Government Accountability Office 2015; Cama et al 2017;Tipirneni et al 2016;Melnikow et al 2020).…”

Medicaid Expansion and Emergency Department Utilization

“…Recently, a secret shopper study was conducted in California where individuals posed as Medicaid enrollees and attempted to schedule a primary care appointment (Melnikow et al ). This study uncovered alarming barriers to office‐based primary care.…”

“…Ideally, it would be useful to incorporate data on the number of local primary care providers who were accepting new Medicaid patients. However, based on the work from Melnikow et al (), it seems that even if a physician reports that they accept Medicaid patients, this means very little in terms of them actually accepting new Medicaid patients. Therefore, I instead consider proximity to clinics to capture access to office‐based primary care.…”