Issues with Medicaid Provider Availability

I think it’s widely assumed that the majority of U.S. doctors are ready to take on the over 70 million individuals enrolled in Medicaid. In theory, that should work out well. But, the reality is a bit trickier.

According to a recent national study from researchers at Oregon Health and Science University, over 25% of doctors enrolled in Medicaid haven’t treated any Medicaid patients in recent years. Even for those who did see Medicaid patients, it was often just a handful.

Interestingly, there are some physicians who are quite active with Medicaid patients. In 2021, the last year for which full data was available, a third of these doctors treated more than 150 Medicaid patients. Dr. Jane Zhu, who led the study, refers to the doctors who don’t treat Medicaid patients as “ghost” providers, while those actively seeing patients are the vital contributors to Medicaid care.

Zhu argues that this situation highlights a need for policymakers to look beyond just the lists of providers. It’s not uncommon for state Medicaid insurance plans to include doctors who don’t provide care. This mismatch can lead to serious challenges, for instance, when someone struggling with mental health issues can’t find a psychiatrist in their network who will see them without long delays.

Wait times for care are definitely a concern, often tied to physician shortages. Yet, if the actual participation rate of doctors in Medicaid is unclear or incorrect, then efforts to improve access might be misguided. There’s this ongoing scenario where some health systems might prefer to be part of more lucrative commercial insurance networks, yet end up with Medicaid contracts they’re hesitant to fulfill.

On the other hand, Medicaid insurers are subject to network adequacy rules, which can result in a higher number of listed providers, even if many of them aren’t taking on patients. This isn’t just hypothetical; Zhu’s previous study uncovered that 58% of mental health providers listed in Oregon’s Medicaid network hadn’t actually treated a Medicaid patient in the previous year.

The current study goes beyond insurance networks, examining state registries with many providers who end up in those insurance lists, whether active or not. There were noteworthy differences among provider types. Psychiatrists showed the highest likelihood of being ghost providers at 43%, compared to 18% for cardiologists and 26% for primary care physicians.

In 2021, Medicaid psychiatrists averaged seeing only three Medicaid patients, while primary care doctors enrolled in Medicaid treated about 59. What’s curious is that some doctors—who might traditionally shy away from seeing Medicaid patients—are starting to participate more. Over the last three years studied, about 20% of ghost doctors began taking Medicaid patients, and some previously inactive doctors ramped up their numbers.

“There will always be some doctors who won’t see Medicaid patients,” Zhu points out. “But there are definitely others who might want to but face barriers.” She suggests that this indicates a potential pool that policymakers could tap into. Moving forward, though, the focus might need to be on these core providers who significantly impact Medicaid care delivery.

She advocates for more targeted support to these active providers to ensure they can continue in the program, as losing just one could significantly affect their patient population.